Every finding on record at Creasy Springs Health Campus

Based on observation, interview and record review, the facility failed to ensure a resident was assessed to self-administer medications for 1 of 1 resident randomly reviewed for self-medication administration. (Resident 73)Findings include:During an observation, on 2/4/26 at 2:02 p.m., a clear plastic bag, labeled with prescription information containing Nystatin cream, was found on Resident 73's bedside table.The clinical record for Resident 73 was reviewed on 2/6/26 at 12:14 p.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus with skin complications, rash, and nonspecific skin eruptions.A physician's order, dated 12/22/25, indicated to administer Nystatin ointment topical to the areas of noted rash twice a day.A care plan, dated 1/29/26, indicated the resident had moisture associated skin damage (MASD) to the left buttock. Interventions included, but were not limited to, treatment as ordered.The clinical record did not contain an assessment or a physician's order completed by the interdisciplinary team to determine Resident 73 could self-administer medications.During an interview, on 2/4/26 at 2:02 p.m., Resident 73 indicated the cream on his bedside table was for a sore area.During an observation and interview, on 2/4/26 at 2:10 p.m., the Executive Director (ED) entered Resident 73's room and removed the Nystatin cream from the bedside table. The ED indicated he would need to see if the resident had an evaluation completed to self-administer the medication.During an interview, on 2/4/26 at 2:16 p.m., the ED indicated Resident 73 was not supposed to self-administer the Nystatin cream and it should not have been in his room.During an interview, on 2/11/26 at 10:37 a.m., Registered Nurse (RN) 7 indicated medication cream should be stored in the treatment cart. If a resident had any medication at their bedside, there should be an evaluation completed and a doctor's order to self-administer medications.During an interview, on 2/11/26 at 10:56 a.m., the Director of Nursing (DON) indicated if a resident had a medication at their bedside, there should be a self-administration observation or evaluation completed.A current facility policy, titled Self-Administration of Medications, dated as last revised January 2018 and received from the ED on 2/9/26 at 1:56 p.m., indicated .For those residents who self-administer, the interdisciplinary team verifies the resident's ability to self-administer medications by means of a skill assessment conducted on a quarterly basis or when there is a significant change in condition.if the resident demonstrates the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage is conducted.3.1-11(a)

Based on interview and record review, the facility failed to ensure the physician was notified of a weight gain according to the parameters ordered for 1 of 1 resident reviewed for notification. (Resident 9)Findings include:The clinical record for Resident 9 was reviewed on 2/6/26 at 1:24 p.m. The diagnoses included, but were not limited to, congestive heart failure (CHF), edema, fluid overload, hypertensive chronic kidney disease, depression, and diabetes mellitus. A physician's order, dated 12/10/25 and discontinued on 1/5/26, indicated to notify the physician of a weight gain greater than 2 pounds in 24 hours or 5 pounds in one week. Resident 9 was to be weighed every day right after she got up, had voided, still in bedclothes, and before breakfast.A review of Resident 9's daily weights indicated the following:a. On 12/18/25, Resident 9 had a documented 3.2 pounds weight increase.b. On 12/23/25, Resident 9 had a documented 15.6 pounds weight increase.c. On 12/26/25, Resident 9 had a documented 15.2 pounds weight increase.d. On 12/29/25, Resident 9 had a documented 13 pounds weight increase.e. On 1/1/26, Resident 9 had a documented 4 pounds weight increase.f. On 1/2/26, Resident 9 had a documented 15.2 pounds weight increase.g. On 1/5/26, Resident 9 had a documented 9 pounds weight increase.h. On 2/8/26, Resident 9 had a documented 10 pounds weight increase.During an interview, on 2/9/26 at 11:28 a.m., QMA 10 indicated when if a resident required a daily weight and had an order to notify the physician, she would notify the nurse when needed and the nurse would notify the physician. During an interview, on 2/11/26 at 9:48 a.m., RN 5 indicated daily weights were to be completed every day, at approximately at the same time in the morning, with no shoes or heavy clothing, no portable oxygen concentrators on the back of wheelchairs, in the same wheelchair and with an empty bladder.During an interview, on 2/11/25 at 11:01 a.m., the Director of Nursing (DON) indicated residents with orders for a daily weight had parameters to follow. The nurse would call the physician if the resident had a weight gain of 2 pounds in 2 days and 5 pounds in one week.During an interview, on 2/10/26 at 12:26 p.m., the Clinical Support Nurse 4 indicated the facility did not have a policy related to congestive heart failure or daily weights. The facility followed the state regulations.3.1-5(a)(1)3.1-5(a)(2)

Based on interview and record review, the facility failed to ensure the resident or resident's representative were given notification in writing of the facility bed hold policy for 2 of 3 residents reviewed for hospitalization. (Resident 11 and 3)Findings include:1. The clinical record for Resident 11 was reviewed on 2/8/26 at 11:04 a.m. The diagnoses included, but were not limited to, pneumonia, sepsis, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and chronic kidney disease stage 3. a. A nursing progress note, dated 6/21/25 at 7:58 a.m., indicated the resident was sent to emergency room for respiratory distress. A nursing progress note, dated 6/26/25 at 8:30 p.m., indicated the resident returned to the facility after a hospital stay for pneumonia. b. A nursing progress note, dated 9/28/35 at 4:24 a.m., indicated the resident was sent to the emergency room for evaluation of chest pain. A nursing progress note, dated 9/30/25 at 4:10 p.m., indicated the resident returned to the facility after a hospital stay for pneumonia and hyperkalemia (an elevated level of potassium in the blood). The clinical record did not contain documentation the resident or resident's representative were given information in writing of the facility bed hold policy, including the reserve bed payment. During an interview, on 2/10/26 at 9:40 a.m., the Executive Director (ED) indicated the bed hold policy and reserve bed cost were not given to Resident 11 or the resident's representative in writing. During an interview, on 2/11/26 at 10:37 a.m., Registered Nurse (RN) 7 indicated if a resident was sent to the hospital, the resident should be given paperwork, including the facility bed hold policy. 2. The clinical record for Resident 3 was reviewed on 2/10/26 at 11:24 a.m. The diagnoses included, but were not limited to, pneumonitis due to inhalation of food and vomit, influenza with other respiratory manifestations, dysphagia, irritable bowel syndrome, chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, acute and chronic respiratory failure, and pneumonia. A nursing progress note, dated 12/5/25 1:07 p.m., indicated Resident 3 was sent to the emergency room for shortness of breath and difficulty breathing. A nursing progress note, dated 12/11/25 at 7:50 p.m., indicated Resident 3 returned from a hospital stay. A nursing progress note, dated 12/30/25 at 9:25 a.m., indicated Resident 3 was sent to the emergency room for a cough, pressure in chest, and a fever. The clinical record did not contain documentation the resident or resident's representative were given information in writing of the facility bed hold policy, including the reserve bed payment. During an interview, on 2/11/26 at 9:58 a.m., Registered Nurse 5 indicated a bed hold policy should be given to the resident or the resident's representative when being sent to the hospital. A copy was made and kept for the facility. During an interview, on 2/11/26 at 10:52 a.m., the Clinical Support Nurse indicated there were no bed hold policies completed for either of Resident 3's hospitalizations. During an interview, on 2/11/26 at 10:56 a.m., the Director of Nursing (DON) indicated a bed hold policy should be completed when a resident went to the hospital. The residents should be given the bed hold policy. During an interview, on 2/11/26 at 10:57 a.m., the Administrator indicated a bed hold policy should be completed, signed, and given to the resident or the resident's representative. The bed hold policy should be mailed by certified mail if indicated. A current facility policy, titled Bed Hold Policy, dated as last revised 11/18/16 and received from the Executive Director on 2/9/26 at 1:56 p.m., indicated .To establish a policy and procedure following state and federal guidelines as it pertains to a resident notification and billing procedures for hospital therapeutic leave bed-hold. 3.1-12(a)(25)(A) 3.1-12(a)(25)(B)

Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment was coded accurately for 2 of 2 residents reviewed for MDS accuracy. (Resident 9 and 2)Findings include: 1. The clinical record for Resident 9 was reviewed on 2/6/26 at 1:24 p.m. The diagnoses included, but were not limited to, congestive heart failure, edema, fluid overload, and hypertensive chronic kidney disease. A physician's order, dated 12/10/25, indicated to administer furosemide (a diuretic medication) 80 milligrams (mg) twice a day. During an interview, on 2/9/26 at 3:49 p.m., the MDS Coordinator indicated the congestive heart failure diagnosis was not included in the resident's quarterly MDS assessment on 12/12/25. 2. The clinical record for Resident 2 was reviewed 2/9/26 at 9:00 am. The diagnosis included, but were not limited to, dementia, depression, anxiety, and post-traumatic stress disorder. The clinical record review did not include post-traumatic stress disorder under Resident 2's diagnoses list. The social history observation, dated 1/26/26, indicated Resident 2 had no traumatic history. The Minimum Data Set (MDS) assessment did not indicate Resident 2 had a diagnosis of post-traumatic stress disorder. There was no care plan located related to post-traumatic stress disorder. During an interview, on 2/10/26 at 2:38 p.m., Licensed Practical Nurse 6 indicated Resident 2 had a diagnosis of post-traumatic stress disorder related to being in a war. Resident 2 did not have a care plan in place for post-traumatic stress disorder. During an interview, on 2/10/26 at 2:42 p.m., the Dementia Care Director indicated Resident 2 did have a diagnosis of post-traumatic stress disorder and there was no care plan in place. During an interview, on 2/11/26 at 11:04 a.m., the Director of Nursing (DON) indicated Resident 2 was admitted with the diagnosis of post-traumatic stress disorder. The DON indicated the MDS assessment should have listed the diagnosis of post-traumatic stress disorder, and a care plan should have been in place. During an interview, on 2/9/26 at 3:55 p.m., Clinical Support Nurse indicated there was not a facility policy for MDS accuracy. The facility followed the Resident Assessment Instrument (RAI) manual. 3.1-31(a) 3.1-31(c)(1) 3.1-31(d)

Based on interview and record review, the facility failed to ensure comprehensive person-centered care plans were developed and implemented for 2 of 2 residents reviewed for care plans. (Resident 9 and 2)Findings include:1. The clinical record for Resident 9 was reviewed on 2/6/26 at 1:24 p.m. The diagnoses included, but were not limited to, congestive heart failure, edema, fluid overload, and hypertensive chronic kidney disease. A physician's order, dated 12/10/25, indicated to administer furosemide (a diuretic medication) 80 milligrams (mg) twice a day. A physician's order, dated 12/13/25, indicated to administer metolazone (a diuretic medication) 5 mg tablet daily. A comprehensive person-centered care plan related to congestive heart failure and the use of multiple diuretic medications was not initiated until 2/9/26, after the start of the survey. 2. The clinical record for Resident 2 was reviewed on 2/9/26 at 9:00 am. The diagnosis included, but were not limited to, dementia, depression, anxiety, and post-traumatic stress disorder. The social history observation, dated 1/26/26 at 3:08 p.m., indicated Resident 2 had no traumatic history. The clinical record did not contain a comprehensive person-centered care plan related to post-traumatic stress disorder. During an interview, on 2/10/26 at 2:38 p.m., Licensed Practical Nurse 6 indicated Resident 2 had a diagnosis of post-traumatic stress disorder related to being in a war and Resident 2 did not have a care plan in place related to the post-traumatic stress disorder. During an interview, on 2/10/26 at 2:42 p.m., the Dementia Care Director indicated Resident 2 had a diagnosis of post-traumatic stress disorder and did not have a care plan. A current facility policy, titled Comprehensive Care Plan Guidelines, dated as last reviewed 12/10/25 and received from the Clinical Support Nurse on 2/11/26 at 10:02 a.m., indicated .to ensure appropriateness of services and communication that will meet the resident's needs, severity/stability of conditions, impairment, disability, or disease in accordance with state and federal guidelines .A comprehensive care plan will be developed within 7 days of the admission comprehensive assessment.Comprehensive care plans need to remain accurate and current 3.1-35(a) 3.1-35(b)(1)

Based on interview and record review, the facility failed to ensure staff administered medications as ordered and followed the physician ordered medication parameters for 2 of 2 residents reviewed for quality of care. (Resident 64 and 8)Findings include:1. The clinical record for Resident 64 was reviewed on 2/5/26 at 2:33 p.m. The diagnoses included, but were not limited to, right distal femur fracture, depression, paraplegia, spinal cord injury, congestive heart failure, edema, fluid overload, hypertensive chronic kidney disease, depression, and dementia.A care plan, dated 9/16/25, indicated the resident had chronic pain. The interventions included, but were not limited to, administer medications and opioids as ordered.a. A physician's order, dated 10/11/25, indicated to administer two (2) capsules of pregabalin (a medication used to treat neuropathic pain) 50 milligrams three times a day. A controlled drug record indicated Resident 64 received one (1) capsule of pregabalin 50 mg on 10/11/25 at 1:15 p.m., and one (1) capsule on 10/13/25 at 8:30 a.m. Resident 64 should have received two (2) capsules at each administration. b. A physician's order, dated 12/10/25, indicated to administer morphine sulfate (a narcotic pain medication) ER (extended release) 15 milligram tablet every 8 hours. A nursing progress note, dated 10/11/25 at 6:29 a.m., indicated Resident 64 refused to take his evening medications. RN 8 offered the resident the medication prepared by the evening shift nurse at 12:30 a.m. The resident indicated he would take the medication prepared by the previous nurse. The morning dose of morphine was not given due to being too close to the previous dose.A controlled drug record indicated the morphine 15 mg tablet was signed out on 10/11/25 for the 9:00 p.m. dose. There was no documentation Resident 64 had refused the 9:00 p.m. dose by the evening shift nurse.The midnight shift nurse administered Resident 64 the evening medications prepared by the previously scheduled nurse at 12:30 a.m., which resulted in Resident 64 missing his morning dose of morphine and another dose was not administered until 1:15 p.m., on 10/12/25. During an interview, on 2/6/26 at 11:35 a.m., the Clinical Support Nurse 3 indicated Resident 64 missed his morning dose of morphine and could have been in pain before his next scheduled dose. During an interview, on 2/10/26 at 2:21 p.m., RN 3 indicated she administered the medications the evening shift nurse prepared. The medication administered included morphine and pregabalin. She then did not administer Resident 64's 6:00 a.m. dose. The resident missed his morning dose and could have been hurting before his next dose was due. 2. The clinical record for Resident 8 was reviewed on 2/6/26 at 12:28 p.m. The diagnoses included, but were not limited to, congestive heart failure, osteomyelitis (a serious bone infection) of the left ankle and foot, diabetes mellitus, and chronic kidney disease. A physician's order, dated 8/21/25, indicated to administer spironolactone (a diuretic medication which helps treat high blood pressure) 12.5 milligrams (mg) daily and hold the medication for a systolic blood pressure less than 105.The spironolactone 12.5 milligrams was administered when the following systolic blood pressures were less than 105:a. On 11/2/25, the blood pressure was 98/62.b. On 11/5/25, the blood pressure was 82/49.c. On 11/6/25, the blood pressure was 99/64.d. On 11/10/25, the blood pressure was 99/61.e. On 11/18/25, the blood pressure was 103/62.f. On 11/25/25, the blood pressure was 82/52.g. On 12/15/25, the blood pressure was 98/62.h. On 2/1/26, the blood pressure was 103/65.The clinical record also did not contain documentation that the low blood pressures were re-checked after the medication was administered until the resident's next dose.During an interview, on 2/10/26 at 11:30 a.m., Clinical Support Nurse 3 indicated the medication was supposed to be held and not given when the systolic blood pressure was less than 105. The staff should follow the physician's order and hold the medication when needed.During an interview, on 2/11/26 at 11:02 a.m., QMA 10 indicated if the blood pressure was out of range and the medication had a hold parameter, it should be documented in the Medication Administration Record (MAR) and the medication held.A current facility policy, titled Medication Administration - General Guidelines, dated as revised 1/2018 and received from the Clinical Support Nurse on 2/6/26 at 11:35 a.m., indicated .The person who prepares the dose for administration is the person who administers the dose.Medications are administered within 60 minutes of scheduled time.The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given.At the end of each medication pass, the person administering the medication reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medication report off=duty without first recording the administration of any medication.If a dose of regularly scheduled medication is withheld, refused.it is documented on MAR or n the EHR. An explanatory note is also entered.3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure an enteral feeding bag was labeled with the product name, date, and time for 1 of 1 resident reviewed for enteral feeding. (Resident 3)Findings include:During an observation, on 2/4/26 at 12:22 p.m., Resident 3 had two clear bags hanging on a feeding pump, which was turned off, and not connected to the resident. One bag was half full of a clear liquid without a label with the date, time or substance and the other bag was half full of a tan colored liquid without a label with the date, time or substance.During an interview, on 2/4/26 at 12:22 p.m., Registered Nurse 5 indicated the bags should have been labeled with a date, time, rate and what the substance was in the bag. During an interview, on 2/10/26 at 10:49 a.m., the Clinical Support Nurse indicated the enteral feeding bags should have had a label with the date, time and name of substance in bag.The clinical record for Resident 3 was reviewed on 2/10/26 11:24 a.m. The diagnoses included, but were not limited to, pneumonitis due to inhalation of food and vomit, influenza, dysphagia, gastrostomy status, irritable bowel syndrome, chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, acute and chronic respiratory failure, and pneumonia.A physician's order, dated 1/28/26, indicated to administer the enteral feeding formula [NAME] Farms 1.4 at a flow rate of 60ml/hour for 14 hours, on at 6 p.m. and off at 8 a.m.A physician's order, dated 1/14/26, indicated to administer a free water flush of 120 milliliters (ml) every 4 hours.A physician's order, dated 1/8/26, indicated to change the enteral feeding bag every day.Durning an observation, on 2/11/26 at 9:57 a.m., an unopened 325 ml container of [NAME] Farms enteral feeding indicated once opened it must be used within 24 hours in a healthcare setting.During an interview, on 2/11/26 at 10:59 a.m., the Director of Nursing (DON) indicated the enteral feeding bags should have been labeled with a date, time, and name of the substance.A current facility policy, titled Tube Feedings, dated as revised 5/10/24 and received from the Clinical Support Nurse on 2/10/26 at 10:49 a.m., indicated .TF recommendations should include product.3.1-44(a)(2)

Based on interview and record review, the facility failed to ensure the nursing staff administered medications in a safe and competent manner for 1 of 1 resident reviewed for competent nurse staffing. (Resident 64)Findings include:The clinical record for Resident 64 was reviewed on 2/5/26 at 2:33 p.m. The diagnoses included, but were not limited to, right distal femur fracture, depression, paraplegia, spinal cord injury, congestive heart failure, edema, fluid overload, hypertensive chronic kidney disease, depression, and dementia.A care plan, dated 9/16/25, indicated the resident had chronic pain. The interventions included, but were not limited to, administer medications and opioids as ordered.A nursing progress note, dated 10/11/25 at 6:29 a.m., indicated Resident 64 refused to take his evening medications. RN 8 offered the resident the medication prepared by the evening shift nurse at 12:30 a.m. The resident indicated he would take the medication prepared by the previous nurse. The morning dose of morphine was not given due to being too close to the previous dose.A controlled drug record indicated the morphine 15 mg tablet was signed out on 10/11/25 for the 9:00 p.m. dose. There was no documentation Resident 64 had refused the 9:00 p.m. dose by the evening shift nurse.The midnight shift nurse administered Resident 64 the evening medications prepared by the previously scheduled nurse at 12:30 a.m., which resulted in Resident 64 missing his morning dose of morphine and another dose was not administered until 1:15 p.m., on 10/12/25. During an interview, on 2/6/26 at 11:35 a.m., the Clinical Support Nurse 3 indicated RN 3 should not have administered pills prepared by another nurse on a previous shift. During an interview, on 2/10/26 at 2:21 p.m., RN 3 indicated she administered the medications the evening shift nurse prepared. The medication should have been destroyed. Medications prepared by another nurse should not be administered and she should not have administered the medications another nurse or QMA had prepared.During an interview, on 2/11/26 at 12:30 p.m., the Clinical Support Nurse 3 indicated the nurses should only administer medication they prepared. A current facility policy, titled Medication Administration - General Guidelines, dated as revised 1/2018 and received from the Clinical Support Nurse 4 on 2/6/26 at 11:35 a.m., indicated .Five Rights - Right resident, right dose, right route and right time, are applied for each medication being administrated.The person who prepares the dose for administration is the person who administers the dose.Medications are administered within 60 minutes of scheduled time, except for, with or after meal orders.In no case should the individual who administered the medication report off=duty without first recording the administration of any medication.If a dose of regularly scheduled medication is withheld, refused.it is documented on MAR or in the EHR. An explanatory note is also entered.3.1-17(a)

Based on observation, interview and record review, the facility failed to ensure enhanced barrier precaution infection control practices were implemented and followed for 1 of 1 resident reviewed for infection control. (Resident 3)Findings include:The clinical record for Resident 3 was reviewed on 2/10/26 at 11:24 a.m. The diagnoses included, but were not limited to, gastrostomy status and irritable bowel syndrome.A care plan, dated 12/12/25, indicated Resident 3 required enhanced barrier precautions (EBP) during high contact care related to the presence of a feeding tube. Interventions included, but were not limited to, utilize a gown and gloves according to the enhanced barrier precautions policy.A physician's order, dated 1/7/26, indicated Resident 3 required enhanced barrier precautions due to the gastrostomy tube.During an observation, on 2/4/26 at 12:22 p.m., no personal protective equipment (PPE) was placed outside or inside Resident 3's room and an enhanced barrier precautions (EBP) sign was not displayed inside or outside Resident 3's room or on the door.During an observation, on 2/4/26 at 12:49 p.m., an EBP sign was taped to the exterior side of Resident 3's door. The Administrator was observed in the hall with a tape dispenser and EBP signs.During an interview, on 2/4/26 at 12:49 p.m., the Administrator indicated he did not tape the EBP sign outside of Resident 3's room, a certified nursing assistant did. He did hang the EBP signs on the other doors and the signs should have been placed on the doors prior. During an observation, on 2/6/25 at 11:43 a.m., RN 5 administered medications through Resident 3's gastrostomy tube with only gloves and no other personal protective equipment.During an interview, on 2/6/26 at 12:47 p.m., the Clinical Support Nurse indicated PPE should be worn for any care provided to a resident with a gastrostomy tube.During an interview, on 2/9/26 at 9:38 a.m., QMA 10 indicated PPE should be worn when administering medications or feeding to someone with a gastrostomy tube.During an interview, on 2/11/26 at 9:50 a.m., RN 5 indicated if a resident had a gastrostomy tube an EBP sign should be displayed at the entrance of the room with PPE close by. When administering medications via gastrostomy tube, hand hygiene should be performed and PPE should be worn. During an interview, on 2/11/26 at 10:54 a.m., the Director of Nursing (DON) indicated staff should wear PPE, as indicated for EBP, when administering medication through a gastrostomy tube.A current facility policy, titled Enhanced Barrier Precautions Standard Operating Procedure, dated as last reviewed 12/3/25 and provided by the Clinical Support on 2/6/26 at 12:47 p.m., indicated .EBP will be in place during high-contact care activities for residents with the following condition.All Residents with indwelling medical devices.feeding tubes.At minimum, staff shall wear gloves and gowns during high-contact care activities.3.1-18(b)(2)

Based on observation, interview and record review, the facility failed to ensure a call light was accessible to a resident while at her bathroom sink for 1 of 1 resident reviewed for call light accessibility. (Resident 4)Findings include:During an interview, on 2/5/26 at 12:30 p.m., Resident 4 indicated she could not reach her call light while she was sitting at the sink in her wheelchair. She indicated the staff positioned her at the sink to finish her personal hygiene and would leave the room. Her right arm was weakened due to a stroke, and the call light was on her right side and out of reach when she sat at the sink. Due to her arm weakness, she could not maneuver her wheelchair away from the sink.The clinical record for Resident 4 was reviewed on 2/6/26 at 11:16 a.m. The diagnoses included, but were not limited to, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, muscle wasting and atrophy, lack of coordination, and weakness.A care plan, dated 10/22/25, indicated Resident 4 was at risk for falling related to weakness, incontinence, and medications. Interventions included, but were not limited to, keeping the call light within reach.During an interview, on 2/6/26 at 10:50 a.m., the Clinical Support Nurse indicated the call light should always be in reach of the residents.During an interview, on 2/6/26 at 10:55 a.m., the Administrator indicated the call light in the bathroom was too short to reach the resident if she was sitting at the sink.During an interview, on 2/10/26 at 3:24 p.m., CNA 2 indicated a resident should not be left alone if they could not reach their call light.A current facility policy, titled Guidelines for Answering Call Lights, dated as last revised 5/11/16 and provided by the Administrator on 2/9/26 at 1:56 a.m., indicated .Ensure the call light is plugged in securely to the outlet and in reach of the resident.After the requested service has been provided.return the call light to within reach of the resident.3.1-19(u)(1)3.1-19(u)(2)

Based on interview and record review, the facility failed to ensure medications were transcribed correctly upon admission for 1 of 2 residents reviewed for significant medication errors. (Resident B)Findings include: During an interview, on 9/29/25 at 12:37 p.m., Resident B's family member indicated, on 8/16/25, she witnessed a staff member attempting to administer her husband medication he had never received before. The staff member called the physician and did not administer the medication. A staff member informed her, on 8/18/25, Resident B had received the wrong medications on 8/15/25, 8/16/25, 8/17/25 and 8/18/25. The Director of Health Services (DHS) informed her the facility was monitoring Resident B for reactions related to receiving the wrong medications. Resident B's family was very upset with the nursing staff and was more distressed to see the same nurses still working and administering Resident B's medications. She had told the administration staff about her concerns, and nothing was done. Resident B was at home now and was doing okay. She wanted the facility to prevent this from occurring to other residents.The clinical record for Resident B was reviewed on 9/29/25 at 2:10 p.m. The diagnoses included, but were not limited to, metabolic encephalopathy, myocardial infarction, non-traumatic subdural hemorrhage, and malignant neoplasm of prostate.A nursing progress note, dated 8/16/25 at 3:57 p.m., indicated Resident B's wife reported the resident had not previously taken tramadol or lorazepam medications prior to his hospitalization. LPN 3 contacted the Nurse Practitioner (NP) regarding the wife's concern, and the NP discontinued the medications for lorazepam and tramadol. A nursing progress note, dated 8/18/25 at 2:57 p.m., indicated a medication error had been discovered on Resident B's medication orders and medication administration record. The family and physician were notified of the errors. Resident B was monitored for adverse reactions. The physician's orders were updated in the matrix.The discharge medication orders from the hospital on 8/15/25 and the admission medication orders placed at the facility on 8/15/25 were reviewed and indicated there were 11 medication orders which were not found on the medication orders from the transferring hospital.The 11 medications included the following:1. Memantine (a medication used to treat Alzheimer's disease) 10 milligrams (mg) tablet twice a day. This medication was administered on 8/15/25, 8/16/25, 8/17/25 and 8/18/25 for a total of six (6) times given in error.2. Mirabegron (a medication used to treat overactive bladder) 50 mg tablet once a day. This medication was administered on 8/16/25, 8/17/25 and 8/18/25 for a total of three (3) times given in error.3. Lorazepam (a medication used to treat anxiety disorders) 1 mg tablet twice a day.4. Lisinopril (a medication used to treat high blood pressure) 20 mg tablet once a day. This medication was administered on 8/16/25, 8/17/25 and 8/18/25 for a total of three (3) times given in error.5. Loperamide (a medication used to treat symptoms of diarrhea) 2 mg one or two capsules every 8 hours as needed. This medication was administered on 8/16/25 for a total of two (2) given in error.6. Pantoprazole (a medication used to treat excessive acid in the stomach) 40 mg tablet once a day. This medication was administered on 8/16/25, 8/17/25 and 8/18/25 for a total of three (3) times given in error.7. Potassium chloride (a supplement used to treat low potassium) 10 milliequivalent (mEq) capsule once a day. This medication was administered on 8/16/25, 8/17/25 and 8/18/25 for a total of three (3) times given in error.8. Tramadol (a medication used to treat pain) 50 mg tablet once a day.9. Trazodone (a medication used to treat depression) 50 mg tablet at bedtime. This medication was administered on 8/15/25, 8/16/25 and 8/17/25 for a total of three (3) times given in error.10. Meclizine (a medication used to control nausea, vomiting, and dizziness) 12.5 mg tablet every 8 hours as needed.11. Senna (a medication used to treat constipation) 8.6 mg tablet as needed at bedtime. During an interview, on 9/29/25 at 12:10 p.m., the Director of Health Services (DHS) indicated LPN 3 transcribed the correct medications for Resident B from the hospital. RN 2 was to review the transcriptions. RN 2 did not review the transcriptions for Resident B and instead entered the admitting medications for Resident C into Resident B's record. The records for Resident B and C were not double checked per the policy and procedure. The admitting records for Resident B and C were reviewed on 8/18/25, and the error was found. Resident C did not have any medication errors. Resident B had 11 entries which were entered incorrectly. Resident B received 23 medications in error on 8/15/25, 8/16/25, 8/17/25 and 8/18/25. Some of the medications entered in error had been discontinued on 8/16/25 after Resident B's wife had reviewed some of the medications with LPN 3. The NP was called and medications were discontinued. A complete review of Resident B's medications was not completed by the NP or LPN 3. A second check was not completed until 8/18/25 and the error was discovered. The physician reviewed Resident B's medications, and the orders were updated. Resident B did receive some medications which he should not have received. Resident B was observed for adverse reactions.During an interview, on 9/30/25 at 2:26 p.m., RN 2 indicated she did not complete the second check for the admission orders for Resident B. She did admit Resident C into the facility and transcribed his orders. She indicated all new admission orders were to be checked by a second nurse per the policy and procedure.A current facility policy, titled PREPARATION AND GENERAL GUIDELINES, dated 11/18 and received from the DHS on 9/30/25 at 2:38 p.m., indicated .FIVE RIGHTS - right resident, right drug, right dose, right route and right time, are applied for each medication being administered.If a dose seems excessive considering the residents age and condition, or a medication order seems to be unrelated to the residents current diagnosis or conditions, the facility personnel calls the provider pharmacy for clarification prior to administration of the medication or if necessary contacts the prescriber for clarification.A current facility policy, titled MEDICATION ORDERS, dated 11/18 and received from the DHS on 9/30/25 at 2:38 p.m., indicated .Medication orders are recapped as required by regulation.This citation relates to Complaint 2619363.3.1-48(c)(2)

Based on interview and record review, the facility failed to ensure a resident with a diagnosis of dementia, who resided in the secured locked unit, was not allowed to leave the facility unsupervised for 1 of 1 resident reviewed for elopement. (Resident B) The deficient practice was corrected on 8/25/25, prior to the start of the survey, and was therefore past noncompliance.Findings include:The clinical record for Resident B was reviewed on 9/8/25 at 2:58 p.m. The diagnoses included, but were not limited to, dementia and Alzheimer's disease.Resident B admitted to the facility on [DATE] at 11:21 a.m.An admission assessment, dated 8/22/25 at 11:24 a.m., indicated Resident B was not exit seeking, had no history of elopement, and ambulated without assistive devices. In a facility documented interview, dated 8/22/25, CNA 5 indicated she heard the door alarm and had directed CNA 2 to check the alarm.In a facility documented interview, dated 8/22/25, CNA 2 indicated she heard the door alarm on 8/22/25 at 6:30 p.m. She identified the location of the alarm. CNA 2 observed Resident B had sounded the alarm to the door. She opened the door with the code and reset the alarm. Resident B indicated he needed to go outside, she reentered the code and allowed the resident to go outside. CNA 2 indicated the resident asked where the [NAME] were located and she directed him toward the [NAME]. She then closed the door and reset the alarm. CNA 2 observed Resident B returning to the facility at 6:55 p.m. and was then aware of what had occurred.In a facility documented interview, dated 8/22/25, CNA 4 indicated around 6:45 p.m., she was riding in a car and recognized Resident B walking on the sidewalk north from the facility. She engaged Resident B in conversation, and she walked the resident back to facility. She indicated CNA 2 thought the resident was a family member and let him outside the facility.A nursing progress note, dated 8/23/25 at 12:38 p.m., indicated Resident B was found by CNA 4. The resident was found in a field area down from the facility before the intersection. Resident B was found at 6:45 p.m. The facility was not aware of Resident B's elopement until they were notified by CNA 4. The door alarm in the memory care unit did alarm when the resident opened the door.During an interview, on 9/8/25 at 12:50 p.m., the Executive Director (ED) indicated Resident B was allowed out of the facility by CNA 2 who thought the resident was a visitor. The resident had been admitted at 11:21 a.m. on 8/22/25 and left the facility at 6:30 p.m. Resident B attempted to leave the facility through the back door of the unit. Resident B had asked CNA 2 for directions to the independent [NAME]. CNA 2 let Resident B out the back door. The resident was found by staff at 6:45 p.m. and escorted back to facility by 6:55 p.m. Resident B was 10 minutes away and 0.5 miles. Resident B was assessed and had no injuries. The staff had been reeducated, CNA was disciplined, and audits were ongoing.During an interview, on 9/8/25 at 4:40 p.m., the Director of Health Service (DOHS) indicated CNA 2 should not have allowed Resident B to exit the facility. All staff have been re-educated on the elopement policy and procedures. Staff were the only ones allowed to leave the facility through a door which was not the front door. The facility had ongoing audits, elopement drills, resident assessments related to elopement and exit seeking behaviors.A current facility policy, titled Guideline of Elopement/ Missing Resident, dated as revised on 12/17/24 and provided by the ED on 9/8/25 at 4:48 p.m., indicated .It is the responsibility of all personnel to report any residents attempting to leave the premises or suspected of being missing to the charge nurse as soon as possible The deficient practice was corrected by 8/25/25, after the facility implemented a plan which included a thorough investigation, door checks, elopement assessments and care plans were updated, all staff members were re-educated on elopement, ongoing elopement drills and audits are being conducted, CNA 2 was suspended and disciplined.This citation relates to Intake 2598553.3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure a resident was treated with respect and dignity by a staff member during meal service for 1 of 1 resident reviewed for dignity. (Resident 26) Findings include: During an observation, on 1/30/25 at 12:10 p.m., Resident 26 was sitting in his wheelchair in the dining room. Certified Nursing Assistant (CNA) 9 was standing on Resident 26's left side as she assisted him with feeding. CNA 9 remained standing for the entirety of the meal. The clinical record for Resident 26 was reviewed on 2/4/25 at 10:27 a.m. The diagnoses included, but were not limited to, Alzheimer's, hypertensive, anxiety disorder, tachycardia, dementia, and acute kidney failure. A care plan, dated 12/27/24, indicated the resident had experienced significant weight loss. The interventions included, but were not limited to, offer the resident encouragement and assistance with eating and report difficulties swallowing. During an interview, on 1/30/25 at 12:19 p.m., CNA 2 indicated she would sometime stand up and walk around feeding multiple residents if the room was full. CNA 2 indicated staff should not stand when feeding residents. During an interview, on 2/4/25 at 8:50 a.m., CNA 9 indicated she was not supposed to stand up while feeding the resident. She indicated standing up while feeding a resident could make the resident feel intimated. A facility document, titled Resident Rights, indicated .examples of treating residents with dignity and respect include .promoting resident independence and dignity while dining, such as avoiding .staff standing over residents while assisting them to eat A current facility policy, titled Resident Rights Guidelines, dated 12/31/23 and received at the entrance conference, indicated .To ensure resident rights are respected and protected and provide an environment in which they can be exercised .Our residents have a right to .be treated with dignity and respect . A current facility procedure, titled FEEDING, undated and received from the Executive Director (ED) on 2/4/25 at 10:34 a.m., indicated .confirm dietary card/tray .explain procedure .have resident wash hands .sit on unaffected side eye level with resident and facing them .make conversation with the resident; atmosphere should be pleasant 3.1-3(t)

Based on interview and record review, the facility failed to promptly implement a do not resuscitate (DNR) order based on a resident's signed advance directive wishes for 2 of 3 residents reviewed for advance directives. (Resident 152 and 160) Findings include: 1. The clinical record for Resident 152 was reviewed on 2/4/25 at 2:31 p.m. The diagnoses included, but were not limited to, cerebral infarction, metabolic encephalopathy, Alzheimer's disease, pneumonia, atrial fibrillation, hypertensive heart and chronic kidney disease with heart failure, and chronic diastolic (congestive) heart failure. An Indiana advance directive form, signed on 1/13/25, indicated the resident wished to not have life prolonging measures. An Indiana Physician Orders for Scope of Treatment (POST) form, signed on 1/13/25, indicated the resident chose to be a DNR. A physician's order, dated 1/23/25 at 2:32 p.m., indicated full code status. A State of Indiana Out of Hospital Do Not Resuscitate Declaration and Order form, signed on 1/23/25, indicated the resident was to be a DNR upon admission to the facility on [DATE]. A physician's order, dated 1/24/25, indicated DNR code status. During an interview, on 2/5/25 at 10:40 a.m., the Legacy Director indicated the facility met with the resident and their representative at admission and discussed their desired code status. Then they make sure the paperwork was signed, scan the forms into the electronic medical record, and put the order in the computer for the chosen code status. As the facility prepared for a new admission, sometimes they would already have advance directive information and would only need to review the choices to make sure those are the current wants. The current code status was listed on the face sheet and at the top of the resident's information bar in the electronic medical record based on the physician's order so staff could quickly see the information during an emergency. 2. The clinical record for Resident 160 was reviewed on 2/3/25 at 12:57 p.m. The diagnoses included, but were not limited to, fracture of neck of right femur, fracture of the lower end of the right radius, metabolic encephalopathy, sepsis, bilateral acute embolism and thrombosis of tibial vein, chronic myeloproliferative disease, and lumbar spinal stenosis. A physician's order, dated 1/7/25, indicated the resident was a full code. A State of Indiana Out of Hospital Do Not Resuscitate Declaration and Order, dated and signed on 1/9/25, indicated the resident wanted a DNR code status. A social service progress note, dated 1/9/25 at 11:59 a.m., indicated the desired advance directive was reviewed with the resident and her family during the admission care plan meeting. A current care plan, dated 1/13/25, indicated the resident had chosen an advance directive of DNR. A physician's order, dated 1/17/25, indicated the resident's code status was DNR. During an interview, on 2/5/25 at 11:07 a.m., QMA 3 indicated during an emergency she would know the resident's code status by looking at the top of the resident information section in the electronic medical record or the resident's information sheet. A current facility policy, titled Guidelines for Advanced Directives, dated 9/26/24 and received from the Clinical Support Nurse on 2/4/25 at 9:00 a.m., indicated .Advanced Directives will be reviewed with resident and/or resident representative .at time of admission The resident or representative will advise .regarding wishes for end of life directives and code status .The nursing staff will obtain an order from the attending physician for the desired code status 3.1-4(f)(5)

Based on interview and record review, the facility failed to ensure a revised Preadmission Screen and Resident Review (PASARR) level I was submitted to reflect a resident's current diagnoses and medications for 1 of 2 residents reviewed for PASARR. (Resident 32) Findings include: The clinical record for Resident 32 was reviewed on 2/4/25 at 11:05 a.m. The diagnoses included, but were not limited to, anxiety, depression, and adjustment disorder with mixed anxiety and depressed mood. A PASARR level I, dated 1/7/25, indicated no mental health diagnoses were known, or suspected and no mental health medications were being prescribed. A physician's order, dated 1/6/25, indicated to give trazodone (an antidepressant medication) 50 milligram (mg) daily. A physician's order, dated 1/7/25, indicated to give sertraline (an antidepressant medication) 25 mg daily. A physician's order, dated 1/7/25, indicated to give buspirone (an anxiety medication) 5 mg daily. There was no PASARR level I completed to reflect the resident's orders for sertraline, trazodone, and buspirone and the resident's mental health diagnoses. During an interview, on 2/5/25 at 2:27 p.m., the Social Service Director (SSD) indicated a new level I PASARR was not completed to reflect the diagnoses and medications, and no mental health diagnoses or medications were included on the PASARR, dated 1/7/25, and submitted by the facility admissions coordinator. A current facility policy, titled PASRR Level 1 and 2 General Quick Reference Guide, undated and received from the Director of Nursing (DON) on 2/5/25 at 3:08 p.m., indicated .Below are items that can/will trigger a Level II PASRR .Individual has a severe mental illness .diagnosis ex .Major Depression Disorder, Anxiety Disorder .individual has a Psych DX and/or Psych Rx regiment from a MD 3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

Based on interview and record review, the facility failed to ensure medications were held according to the physician's ordered parameters for 1 of 5 residents reviewed for unnecessary medications. (Resident 4) Findings include: The clinical record for Resident 4 was reviewed on 2/4/25 at 10:31 a.m. The diagnoses included, but were not limited to, essential primary hypertension, hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, and type 2 diabetes mellitus. A physician's order, dated 4/11/23, indicated to give lisinopril (a blood pressure medication) 20 milligrams (mg) daily with special instructions to hold the medication for a systolic blood pressure less than 110. A Medication Administration Record (MAR), dated 7/1/24 through 7/31/24, indicated lisinopril was administered on 7/7/24 with a systolic blood pressure of 105 and on 7/14/24 with a systolic blood pressure of 102. A MAR, dated 8/1/24 through 8/31/24, indicated lisinopril was administered on 8/15/24 with a systolic blood pressure of 102 and on 8/26/24 with a systolic blood pressure of 103. A MAR, dated 9/1/24 through 9/30/24, indicated lisinopril was administered on 9/11/24 with a systolic blood pressure of 99. A MAR, dated 10/1/24 through 10/31/24, indicated lisinopril was administrated on 10/8/24 with a systolic blood pressure of 97. A care plan, dated 1/28/25, indicated Resident 4 had CKD (chronic kidney disease) with an intervention to administer medications as ordered. During an interview, on 2/4/25 at 2:38 p.m., an anonymous nurse indicated if a resident's blood pressure was outside of a hold parameter, the medication should be held. When a medication was held, there would be parenthesis on the MAR indicating a medication was held. A current facility policy, titled Preparation and General Guidelines IIA2: Medication Administration- General Guidelines, dated 11/18 and received from the Director of Nursing (DON) on 2/4/25 at 10:50 a.m., indicated .Medications are administered as prescribed A current facility policy, titled Specific Medication Administration Procedures IIB2: Oral Medication Administration, dated 11/18 and received from the Clinical Support nurse on 2/4/25 at 11:48 a.m., indicated .Review and confirm medication orders for each individual resident on the Medication Administration Record PRIOR to administering medications .Review medication administration record for any tests or vitals that need to be determined prior to preparing the medication 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure a physician's order was obtained for the administration of oxygen for 2 of 4 residents reviewed for respiratory care. (Resident 150 and 156) Findings include: 1. During an observation, on 1/30/25 at 10:20 a.m., the resident was sitting in the chair in his room wearing 2 liters of oxygen via nasal cannula. He indicated he had been wearing oxygen yesterday and all during the night. The clinical record for Resident 150 was reviewed on 1/31/25 at 2:30 p.m. The diagnoses included, but were not limited to, pulmonary fibrosis, metabolic encephalopathy, chronic obstructive pulmonary disease, atelectasis, hypertensive heart and chronic kidney disease with heart failure, pulmonary hypertension, atrial fibrillation, and peripheral vascular disease. A vital signs report, dated 1/27/25 through 1/31/25, indicated the resident was on 1.5 liters of oxygen on 1/30/25 at 2:51 a.m. and on 2 liters of oxygen at 8:49 a.m. A current care plan, dated 1/28/25, indicated the resident had shortness of breath related to pulmonary fibrosis and to administer oxygen per the physician's order. A nursing progress note, dated 1/29/25 at 9:49 p.m., indicated the resident used oxygen at night at the hospital prior to his arrival at the facility. A nursing progress note, dated 1/30/25 at 9:03 a.m., indicated the resident was on 2 liters of oxygen via nasal cannula. An Interdisciplinary Team (IDT) progress note, dated 1/30/25 at 5:10 p.m., indicated the hospital reported the resident used oxygen at night. A physician's order, dated 1/30/25 at 5:13 p.m., indicated to administer oxygen at 2 liters per minute per nasal cannula as needed to keep sats >92%. During an interview, on 2/3/25 at 9:53 a.m., the Clinical Support Nurse indicated the resident did not have an order for oxygen administration prior to 1/30/25. 2. The clinical record for Resident 156 was reviewed on 1/31/25 at 2:27 p.m. The diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, facial weakness, type 2 diabetes mellitus, hypertensive heart and chronic kidney disease with heart failure, acute systolic congestive heart failure, chronic kidney disease, non-ST elevation myocardial (NSTEMI), and asthma. A nursing progress note, dated 1/25/25 at 2:23 a.m., indicated the resident was placed on oxygen at 2 liters per nasal cannula for O2 saturations of 88%. A nursing progress note, dated 1/25/25 at 11:30 p.m., indicated the resident's oxygen was increased to 3 liters per nasal cannula. An IDT Respiratory/Emesis/SOB event note, dated 1/27/25 at 11:40 a.m., indicated the nurse practitioner was notified of the resident's signs and symptoms and multiple orders were received which did not include an order for oxygen administration. A nursing progress note, dated 1/27/25 at 11:05 p.m., indicated the resident was on oxygen. A nursing progress note, dated 1/28/25 at 10:31 p.m., indicated the resident was on oxygen. A physician's order, dated 1/29/25, indicated to administer oxygen at 1-5 liters per minute per nasal cannula to keep O2 saturation about 92%. During an interview, on 2/3/25 at 9:53 a.m., the Clinical Support Nurse indicated the resident did not have an order for oxygen administration prior to 1/29/25. During an interview, on 2/5/25 at 2:43 p.m., RN 2 indicated if a resident needed oxygen due to low saturations, she would call the physician to let him know and get an order for oxygen. A current facility policy, titled Administration of Oxygen, dated 12/13/24 and provided by the Clinical Support Nurse on 2/4/25 at 9:00 a.m., indicated .Verify physician's order for the procedure. 2. In cases of emergency oxygen may be administered as a nursing intervention until a physician order may be obtained 3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure an order to give Augmentin 500 milligrams (mg) was discontinued when a new order to give Augmentin 875 mg was received which resulted in double doses of the antibiotic for pneumonia for 1 of 2 residents reviewed for antibiotics. (Resident 156) Findings include: During an interview, on 1/31/25 at 10:32 a.m., the resident indicated she had been sick and coughing with pneumonia. The clinical record for Resident 156 was reviewed on 1/31/25 at 2:27 p.m. The diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, facial weakness, type 2 diabetes mellitus with hyperglycemia, hypertensive heart and chronic kidney disease with heart failure, congestive heart failure, non-ST elevation myocardial (NSTEMI), and asthma. A lab report, dated 1/21/25, indicated the resident's GFR (glomerular filtration rate: a blood test to measure kidney function) was low at 24. The normal range was greater than 60. A physician's order, dated 1/24/25, indicated to give Augmentin (amoxicillin and clavulanate potassium) 500-125 milligram (mg) tablet every 12 hours with a stop date of 2/2/25. A physician's order, dated 1/27/25, indicated to give Augmentin 875-125 mg tablet every 12 hours with a stop date of 2/2/25. A Medication Administration Record (MAR), dated 1/27/25 through 2/3/25, indicated the resident received the generic form of Augmentin 875-125 mg at 7:00 a.m. and 7:00 p.m. and the generic form of Augmentin 500-125 mg at 9:00 a.m. and 9:00 p.m. until 2/2/25. During an interview, on 2/4/25 at 3:45 p.m., the Assistant Director of Nursing/Infection Preventionist indicated she was aware the resident was ordered a second dosing of the same antibiotic for pneumonia but had not verified the first dose had been discontinued. During an interview, on 2/5/25 at 2:44 p.m., Pharmacist 4 indicated when the pharmacy received a new order the pharmacist looked for duplicates and would cancel the previous order in their system. The facility usually sent a discontinue order for the duplicate with the new order, but he did not see one for the Augmentin. The pharmacy system did not flow over to the facility's MAR, so both doses would remain on the facility's MAR if the facility did not discontinue the order for the first dose. Residents with impaired kidney function needed a lower dose of Augmentin. He thought the 500 mg dose would have been okay for the resident but not the 875 mg. She should not receive both doses with her GFR of 24. During an interview, on 2/5/25 at 3:59 p.m., LPN 5 indicated if she would see a duplicate medication on the MAR with different doses, she would check the doctor's orders and the progress notes to see what she should give. If she still was not sure, she would call the pharmacy number and get in touch with a pharmacist who could help her determine what to do. LPN 5 had not given the resident medications during the double dosing period. A Medication Error Event progress note, dated 2/4/25 at 4:34 p.m., indicated a medication error occurred on 1/27/25 at 12:51 p.m. of a duplicate order resulting in the resident receiving Augmentin 875-125 mg every 12 hours and Augmentin 500-125 mg every 12 hours. FDA DOSAGE AND ADMINISTRATION: HIGHLIGHTS OF PRESCRIBING INFORMATION. Augmentin (amoxicillin and clavulanate potassium), https://www.accessdata.fda.gov. Accessed 4 February 2025. indicated The usual adult dose is one 500-mg tablet of AUGMENTIN every 12 hours or one 250-mg tablet of AUGMENTIN every 8 hours. For more severe infections and infections of the respiratory tract, the dose should be one 875-mg tablet of AUGMENTIN every 12 hours or one 500-mg tablet of AUGMENTIN every 8 hours .Patients with impaired renal function .Severely impaired patients with a glomerular filtration rate of <30 mL/min. should not receive the 875-mg tablet. Patients with a glomerular filtration rate of 10 to 30 mL/min. should receive 500 mg or 250 mg every 12 hours, depending on the severity of the infection 3.1-48(a)(1)

Based on observation, interview and record review, the facility failed to ensure compromised controlled substance medications were disposed of and unopened insulin was stored in the refrigerator for 2 of 2 medication carts (200 hall and 300 hall) and to ensure supplies were not stored under the sink in a medication room for 1 of 2 medication rooms reviewed for medication storage. (the 200-medication room) Findings include: 1. During an observation, on [DATE] at 1:18 p.m., the 200-hall medication cart had a compromised controlled substance card of lorazepam (for anxiety) 0.5 milligrams (mg) for Resident 26 with the 8 and 16 slots taped on the back of the card. The clinical record for Resident 26 was reviewed on [DATE] at 10:27 a.m. The diagnoses included, but were not limited to, Alzheimer's, hypertensive, anxiety disorder, tachycardia, dementia, and acute kidney failure. The medication card indicated the lorazepam 0.5 mg tablets had expired on [DATE]. There was no current order for the lorazepam 0.5 mg tablets in the Electronic Health Record (EHR). During an interview, on [DATE] at 1:20 p.m., Licensed Practical Nurse (LPN) 10 indicated when she started the shift, she counted the narcotics with the nurse and did not notice the tape on the back of the card. The two pills would need to be destroyed by two nurses. During an interview, on [DATE] at 1:23 p.m., the Assistant Director of Nursing (ADON) indicated the medication card should not have tape on the back of the card. The pills needed to be destroyed by two nurses. 2. During an observation, on [DATE] at 1:36 p.m., the 300-hall medication cart had a plastic bag with an unopened Humalog 100 unit/milliliter (ml) insulin pen for Resident 250. The bag had a sticker with instructions to keep the insulin in the refrigerator until it was opened. The clinical record for Resident 250 was reviewed on [DATE] at 3:40 p.m. The diagnoses included, but were not limited to, diabetes mellitus, atrial fibrillation, acute kidney failure, congestive heart failure, and anxiety disorder. A physician's order, dated [DATE], indicated to inject Humalog 100 unit/ml insulin subcutaneous before meals and to use according to the sliding scale. During an interview, on [DATE] at 1:41 p.m., LPN 11 indicated the package containing the insulin pen had instructions to keep the pen refrigerated until it was opened. During an interview, on [DATE] at 2:05 p.m., the Director of Nursing (DON) indicated an unopened insulin pen should be stored in the refrigerator until it was needed. The insulin pen should be destroyed and not put back in the refrigerator. 3. During an observation, on [DATE] at 1:25 p.m., the 200-medication room had two sleeves of drinking cups stored under the sink. During an interview, on [DATE] at 1:30 p.m., the Assistant Director of Nursing (ADON) indicated nothing should be stored under the sink in the medication room and the cups needed to be destroyed. A current policy, titled Guidelines for Disposal of Controlled Drugs, dated as revised [DATE] and received by the DON on [DATE] at 2:10 p.m., indicated .To ensure controlled substances are destroyed in accordance with State Laws and Federal Regulations .Immediately upon discontinuation, but no longer than three (3) business days after discontinuation of a patient's-controlled substance medication .The same two nurses - and DHS or DON .who removed the controlled substance medication from the medication cart shall transfer the medication to the Med Safe collection receptacle for disposal A current policy, titled Medication Storage in the Facility, dated as revised ,d+[DATE] and received by the DON on [DATE] at 2:10 p.m., indicated .Outdated, contaminated, or deteriorated medication and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal .Expiration dates (beyond-use date) of dispensed medication shall be determined by the pharmacist at the time of dispensing .When the beyond-use dating for a medication identifies a month and year, the medication can be used through the last day of the month .Blister-pack cards .12 months from the date of dispensing .The medication administration personnel will check the expiration date of each medication before administrating it .Disposal of any medications prior to the expiration dating will be required if contamination or decomposition is apparent 3XXX,d+[DATE](m) 3XXX,d+[DATE](o)

Based on observation, interview and record review, the facility failed to accurately initiate the correct diet orders upon admission and to provide a lunch tray in the correct consistency for 2 of 6 residents reviewed for dining. (Resident 151 and 156). Findings include: 1. During an observation, on 1/30/25 at 11:43 a.m., Resident 151 was sitting at a table in the dining room waiting for her lunch. The Administrator entered the dining room carrying the resident's plate and placed it in front of the resident with the chicken tenders facing her. The meal ticket indicated to serve a regular consistency diet, and the plate had 2 large whole chicken tenders, fries, and a piece of blueberry pie with regular crust. The resident grabbed a fry and began eating it. CNA 2 was assisting the resident with getting her fork when the cook brought out another piece of pie. The Speech Therapist looked over and told them Resident 151 was on a mechanical soft diet. The cook took the extra piece of pie with him and exited the dining room. The Speech Therapist indicated the fries were considered a mechanical soft food, but the chicken tenders and pie were not. CNA 2 stood up and turned the plate around so that the fries were in front of the resident and left the resident with the chicken fingers and pie while the CNA went out of the room. The Speech Therapist continued to assist another resident with eating. CNA 2 returned to the speech therapist and told her the kitchen was preparing another plate. The cook brought in a mechanical soft meal and exchanged the plates. He also took the white regular meal ticket and replaced it with a blue mechanical soft ticket. The new plate had cottage cheese, fries, and mechanical soft chicken pot pie covered with brown gravy. The resident started dipping her fry into her cottage cheese and cleared her throat with a soft cough. After a drink and eating a bite of cottage cheese without difficulty, she cleared her throat with a cough after another bite of the fry. The clinical record for Resident 151 was reviewed on 2/3/25 at 2:07 p.m. The diagnoses included, but were not limited to, cerebrovascular accident (CVA), altered mental status, Alzheimer's dementia, hypertension, and dysphagia. A hospital speech therapy note, dated 1/24/25, indicated the recommended diet was minced and moist with 1:1 feeding assistance to implement safe swallow strategies which included to alternate bites of food with drinks, add moisture to foods, and to clear pocketing. A hospital discharge summary, dated 1/27/25, indicated a discharge diet of Level 5 Minced and Moist. A facility nurse's progress note, dated 1/27/25 at 8:00 p.m., indicated the resident was noted to pocket food on a minced diet. A physician's order, dated 1/27/25 and discontinued 1/28/25 at 10:08 a.m., indicated a regular consistency diet. A facility speech therapy note, dated 1/28/25 at 3:09 p.m., indicated to continue the hospital discharge diet with supervision and assistance. To have Resident 151 take small bites and sips, eat slowly, alternate liquids and solids, use a lingual sweep and then provide oral care after meals due to pocketing. A safe feeding technique form was provided at the nursing station and education to the floor nurse was provided. A current care plan, dated 1/28/25, indicated a regular diet and to provide a diet as ordered. A physician's order, dated 1/28/25 and discontinued on 1/29/25 at 8:33 p.m., indicated a mechanical soft consistency diet. A physician's order, dated 1/29/25, indicated to give a mechanical soft diet with pureed meat. During an interview, on 2/5/25 at 10:40 a.m., the Legacy Neighborhood Director indicated they used the hospital discharge orders as the facility admission orders. During an interview, on 2/5/25 at 11:02 a.m., the Director of Dining Services indicated the kitchen's ticket system relied on the diet order placed in the electronic medical record transferring over into their system. The diet tickets for each resident were already printed for lunch, so if the diet had changed close to a mealtime, the staff would need to come let the kitchen know. During an interview, on 2/5/25 at 11:07 a.m., QMA 3 indicated diet modifications and any cueing or swallowing assistance needed by residents were easy to find and on the resident's profile sheet. During an interview, on 2/5/25 at 2:55 p.m., the Speech Therapist indicated she would initially use the hospital discharge summary and speech therapy notes to recommend the diet. She did not change a resident's diet from the hospital's recommendation until she had watched Resident 151 over several days and mealtimes and talked to the staff and family. A current Diet Order Formulary and Translation Guide, dated 2/24 and provided by the Administrator on 2/4/25 at 12:15 p.m., indicated the Mechanical Soft with Pureed meats should be ordered in place of Level 5 Minced and Moist from the hospital. 2. During an observation, on 1/31/25 at 9:08 a.m., Resident 156 was in her room coughing up sputum with 2 liters of oxygen administered via nasal cannula. She indicated she had been sick and coughing for a few days with pneumonia. The clinical record for Resident 156 was reviewed on 1/31/25 at 2:27 p.m. The diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, facial weakness, type 2 diabetes mellitus, hypertensive heart and chronic kidney disease with heart failure, acute systolic congestive heart failure, chronic kidney disease, non-ST elevation myocardial (NSTEMI), and asthma. A hospital after visit summary, dated 1/4/25, indicated a discharge diet order of Level 6 Soft and Bite-Sized consistency. A physician's order, dated 1/4/25, indicated to give a regular consistency diet. A dietitian note, dated 1/8/25 at 9:44 p.m., indicated the Resident 156 was on a regular consistency diet. A speech therapist note, dated 1/10/25 at 4:38 p.m., indicated she attempted to evaluate the resident but was unable to evaluate her due to the resident vomiting. A physician's order, dated 1/14/25, indicated a diet of regular consistency was ordered. A nursing progress note, dated 1/24/25 at 12:30 p.m., indicated the resident had a productive cough and the nurse practitioner was concerned about aspiration due to the resident reported coughing with meals and pneumonia. A speech therapist note, dated 1/24/25 at 3:16 p.m., indicated nursing had reported the resident had pneumonia, and the nurse practitioner would like the resident evaluated for possible aspiration. During an interview, on 2/4/25 at 2:03 p.m., the Clinical Support Nurse indicated the facility did not see the Soft and Bite-sized diet consistency order on the hospital discharge orders, so they ordered a regular diet. A current Diet Order Formulary and Translation Guide, dated 2/24 and provided by the Administrator on 2/4/25 at 12:15 p.m., indicated the Mechanical Soft should be ordered in place of Level 6 Soft and Bite-Sized from the hospital. 3.1-21(a)(3) 3.1-21(b)

Based on interview and record review, the facility failed to hold insulin according to the physician ordered parameters for 1 of 1 resident reviewed for insulin administration. (Resident 29) Resident 29 had hypoglycemia which resulted in an emergency room visit and hospitalization . Finding includes: During an interview, on 12/14/23 at 10:36 a.m., RN 6 indicated Resident 29 became unresponsive, on 12/13/23 at 9:00 p.m., and was sent to the emergency room . The resident had a blood sugar of 18 (mg) milligram/(dL)deciliter (a normal fasting blood sugar level was between 70 mg/dL and 100 mg/dL). The record for Resident 29 was reviewed on 12/18/23 at 4:13 p.m. Diagnoses included, but were not limited to, diabetes mellitus, congestive heart failure, chronic obstructive pulmonary disease, and hypertension. A care plan, dated 11/12/21, indicated the resident had a risk for hypoglycemia and hyperglycemia related to diabetes mellitus. The interventions included, but were not limited to, give medication per orders, monitor blood sugars per physician orders, and to observe for hypoglycemia such as sweating, cold, clammy skin, numbness of the fingers, toes, mouth, rapid heartbeat, tremors, and dizziness. A current physician's order, dated 9/21/22, indicated to give Novolog (a fast-acting insulin) 100 unit/ml subcutaneous (SQ). Give insulin before meals and at bedtime per the following sliding scale: a. If blood sugar was 141 to 150, give 2 units. b. If blood sugar was 151 to 200, give 3 units. c. If blood sugar was 201 to 250, give 5 units. d. If blood sugar was 251 to 300, give 9 units. e. If blood sugar was 301 to 350, give 11 units. f. If blood sugar was 351 to 400, give 13 units. g. If blood sugar was 401 to 450, give 15 units. h. If blood sugar was greater than 450, call MD. A current physician's order, dated 11/18/23, indicated Novolog 100 unit/ml, give 6 units SQ before meals and at bedtime. If the blood glucose was less than 201 hold the insulin. A Medication Administration Record (MAR) indicated the blood sugar level on 12/13/23 at 7:12 p.m., was 197. The resident received 6 units of Novolog. The resident should not have received the insulin, on 12/13/23 since the blood glucose was less than 201. A progress note, dated 12/13/2023 at 9:11 p.m., indicated the resident was found unresponsive to verbal and physical stimuli, eyes glazed, very sweaty, and coarse lung sounds with auditory gurgle. The resident was sent to the emergency department for evaluation and treatment. A hospital document, dated 12/13/23 at 9:34 p.m., indicated the resident presented to the emergency room from the facility and was unresponsive and diaphoretic. The resident's glucose level was less than 20 per emergency physician on call. A hospital document, dated 12/14/23 at 12:52 a.m., indicated the resident had symptomatic hypoglycemia with a history of diabetes mellitus. The emergency blood sugar level was 18. The resident was started on dextrose (used to provide extra water and carbohydrates), intravenous (IV) fluids, and the insulin would be on hold. The resident received an additional or inaccurate insulin dose at the facility. During an interview, on 12/19/23 at 10:45 a.m., the Clinical Support Nurse indicated the resident was sent to the ER for evaluation and treatment. RN 7 found the resident unresponsive. The resident received dextrose in the ER and her blood sugar level did not go up. They started the resident on IV dextrose and when she got to the hospital her blood glucose level was 18. During an interview, on 12/20/23 at 3:11p.m., RN 7 indicated a Certified Resident Care Assistant (CRCA) came to her and said the resident did not look right. When RN 7 entered the resident's room, she was unresponsive. The resident was sweaty, and her lungs sounded course. RN 7 was not sure when she gave insulin to the resident or what time the resident was sent to the hospital. During an interview, on 12/20/23 at 10:54 a.m., the Clinical Support Nurse indicated the resident was given 6 units of insulin when the blood sugar level was 197 at 7:10 p.m. The resident had a hold order for a blood sugar level of less than 201. The nurse gave the 6 units of Novolog with the 3 units. The resident became unresponsive and was sent out to the ER. A current policy, titled Guidelines for Medication Error Reporting, dated as revised 5/10/2017 and received by the Clinical Support Nurse on 12/20/23 at 5:15 p.m., indicated .To identify medications given in error and expedite correction actions .In the event of a medication error, nursing personnel should first take whatever immediate action is necessary to protect the resident's safety and welfare. Notify the attending physician promptly of the error. Implement physician's orders. Notify the resident or responsible party. Initiate the appropriate Event form. Monitor the resident closely for 72 hours or as directed. Document the following in the resident's clinical record: A description of the error (brief). Name of physician and time notified. Physician's subsequent orders. Medication errors will be reviewed by the Quality Assurance Committee to identify trends and/or actions for implementations A current policy, titled Guidelines for Medication Orders, dated as reviewed on 12/31/2022 and received by the Clinical Support Nurse on 12/20/23 at 12:00 p.m., indicated .Each resident shall be under the care of a licensed physician authorized to practice medicine in the state where care is provided and shall be seen by the physician in accordance with regulations and as resident condition warrants A document, titled Understanding Your Daily Insulin Needs, https://www.healthline.com/health/how-much-insulin-to-take-chart, dated May 10, 2023, indicated .Calculating how much insulin to take is usually based on two considerations: Basal insulin dose. A basal insulin dose is an amount that you give yourself daily regardless of the foods you eat. Bolus insulin dose. A bolus insulin dose helps correct or anticipate the carbohydrates you eat throughout the day. You will usually correct this with a bolus dose of rapid-acting insulin .you are estimating how many units of insulin it will take to process the carbohydrates you eat .as a general rule, 1 unit of rapid-acting insulin will process anywhere from 12 to 15 grams of carbohydrates .1 unit of insulin lowers your blood sugar by about 50 milligrams per deciliter (mg/dL) .not all people will process insulin the same way .Insulin has a narrow therapeutic index, which means there is a fine line between a beneficial dose and a harmful one. It's possible to overdose on insulin .Another factor to keep in mind is the 1:50 correction ratio. In general, correcting high blood sugar by 50 mg/dL uses 1 unit of insulin .This correction ratio - also known as the insulin sensitivity factor - can vary for different people or in different situations 3.1-48(c)(2)

Based on interview and record review, the facility failed to access and document a skin condition after a resident received a laceration to her left calf while being transferred from her wheelchair to her bed resulting in a trip to the emergency room where she received 31 stitches and subsequently developed a complicated skin infection 25 days later for 1 of 1 resident reviewed for non-pressure skin conditions. (Resident 17) Finding includes: The record for Resident 17 was reviewed on 10/04/22 at 11:05 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Incident Report, dated 09/01/2022 at 8:51 p.m., indicated Resident 17 was being assisted to bed from her wheelchair and received a laceration to her left lower extremity. On 09/02/22, the facility Nurse Practitioner gave an order to send the resident to the emergency room for evaluation and treatment. A Nurse Practitioner note, dated 09/02/22 at 9:19 a.m., indicated Resident 17 was being seen for a laceration to her left leg and evaluation of the wound. The area measured approximately 6 to 7 inches long and was draining heavy amounts of watery bloody fluid. The staff reported the laceration was deep and fat tissue could be seen at the inner most layer of skin in the body. Her left lower extremity was swollen and purple from bruising. It was very tender to touch. Due to the nature of the injury, the resident was sent out to the hospital for sutures. The initial assessment documentation from the hospital, dated 09/02/22 at 11:30 a.m., indicated the resident had a laceration to her left leg measuring approximately 10 cm (centimeters) in the shape of a C. Discharge instructions from the hospital, dated 09/02/22 at 12:32 p.m., indicated most skin wounds heal within ten days. To keep the wound clean, remove the dressing, wash the area with soap and water, and apply a thin layer of antibiotic ointment. However, even with proper treatment, a wound infection may sometime occur. Therefore, the wound should be assessed daily for signs of infection and the stitches should be removed within 7 to 14 days. There was not a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was also not a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] There was not a care plan with interventions related to the laceration she received on 09/01/22. From 09/02/22 through 09/26/22, the below progress notes were the only documentation related to the assessment of the resident's laceration to her left lower extremity. On 09/02/22 at 2:21 p.m., the resident returned from the emergency room with sutures and a bandage to her left lower extremity. On 09/02/22 at 9:30 p.m., the area was assessed to her left lower extremity and 31 sutures were observed. On 09/05/22, the sutures were intact with no signs or symptoms of infection. On 09/06/22, the dressing to her left lower extremity was clean, dry, and intact. The dressing was changed. On 09/20/22, the dressing to her left lower extremity was changed and the wound had watery bloody drainage and the sutures were intact. On 09/26/22 at 1:11 p.m., the Nurse Practitioner documented the reason the resident was being seen was for her leg wound. She indicated the wound was examined and found to be swollen with marked redness. There was a foul smelling pus drainage noted. Her sutures were still in place and the edges of the entire wound was covered with this drainage. The wound was starting to come apart where sutured and the majority of the laceration was open. The thirty-one sutures were removed from the resident's left lower extremity. The area was swollen, red and warm, there was a foul odor coming from the wound and the area was painful to touch. Almost the entire laceration had signs and symptoms of infection. She indicated the wound infection was intense and complex. On 09/26/22 at 3:22 p.m., the IDT (interdisciplinary team) indicated the resident's sutures were removed that day by the nurse practitioner. A current care plan, dated 09/26/22, indicated the resident had an infection to a skin tear to her left lower extremity. A current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview, on 10/5/22 at 3:19 p.m., the Director of Nursing indicated the resident's discharge instructions from the hospital was considered an order and should have been documented as an order in the resident's chart. The skin tear should have been cleaned and assessed daily and documented with a description and measurements weekly. The sutures should have also been removed within 7 to 14 days prior to 09/26/22. A current policy, titled Pressure/Stasis/Arterial/Diabetic Wound Guidelines, dated as revised 12/01/2021 and provided by the Director Of Nursing on 10/05/22 at 5:00 p.m., indicated .Purpose: To provide weekly documentation of wound measurements and condition .Re-assessment/measurement weekly or with significant change in wound noting the current treatment, medical interventions provided, and comments as needed 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure an elopement of a resident from the secured dementia unit did not occur for 1 of 1 resident reviewed for elopement. The resident, who resided on the locked unit with a [DIAGNOSES REDACTED]. The facility staff was not aware the resident was let out or was missing off the unit. The resident had ambulated across the 4 lane moderately busy street, to the field, by the hospital. The resident was outside the facility for 30 minutes (Resident B). The Immediate Jeopardy began on (MONTH) 8, 2019, when the facility failed to ensure Resident B who resided on the Memory Care secured locked unit with a [DIAGNOSES REDACTED]. The Plant Operations Assistant was outside, in front of the facility, when he observed a gentleman ambulating in front of the facility, in the grassy part of the yard, by where the cars parked, which raised a concern to him because he thought this gentleman looked familiar. He went around the facility, through the service door, into the facility to ask the staff if Resident B was missing. After a head count and room search of the Memory Care unit was completed, it was discovered Resident B was missing. By the time the Plant Operations Assistant went to attempt to locate the resident again, he had left the facility property. Resident B ambulated without his walker across the four lane moderately busy street (Name of Street), down the side street (Name of street) approximately 0.5 miles to the grassy field across from the side of the hospital. The temperature between 12:00 p.m. and 6:00 p.m., for 11/8/19 was a high temperature between 43 F (Fahrenheit) and 39 F. The Assistant Vice President of Clinical Support, Executive Director (ED), Director of Health Services (DHS) and Clinical Support were notified of the Immediate Jeopardy on 11/25/19 at 5:51 p.m. The Immediate Jeopardy was removed on 11/26/19, but noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy. Finding includes: During an interview, on 11/25/19 at 2:08 p.m., the ED and the DHS were in attendance. The ED indicated a video was viewed by himself, the DHS and the resident's (Name of family member) to observe how the resident exited the facility on 11/8/19. Resident B exited the secured locked unit by the front door assisted by another resident's family member, then he was found across the street in a grassy field at the (Name of Hospital). The Plant Operations Assistant was walking over to the Legacy building and looked over across the street to the Hospital and observed a male walking in the field, which raised a concern for him. He entered the Legacy building through the service door entrance on the side of the building and asked the staff if all the residents were accounted for and there was a head count completed at that time. Resident B was not found. The Plant Operations Assistant got the golf cart and went across the street, to the grassy field, and picked Resident B up and brought him back to the facility without any difficulties. He was not sure of the last time someone observed him without looking at his investigation. The resident was missing for 30 minutes. He was observed on the video exiting the secured locked unit at approximately 2:00 p.m. to 2:05 p.m. and was picked up at approximately 2:35 p.m. The resident did not have a wanderguard in place even though he was at risk prior to the elopement because they do not place wanderguard bracelets on the residents in the Legacy building because it was a secured locked unit, so they did not need a wanderguard system. He indicated even if Resident B had a wanderguard bracelet on it would not have made a difference because a family member had placed the code into the door code alarm pad to open the door and the resident would have still been able to exit with the family member. The investigation for the elopement was requested at this time. During an interview, on 11/25/19 at 3:01 p.m., the ED and DHS was in attendance. The ED indicated he was unable to provide the investigation to the elopement due to all the information was in his email and he had not been able to get into his email account. The DHS indicated she would provide what information she was able to provide in a soft file she had in her office. During an interview, on 11/25/19 at 3:30 p.m., the Legacy Neighborhood Director indicated Resident B had the exact same clothes on this day which he was wearing the day he eloped. At that time, she indicated where Resident B was sitting in the lounge. On 11/25/19 at 3:35 p.m., Resident B was observed sitting, on the couch, in an (Name of University) sweatshirt, a pair of jeans, a pair of white crew socks and a pair of gray soft loafer shoes. The resident was alert, but disoriented to place and time. He was unable to express his ideas and indicated he was chilly. During an interview, on 11/25/19 at 3:55 p.m., the Plant Operations Assistant indicated he was coming around the front of the Legacy building on 11/8/19 around 2:00 p.m., when he noticed a man, whom he thought looked familiar, walking in the grassy part of the property, in front of the building, by the parked cars. He walked around the building, entered the service door and checked with the nurses to make sure all the residents were accounted for. The staff completed a head count, room check and figured out Resident B was missing. While the staff members were doing the head count and room check he went to the door and observed Resident B ambulating East on (Name of Street). He and another staff member went to another building on the facility campus to get the golf cart and went to look for Resident B because, by this time, he had left the campus property. He checked for Resident B at the hospital first, then he continued in the East direction until he found him located off the highway. The time he was in the Legacy building after he observed Resident B still on the property outside was approximately 10 minutes. The resident was dressed in a sweatshirt and jeans with shoes on. He got into the cart without any problems and he brought him back to the facility. The resident complained of being chilly. The record review for Resident B was completed on 11/25/19 at 4:15 p.m. [DIAGNOSES REDACTED]. A document titled Admission--(Name of Company)--Admission Observation and Data Collection dated 10/2/19 at 11:01 a.m., included, but was not limited to, the following information, the resident was alert and oriented to person only. His speech was clear, but he had an expressive communication difficulty. Exit/Elopement Review indicated the resident had a history of [REDACTED]. The admission MDS (Minimum Data Set) assessment, dated 10/9/19, indicated the resident was cognitively impaired. The resident's functional status indicated for locomotion off and on the Legacy unit he required supervision of one person physical assist and he required a walker as a mobility device to ambulate. A care plan, dated 10/2/19, addressed the problem he had an impaired cognition with associated short term memory impairment and was at risk for confusion, disorientation, altered mood, impaired or reduced safety awareness related to dementia with behaviors. Approaches included, but were not limited to, .10/14/19--Observe for exit seeking behaviors, wandering into unsafe areas and entering other resident rooms un-invited A care plan, dated 10/2/19, addressed the problem he had an impairment in his functional status in regards to bed mobility, transfers, toileting and eating related to his dementia. Approaches included, but were not limited to, 11/8/19--Required secured/locked unit r/t (related/to) Alzheimer's dementia . A document titled Safety Events--(Name of Company) Exit Seeking Event 07-12-2018 indicated the exit seeking elopement event occurred on 11/8/19 at 2:45 p.m. The resident was not observed exiting the building and he was found off the campus property. He did not have a wandering alert device in place at the time of the exit from the facility. He was observed exit seeking on 11/8/19 at 2:00 p.m. He was found by Environmental Services and a CRCA (Certified Resident Care Assistant). Prior to exiting, Resident B did display a behavior of wandering but he did not attempt to open the doors. The resident did display a change in mental status, prior to exiting the facility, in the form of confusion and restlessness. Resident B had cognitive or memory impairments, which affected his safety and judgement in the form of dementia with behavioral disturbances, he had difficulty understanding and following directions and he refused to comply with safety measures such as the use of a Wanderguard/Secure Care Alarm system. On that day, after he was returned to the facility at 3:02 p.m., the resident's body temperature was 96.9 F. A progress note, dated 11/8/19 at 2:49 p.m., indicated CRCA notified by environmental services that it possibly appeared a resident was crossing parking lot heading to hospital. Staff immediately began to check unit for resident. Unable to find resident at this time. Elopement policy followed. Wife aware. Resident located and uninjured. During an interview, on 11/25/19 at 4:33 p.m., (Name of Family member) indicated the facility notified her on 11/8/19, the resident was missing and staff members were outside the facility looking for him. She came to the facility and by the time she arrived they had found him across the street, in the grassy field, by the hospital and he was sitting on the couch with a blanket wrapped around him and drinking coffee because he was cold. He was dressed in a sweatshirt, a pair of jeans, shoes and socks. She watched the video with the ED and the DHS and she observed the resident walking out behind some visitors. When the visitors were called they admitted they seen the resident behind them but did not think he was a resident. Prior to his admission to the facility, he was admitted to a Psych Hospital at the end of (MONTH) 2019 after he had got out of their house was picked up by the police and sent to the hospital. The facility was made aware, by her, he had a history of [REDACTED]. On 11/25/19 at 5:00 p.m., the ED provided a copy of some of the investigation documents. A documented titled Episodic Event/Past Noncompliance dated 11/8/19, indicated Event: Resident who resides on Legacy lock unit was let out the front door by a guest and walked a 1/2 mile up the street. Root Cause of Analysis: Resident wanted to go for a walk to go home and a guest who was unaware he was a resident let him out the front door. Like Residents: Head count was done to ensure all residents were accounted for and all residents who reside in the unit were assessed for elopement risk review. Plan of Action & Systemic Changes Made: A sign was placed by entrance for all guests/vendors to not assist anyone out of building without staff present or made aware. Staff education on elopement policies and procedures. Auditing/Compliance: Will continue to monitor all residents for exit seeking /assessed all Legacy for elopement risk/all Legacy staff to be educated on elopement procedures. On 11/25/19 at 5:00 p.m., the ED provided a copy of a document titled Employee Counseling Record Form dated 11/8/19, which indicated the Plant Operations Assistant on 11/14/19, was given a verbal warning for disciplinary action due to Employee noticed someone on the property who he felt might be a resident. The expected level of improvement or change would be: If (Name of Employee) believes a legacy resident has exited the building, he is to stay with that resident and attempt to assist them into the building. On 11/26/19 at 3:04 p.m., with the Administrator and Director of Plant Operations in attendance, the video of Resident B leaving the secured Memory Care unit on 11/8/19 was viewed. The video was dated 11/8/19 and the time was (1502) 3:02 p.m., in the video. At that time, the Director of Plant Operations (DPO) indicated the time on the video was not the same as our time, which would have been 2:02 p.m., because of the time change and the video time did not change. At 2:02 p.m., a male visitor 5 (the DPO describes him as the Day Care Driver) came in who place the code to the locked door into the alarm key pad at the front door, then he came into the front door. At 2:05 p.m., the same male visitor came back to the locked front door with a female walking with a walker (the DPO indicated the name of the resident and she was a day care resident) and standing right behind them in a pair of jeans, a gray sweatshirt and gray deck shoes was another male (the DPO indicated that male was Resident B). The male visitor placed the code into the key pad and opened the door to allow the female to come out, then Resident B holds the door, so both of them can go ahead of him. Male visitor 5 already had the second door opened and Resident B let the first door close, but through the frosted window Resident B was observed grasping the second door while Male visitor 5 held it open for the female with her walker and Resident B held the door open for both of them. During this time, while Resident B was waiting for the male visitor to place the code into the key pad Life Enrichment Assistant (LEA) 3 walked around Resident B while he stood at the door waiting to go outside, then she went into her office next to the front door. After all of them exited the front door, LEA 3 was observed coming out of her office and placing a code into the key pad. At that time, the DPO indicated the door was opened to long waiting for the three of them to go through, so the door alarm sounded, so she had to put the code in to shut the alarm off. The DPO and Administrator verified at that time, Resident B left the facility at 2:05 p.m. on 11/8/19. During an interview, on 11/26/19 at 3:27 p.m., CNA 4 indicated on 11/8/19, she could not remember the time, the Plant Operations Assistant came into the facility and said he could not find Resident B. They started the elopement policy and did a head count and searched all the rooms, which the Plant Operations Assistant assisted with. Staff split up and went outside and walked and drove looking for him. The Plant Operations Assistant got his golf cart and she rode with him and he drove to the hospital looking throughout the parking lot, then he drove East to look for him. He drove down the side street (Name of Street) straight down from the facility, next to the hospital and Resident B was found in the grassy field next to the apartments. The Plant Operations Assistant took off his coat and gave it to Resident B because he did not have a coat on and he was cold. She and the Plant Operations Assistant had coats on when they left to go search for the resident due to the temperature on that day. On 11/26/19 at 4:01 p.m., with the Vice President of Clinical Support, Administrator and Director of Plant Operations in attendance, the video of Resident B returning to the secured Memory Care unit on 11/8/19 was viewed. The video was dated 11/8/19 and the time was (1551) 3:51 p.m., in the video. At that time, the Director of Plant Operations (DPO) indicated the time on the video was not the same as our time, which would have been 3:51 p.m., because of the time change and the video time did not change. At 2:51 p.m., the resident was observed walking into the facility followed by the Plant Operations Assistant and other facility staff members. During a telephone interview, on 11/26/19 at 4:16 p.m., Male visitor 5 indicated he used to go to the facility daily to drop off and pick up his grandma for daycare. The Life Enrichment Program Director of the Memory care unit gave the code for the door to his sister to give to him, so he would not have to wait for someone to open the door for him every time, since he came in and out, so much. The alarm on the door alarmed and he knew how to fix it also. He picked her up on 11/8/19 and he remembered a gentleman standing behind them in jeans and a gray sweatshirt waiting patiently for them to go out, so he could leave. He did not think anything about him being a resident because this man held the doors open for him to him get his grandma out the door and then he went over to the right of the parking lot where the cars were parked and stood beside a car, so he thought he was getting in his car. He did not know a resident had left until someone from the facility called and told him he let a resident outside. He indicated he did not let the resident outside. The resident walked out by himself and he held the doors for him, so he could get her through the doors with her walker. During an interview, on 11/26/19 at 4:52 p.m., LPN 6 indicated during report with another nurse on 11/8/19 at 2:30 p.m., the shift to shift report had to be stopped because the Plant Operations Assistant said he thought he seen Resident B outside the facility. The elopement policy and procedure was started at that time. A current facility policy, titled Guideline for Elopement/Missing Resident dated 3/20/2017, with a review date of 5/23/2018, provided by the ED on 11/25/19 at 3:00 p.m., indicated the following: Purpose: To establish guidelines to report and investigate all reports of elopement/missing persons. It is the responsibility of all personnel to report any resident attempting to leave the premises or suspected of being missing to the charge nurse as soon as possible. Procedure: 2. Disoriented Resident (already deemed an elopement risk observed exiting the campus door: a. Attempt to prevent the departure and re-direct b. Obtain assistance from other staff members in the immediate vicinity .e. Stay with the resident until a nurse assesses the need for further interventions .3. Door Alarm Sounding/Missing Resident: 3 .d. If the resident is not found at the campus, one of the above members of the staff or designee should notify the local police department, attending physician, and responsible party. e. Local transportation companies should be contacted to determine if the resident has sought their services. (bus, taxi, etc.) .h. Request the resident be announced on your local 'Golden /Silver Alert' procedures if available in your state The immediate jeopardy that began on 11/8/19 was removed on 11/26/19, when the facility continued re-educating all staff on the elopement policies and procedures and new signage, but the noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that was not immediate jeopardy, because all the staff was not re-educated on the elopement policy and procedures and signage as of the exit date of 11/26/19. This Federal tag related to Complaint IN 853 3.1-45(a)(2)

Based on interview and record review, the facility failed to follow facility policy for elopement of a resident who eloped and was outside the facility for greater than two hours with whereabouts unknown for 1 of 3 residents reviewed for elopement (Resident B). The Immediate Jeopardy began on 8/9/16 when the facility failed to follow their elopement policy to thoroughly check resident whereabouts when a door alarm sounded on a locked unit. The resident had exited the building and was not identified as having eloped for greater than 2 hours. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 9/1/16 at 2:20 p.m. The Immediate Jeopardy was removed on 8/10/16 and the deficient practice corrected on 8/19/16 prior to the start of the survey and was therefore Past Noncompliance. Findings include: The clinical record of Resident B was reviewed on 09/01/16 at 10:30 a.m. [DIAGNOSES REDACTED]. Resident B was admitted to the secure Legacy unit on 8/04/16. An Admissions MDS (Minimum Data Set), dated 08/16/16, indicated Resident B had severe cognitive impairment. A Preadmission Screening and Resident Review, dated 08/04/2016, indicated Resident B needed a secure unit for safety due to his elopement risk. A temporary care plan, dated 08/04/2016, put in place upon admission, indicated Resident B had a cognitive impairment that effected safety/judgment, difficulty understanding and following directions, was non-compliant with safety measures, and had a history of [REDACTED]. Interventions included, but were not limited to, ensure call light in reach, redirect resident, and observe for compliance with safety interventions. Nursing Progress Notes, signed by LPN #1, dated 8/10/16, for the night of 8/9/16, indicated .Res (resident) was noted to be in room at or around 0107 am (1:07 a.m.) eating cookies when another res was retrieved from the area by a CRCA (Certified Resident Care Associate). At 0123 (1:23 a.m.) when the same resident went back to the area res was noted to not be in his room any longer. CRCA and writer carefully searched all the rooms including bathrooms closets and under the beds. When a thorough search revealed no trace of the resident on call nurse was called at approximately 0130 (1:30 a.m.). We were advised to do a perimeter search and to enlist assistance from the main building to search the perimeter there. A CRCA came to do a repeat search of the building. When that was also negative we were advised to do a repeat search of the outside with inclusion of the clubhouse and Villas. This search was successful and res was found by a CRCA and a nurse from the other building. Res was located at 0154 (1:54 a.m.) near the clubhouse sitting on the grass. The other nurse reported that she had done the initial assessment and that he had no injuries or difficulty ambulating. She said that he had said 'Have you ever walked a few steps and just sat down?' He was escorted back to the Legacy building by writer and 2 CRCA's Facility documentation of the investigation was reviewed on 08/31/16 at 11:05 p.m. The investigation indicated the Assisted Living Legacy outside door alarm did sound at 11:14 p.m., on 8/09/16. Video of the incident indicated LPN #1 responded to the alarm, opened the door and looked out for any residents. It was determined Resident B did exit the Assisted Living Legacy door at 11:14 p.m. During an interview on 8/31/16 at 11:15 p.m., the Director of Health Services indicated she received a phone call from the on call nurse at 1:40 a.m., on 8/10/16. The on call nurse indicated Resident B was missing and staff could not find him. During that call, Resident B was located outside of the facility, adjacent to the new villa clubhouse. During the investigation of the incident, LPN #1 stated she had not heard an alarm sound. The on call nurse checked all doors when she arrived at the facility and all were functioning. The video feed from the locked unit was checked and indicated Resident B went to an exit door at 11:14 p.m. After 15 seconds, the door released for safety/emergency reasons. He exited and turned left out of the facility. The video did not show him re-entering into the building. LPN #1 did respond approximately 30 seconds after Resident B exited the door. The alarm was still sounding and she entered the code to stop the alarm. LPN #1 stepped outside and looked around and then re-entered the building. When the staff performed a bed check at 1:15 a.m., they noticed he was not in his bed. CRCA #2 and LPN #1 were shown the video of the elopement, but still indicated the resident had been in his room eating cookies around 1:07 a.m. Resident B was outside for approximately 2 hours. He would not have been able to re-enter the building as the doors were locked and required a code. LPN #1 did not go outside and do a perimeter search and did not account for all residents. LPN #1 was terminated on 8/12/16, following suspension during the investigation, due to failure to follow elopement policy and procedure. CRCA #2 was terminated on 8/12/16, following suspension during the investigation, due to false statements regarding the elopement of a resident. A review of staff education on 8/31/16 at 11:25 p.m. indicated LPN #1 had completed elopement training upon hire and had received her last annual training regarding elopement procedures on 7/29/15. A current policy, titled Procedure Guidelines Missing Resident, dated 05/11/2016, provided by the Director of Health Services on 08/31/16 at 11:17 p.m., indicated, .5. Facilities that have a sounding alarmed door: a. staff should respond promptly to a sounding door alarm .b. The charge nurse, facility supervisor or Executive Director should designate a staff person to perform a facility head count to determine who may be missing .c. Two additional staff members should exit the alarming doorway and go in opposite directions around the building perimeter The Past Noncompliance Immediate Jeopardy began on 8/09/16. The immediate jeopardy was removed on 8/10/16 and the deficient practice corrected by 8/19/16 when the facility completed the following: 1. Resident B was placed on 1:1 with a staff member immediately following the incident 2. The on-call nurse checked door alarms for proper function, completed 8/10/16 3. Resident B was placed on 30 minute checks following 1:1, started 8/10/16 and continued through the time that Resident B was transferred to the Assisted Living Legacy on 8/19/16. 4. The Director of Plant Operations verified alarms were functioning correctly and changed the door alarm codes, completed 8/10/16 5. Resident B was reviewed by the physician, completed 8/10/16 6. A permanent elopement care plan was put into place for Resident B, completed 8/10/16 7. A bed alarm was put into place in order to notify staff of night time wandering, ordered 8/11/16 8. Employees completed inservices regarding elopement, completed 8/10/16 - 8/16/16 9. Termination of CRCA #2 and LPN #1 on 8/12/16, following suspension during investigation Through record review and interviews, staff were able to identify the steps to take in the event of a missing resident and indicated they had participated in inservicing and facility elopement drills. This Federal tag relates to complaint IN 925. 3.1-45 (a)(2)

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and implementation of interventions to prevent falls resulting in a fractured neck and broken tooth (Resident A). This affected 3 of 5 residents with falls in a sample of 5. (Residents #A, #B, #C). Findings include: 1. Resident #A's closed clinical record was reviewed on 4/23/12 at 10:00 A.M. The record indicated the resident was admitted with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) Quarterly Assessment, dated 11/16/11, indicated the resident was severely impaired in cognitive decision-making skills, required extensive one-person physical assistance for transfer and toilet use, was non-ambulatory, was incontinent of bowel and bladder, and had one fall. A "Nursing Assessment and Data Collection," dated 1/10/12, indicated the resident had bed and chair alarms, had cognitive impairment which effected safety/judgment, had difficulty understanding and following directions, required assistive device and/or forgot or refused to use, and was non-compliant with safety measures. Further review indicated the resident was at risk for falls. Review of "Fall Circumstance, Assessment, and Intervention" forms indicated the resident had fallen on 10/17/11, 11/4/11, and 12/4/11. A resident care plan indicated: 1/31/12 "...Behavior Problem...Resists Care when waiting for help with transfers and ambulation...bed and chair alarms to alert staff to any unassisted transfers..." 8/24/11 and updated 11/17/11 "...Hx (history of anxiety or agitation AEB (as evidenced by) being easily annoyed...Re-direct, 1:1, offer to return to room, offer to toilet, offer food or fluid, Offer to change position, offer back rub..." 10/17/11 and updated 1/17/12 "...Falls At risk for fall/injury...safety measures to reduce fall risk...additional approaches: Bed pad alarm, chair pad alarm..." A Nurses' Note, dated 3/24/12 at 11:57 P.M., indicated "Res has been up (indicated by arrow) agitated et (and) shown increase (indicated by arrow) in cognitive deficit over last 3 days. UA (urinalysis) obtained...Over the course of evening resident was up and down (indicated by arrows). Staff unable to redirect effectively, but resident did rest off/on. At 11 PM, res (resident) attempted to get up (indicated by arrow) et was repeatedly stating he wanted to go to farm...Assisted to BR (bathroom) back to bed et in out of W/C (wheelchair). While in W/C resident put arms out et would not allow staff to take out of room. 1:1 provided until res stopped attempting to stand s (without) reason. At 1140 (11:40) PM, staff was alerted to room by W/C alarm et res was lying on floor in front of W/C..." At 11:58 P.M. "...Found resident lying on his (L) side on the floor of his room...Found resident's tooth on carpet..." An "Incident Report Form," dated 3/24/12, indicated "...On 3/24/12 at 2300 (11:00 P.M.) Resident was restless and attempting to ambulate multiple times. RN stayed with Resident after toileting until it appeared Resident was calm and sitting in wheel chair with ordered alarms on wheel chair in his room. The RN returned to the nurses station. At 2340 (11:40 P.M.), RN, LPN, and CNA immediately (sic) responded to this Resident's chair alarm and observed the Resident laying on his left side on the floor of his room. Type of injury/Injuries: Broken tooth, C-2 (second cervical vertebra) Fracture, Skin tear to left arm, swelling to left hip..." A "Fall Circumstance, Assessment and Intervention" form, dated 3/24/12, indicated "...Witnessed N (no)...Hit head Y (yes)...lost tooth...Activity at time of fall: Transferring self (indicated by checkmark)...other: unknown...Recent agitation or restlessness...Safety equipment in place and functioning at time of incident? Y (yes)...Root cause: Anxiety/Restlessness, S/S (signs/symptoms) of UTI (urinary tract infection)...Will update upon return..." A Medication Administration Record (MAR) dated, March 2012, indicated "Ativan (an antianxiety medication) 0.5 mg (milligrams) i (one) PO (by mouth) q4hrs (every four hours) anxiety..." Documentation was lacking related to the Ativan having been administered on 3/24/12. A hospital "Preliminary Radiology Report," dated 3/25/12, indicated "...Fall at (name of facility)...Age indeterminate, but probably acute, displaced odontoid (at base of skull) fracture. There is probable severe (sic) resulting spinal canal stenosis (narrowing) at C1-2..." A hospital history and physical, dated 3/25/12, indicated "...patient at the ECF (extended care facility) found down and also the amount of time was uncertain. The patient was noted to have abrasion on that day. Also has rotted tooth. The patient was brought in the ER (emergency room ). The patient was sleepy initially. After evaluation was found to have a CT (computed tomography) scan suggesting of displaced odontoid fracture with severe spinal stenosis at C1-C2...He was just found down by the staff at the ECF...Altered mental status, likely related to the fall and C2 compression fracture..." Interview on 4/23/12 at 10:25 A.M., with the Director of Nursing indicated the resident had increased anxiety and restlessness. She indicated the resident had been brought to the nurses station but wanted to go back to his room. "He asked the nurse to leave" so the nurse left the room, leaving the resident alone, and went to the nurses' station. The alarm sounded and the resident was then found on the floor. She indicated "he was impatient." Interview on 4/24/12 at 9:30 A.M., with the Director of Nursing indicated the resident "wanted the nurse out of the room." She indicated the nurse left the room to answer another alarm and left the resident alone in the room. The CNA was with another resident. She indicated there was another nurse at the medication cart "trying to get the Ativan" but the resident fell before the nurse could get back to the room. Interview on 3/24/12 at 9:55 A.M., with the Corporate Nurse indicated the resident would "be calm for 5 to 7 minutes and then get agitated again." She indicated the resident fell "before the Ativan could be given." 2. On 4/23/12 at 8:30 A.M., during an initial tour with the MDS Coordinator, Resident #B was identified as having no falls. On 4/23/12 at 11:05 A.M., Resident #B was observed sitting in a wheelchair in her room. There was a chair alarm in place. On 3/23/12 at 11:00 A.M., Resident #B's clinical record was reviewed. The record indicated the resident was admitted with [DIAGNOSES REDACTED]. An MDS Admission Assessment, dated 3/19/12, indicated the resident was severely impaired in cognitive decision-making skills, required extensive two-person physical assistance for transfer and toilet use, was non-ambulatory, was incontinent of bowel and bladder, and had no previous falls. A "Nursing Admission Assessment & Data Collection" form, dated 3/12/12, indicated the resident had long- and short-term memory problems, required bed and chair alarms, had "cognitive impairment that effects safety/judgement", and was at risk for falls. A resident care plan, dated 3/13/12, indicated "...At risk for fall/injury...Bed & chair alarms..." Nurses' Notes indicated: 3/23/12 at 4:45 A.M. "Lab tech (laboratory technician) here; called to BR (bathroom) of (room number) stating he heard a yell - (w) (writer) entered BR to observe res (resident) lying on stomach on floor of BR - head against wall, face down...states 'I hit my head'. Lg (large) swollen blue area noted forming above (L) (left) eye...Bruise over (L) eye darkening in color - dk (dark) blue/purple - swelling increasing over (L) eye - swelling now incorporating above eyebrow et (and) eyelid - upper et down outer eye...911 called et (hospital name) ER called...Res transferred to ER @ 0520 (5:20 A.M.) via amb (ambulance) transport..." 3/23/12 at 9:00 A.M. "...New alarms applied to bed and chair and are properly functioning..." A "Fall Circumstance, Assessment and Intervention" form, dated 3/23/12, indicated "... Witnessed N (no)...Goose egg (L) eye...Activity at time of fall: Transferring self...Toileting...Non-compliant...Safety equipment in place and functioning at time of incident? Y (yes)...W/C in locked position @ foot of bed - Res walked around it - Bed alarm not sounding - however in place et Fx (functioning) properly...Upon return new pressure pad alarm applied. Old pressure pad alarm discarded...Root cause: Attempting to toilet self, Bed alarm did not sound..." A resident care plan, dated 3/12/12, indicated "...3/23/12 New bed/chair alarm applied/ current one replaced. Check (indicated by checkmark) function/placement QS (every shift)..." The record indicated the resident was admitted to the hospital on [DATE] for congestive heart failure. She returned to the facility on [DATE]. A hospital "Patient Transfer Record," dated 4/5/12, indicated "...Fall Precautions...2 assist c (with) transfers & ambulation...Bruises on face from fall @ ECF..." A "Nursing Admission Assessment & Data Collection" form, dated 4/5/12, indicated "...Alarm type: the form was blank..." Further review indicated the resident was at risk for falls. A resident care plan, dated 4/6/12, "...At risk for fall/injury...4/5/12 Bed/Chair Alarms..." A "PT (physical therapy) - Plan of Care," dated 4/9/12, indicated "...Transfers, Bed <> (to and from) Chair...moderate assistance x 2 (26-75% with 2 people)...Transfers, Sit <>Stand...moderate assistance x 2 (26-75% with 2 people)...Balance, Static Standing...P+ (poor plus) (requires handhold support and moderate assistance to maintain position)...Balance, Dynamic Standing...P+ (unable to accept challenge but can move head without loss of balance)..." A Nurses' Note, dated 4/9/12 at 11:00 P.M., indicated "Res continued to be very restless et up et down from chair. Res assisted to floor by aide..." Documentation was lacking related to the resident being assisted by two staff members. A "Fall Circumstance, Assessment and Intervention" form, dated 4/9/12 indicated "...Witnessed Y (yes)...Assisted to floor...Activity at time of fall: Transferring self (indicated by X)...restlessness...Prevention update...Frequently used items in reach...Diversional activities...Root cause: Restless...When resident appears restless, offer to ambulate e (with) ii (two) assist..." A resident care plan, dated 4/6/12, indicated "...4/10/12 When Resident appears restless offer to ambulate resident c (with) ii (two) assist..." A Nurses Note, dated 4/11/12, (no time) indicated "reported res up (indicated by arrow) in w/c @ NS (nurses' station). Res noted to be on knees. Couch in front of her et upper (indicated by arrow) body arms resident (sic) on couch...new alarm pad placed et functioning..." A "Fall Circumstance, Assessment and Intervention" form, dated 4/11/12, indicated"...Witnessed N (no)...Found on floor...Activity at time of fall: Transferring self (indicated by X)...Safety equipment in place and functioning at time of incident? N (no) in place 0 (no) alarming...Prevention update...Bed and/or chair alarm replaced...Root cause: Restless...Add med (medication) review et monitor @ nurses station during periods of restlessness/anxiety..." A resident care plan, dated 4/6/12, indicated "4/11/12 Monitor at nursing station during periods of restlessness/anxiety...4/11/12 med review to address increased restlessness/anxiety..." Interview on 4/23/12 at 11:40 A.M., with the Director of Nursing indicated the alarm was not sounding at the time of the 3/23/12 and 4/11/12 falls. She indicated "another staff member was added" for ambulating the resident after the 4/9/12 fall. Interview on 4/24/12 at 9:30 A.M., with the Director of Nursing indicated she was unaware of why the alarm didn't sound for the 3/23/12 fall but indicated the alarm had sounded for the 4/11/12 fall. She indicated the resident slid forward in the wheelchair and "then the alarm didn't sound until she went to the floor." 3. On 4/23/12 at 8:30 A.M., during an initial tour with the MDS Coordinator, Resident #C was identified as having had no falls. On 4/23/12 at 11:00 A.M., Resident #C was observed lying in bed in her room. There was a bed alarm in place. Resident #C's clinical record was reviewed on 4/23/12 at 11:30 A.M. The record indicated the resident was admitted with [DIAGNOSES REDACTED]. An MDS Quarterly Assessment, dated 1/1/12, indicated the resident was severely impaired in cognitive decision-making skills, required extensive one-person physical assistance for transfer and toilet use, was non-ambulatory, was unsteady and only able to stabilize with human assistance when walking, and had no previous falls. A "Nursing Admission Assessment & Data Collection" form, dated 4/2/11, indicated the resident was at risk for falls. A resident care plan, dated 4/11/11 and updated 7/11/11 and 4/2/12, indicated "...At risk for fall/injury...bed & wc (wheelchair) alarms..." A Nurses' Notes indicated: 4/11/12 (no time) "Called to res rm (room), res sitting up (indicated by arrow) leaning up (indicated by arrow) against bed...assessed alarm functioning et connector broke et not connected to pad. New pad placed on bed et functions after checking (indicated by checkmark)..." 4/12/12 (no time) "Res had some pain to L (left) thigh during transfer this am..." The resident had x-rays done which were negative. A "Fall Circumstance, Assessment and Intervention" form, dated 4/11/12, indicated"...Witnessed N (no)...Found on floor...Activity at time of fall: Transferring self ...Safety equipment in place and functioning at time of incident? N (no)...bed alarm in place, not properly functioning...Prevention update...Toilet p (after) fall...new pad replaced (alarm)...Root cause: Resident attempting to toilet self...Request UA/C&S (urinalysis/culture&sensitivity)... D/T (due to) increase (indicated by arrow) repetitive statements..." Documentation was lacking related to any additional interventions implemented to prevent falls. A resident care plan, dated 4/11/11, indicated "...4-11/12 Check UA/C&S..." Interview on 4/23/12 at 11:40 A.M., with the Director of Nursing indicated the alarms were not functioning at the time of the 4/11/12 fall. Interview on 4/24/12 at 9:30 A.M., with the Director of Nursing indicated the connector was broken on the alarm and it did not sound. "We got her a new one." Review on 4/23/12 at 12:25 P.M., of a facility policy and procedure, dated 1/06 and revised 3/08, provided by the Director of Nursing, identified as current, and titled "Falls Management Program Guidelines" indicated "...Should the resident experience a fall the attending nurse shall complete the "Fall Circumstance and Reassessment Form." The form included an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode and a review by the IDT (interdisciplinary team) to evaluate thoroughness of the investigation and appropriateness of interventions...." This Federal tag relates to Complaint IN 340. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure residents were provided necessary care and services related to obtaining an x-ray as ordered by the physician after a fall resulting in continued pain and delay in treatment for 1 of 3 residents with falls and related to obtaining pacemaker parameters for 1 of 1 resident with a pacemaker, in a sample of 4. (Residents #B and #D). Findings include: 1. Resident #D's closed clinical record was reviewed on 2/28/12 at 1:15 P.M. The record indicated the resident was admitted with [DIAGNOSES REDACTED]. The resident had been admitted to the facility after sustaining a fall at home resulting in a fractured femur. Nurses' notes indicated the resident had fallen on 11/5/11 resulting in a [MEDICAL CONDITION] and had been admitted to the hospital. A "Skilled Nursing Assessment and Data Collection" form dated 11/20/11 (no time) indicated "...Res (resident) placed on toilet. Informed staff to be back was getting drsg (dressing) supplies. Upon return res calling out et (and) on floor in front of toilet. Res states she put herself back in her W/C (wheelchair) et leaned over to get TED ([MEDICAL CONDITION] devices) hose et fell out of W/C. Assist to W/C via 2 staff. Some pain to hips x 2 but 0 (no) increase (indicated by arrow) than normal once up (indicated by arrow) in W/C...Sat up (indicated by arrow) in W/C for 2-3 hrs (hours)..." A physician's orders [REDACTED]. If (-) (negative) et cont (continues) c (with) increased (indicated by arrow) pain may send to hosp (hospital) for xray..." An xray of the left hip was obtained and was negative for [MEDICAL CONDITION]. The femur was not xrayed. A nurses' note dated 11/20/11 at 8:00 P.M. indicated "Res cont (continues) to c/o (complain of) pain left leg. Leg has some general [MEDICAL CONDITION] of that leg from hip down through the foot but only pitting on the inside of left knee. No bruising or hematomas noted at all on that leg. Res has good ROM for that leg - given previous hip fx (fracture). Res stating pain 9 of 10 & whole leg tender to touch. No redness noted on left leg. Res had ice on left hip/thigh/knee...will continue to monitor." A Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"[MEDICATION NAME] (a narcotic pain medication) 10/325 mg (milligrams) 1/1 PO (by mouth) q (every) 3 hrs (hours) PRN (as needed)..." The [MEDICATION NAME] had been given 4 times on 11/20/11. Further review indicated "[MEDICATION NAME] 10/325 mg 1/1 PO q 6 hrs...." The [MEDICATION NAME] had been given routinely at 5AM, 11AM, 5PM, and 11PM. A "Skilled Nursing Assessment and Data Collection" form indicated: 11/22/11 at 1:00 A.M. "Distressed - banging on side table c (with) cup et (and) pen...A & O x 3 (alert and orient times three) but very [MEDICATION NAME] (antianxiety medication) adm (administered) per PRN order..." Documentation was lacking related to an assessment of the resident's leg or pain. 11/22/11 at 9:00 A.M. "Res in bed. pp+ (pedal pulses positive) bil (bilateral) (l) upper (indicated by arrow) leg c (with) [MEDICAL CONDITION]. N.O. order received to xray femur & knee. (Company name) called...Xray results in femur fx (fracture) to (L)...Res c (with) (continuous) pain. Has diff (difficulty) moving L (left) foot...N.O. (new order) to direct admit res to (hospital name)..." An xray report dated 11/22/11 indicated "...There is a fracture involving left mid to distal femur with modest displacement...Acute appearing left femur fracture...." Interview on 2/29/12 at 9:40 A.M. with the Director of Nursing indicated "I have no explanation for why she wasn't sent to the hospital" for additional xrays. She indicated the resident should have been sent on 11/20/11. Review on 2/29/12 at 9:10 A.M. of a facility policy and procedure dated 1/06, provided by the Director of Nursing, identified as current, and titled "Falls Management Program Guidelines" indicated "...Any orders received from the physician should be noted and carried out..." 2. Resident #B's clinical record was reviewed on 2/29/12 at 8:15 A.M. The record indicated the resident was admitted with [DIAGNOSES REDACTED]. A chest xray report dated 1/9/12 indicated "...There is a pacemaker in position..." Documentation was lacking in the clinical record to indicate what type of pacemaker the resident had implanted. A "Nursing Admission Assessment & Data Collection" form dated 2/20/12, indicated "Cardiac Plan of Care." Further review indicated "Pacemaker checks as ordered due Mar '12..." Documentation was lacking related to checking the resident's pulse and related to pulse parameters for the resident's pacemaker. A physician orders [REDACTED]. Interview on 2/29/12 at 9:40 A.M. with the Director of Nursing indicated the resident's pulse should be checked daily. She indicated there were no pulse parameters ordered by the physician. Review on 2/29/12 at 10:30 A.M. of an undated facility policy and procedure, provided by the Director of Nursing, identified a current, and titled "Guidelines for Pacemaker" indicated "...The physician shall provide the facility with the specific maximum heart rate above the pacemaker rate that is acceptable...The physician shall provide the programmed lower and upper rate for the pacemaker...Pulse shall be taken per the physician orders..." This federal tag relates to complaint IN 679. 3.1-37(a)

Based on interview and record review, the facility failed to ensure interventions were implemented to prevent falls resulting in a hip fracture and a femur fracture for 1 of 3 residents with falls in a sample of 4. (Resident #D). Findings include: Resident #D's closed clinical record was reviewed on [DATE] at 1:15 P.M. The record indicated the resident was admitted with [DIAGNOSES REDACTED]. A hospital history and physical dated [DATE], indicated "...the patient reportedly slid off the kitchen chair at home and feel (sic) on her buttocks...evaluation at the emergency room included x-ray of the left femur which revealed an oblique fracture with minimal displacement...she stated that she was just getting over the last left hip surgery of 2010..." A Minimum Data Set (MDS) Admission assessment dated [DATE], indicated the resident was cognitively intact, required extensive two-person physical assistance for transfer, was non-ambulatory, required extensive one-person assistance for toilet use, balance was not assessed, and had a fracture related to a fall in the previous 6 months. A "Nursing Admission Assessment & Data Collection" form dated [DATE], indicated "...Has cognitive impairment that effects safety/judgement @ (at) times Y (yes)...Has a history of falls Y (yes)...Takes meds (medications) that may affect balance, cognition or gait Y (yes)...Non-compliant with safety measures @ times Y (yes)..." Further review indicated "...Safety Plan of Care...Provide assistance for transfers and ambulation as needed...Toilet resident per toileting schedule...Ensure call light is within reach...Observe for compliance with safety interventions...Instruct resident on use of call light..." A resident care plan dated [DATE], indicated "...At risk for fall/injury AEB (as evidenced by)...History of Falls...Potential for falls...Interventions...Call light within reach...Lock breaks (sic) on bed, chair etc before transferring...When rising from a lying position, sit on side of bed for a few minutes before transferring/stand..." Nurses' notes indicated: [DATE] at 11:15 P.M. "Res (resident) found on floor in bathroom next to her toilet & sitting on her butt. Denied any pain in extremities but had bumped the Rt (right) side of her forehead. Ice applied to hematoma that formed...Res able to move all extremities c s (without) diff (difficulty)..." [DATE] at 12:00 A.M. "Upon further skin inspection - discovered (sic) that a hematoma had formed on Rt hip - fluid filled but 0 (no) redness or bruising. Res also has 2 1 cm (centimeter) skin tears on Rt elbow. Ice applied to Rt hip hematoma - res denies pain & has normal ROM (range of motion) of that leg & hip..." [DATE] at 1:00 A.M. "Res states her Rt hip is starting to hurt..." At 1:45 A.M. the resident was sent to the hospital by ambulance. [DATE] at 5:45 A.M. "(Hospital name) ER (emergency room ) nurse called to let us know that res was admitted for Rt hip fx (fracture)..." A "Fall Circumstance, Assessment and Intervention" form dated [DATE], indicated "...Location of fall...Res bathroom...Found on floor...transferring self...toileting...Resident has cognitive or memory impairment that effects safety and judgement? Y (yes)...Resident requires assistance to transfer? Y (yes)...Resident requires assistance to ambulate safely with or without assistive device? Y (yes)...Prevention update...had res @ nurses station to monitor...will reassess upon return from hospital..." A hospital history and physical dated [DATE], indicated "...X-ray of the pelvis shows right subcapital femoral neck fracture...right hip fracture..." A "Nursing Admission Assessment & Data Collection" form dated [DATE], indicated "...Has cognitive impairment that effects safety/judgement @ (at) times N (no)...Has a history of falls Y (yes)...Takes meds (medications) that may affect balance, cognition or gait N (no)...Non-compliant with safety measures @ times N (no)..." Further review indicated "...Safety Plan of Care...Refer to therapy...Ensure call light is within reach...Obtain physician order [REDACTED]. Full 2 (circled)..." A resident care plan dated [DATE], indicated documentation was lacking related to any additional interventions implemented to prevent falls after the [DATE] fall. A "Physical Therapy Discharge Summary" dated [DATE] indicated "...Patient currently requires max (maximum) assist with transfers and standing and is at risk for falls and injury..." Interview on [DATE] at 9:40 A.M. with the Director of Nursing indicated the resident "used her call light." She indicated the resident was asked why she fell and had said "Physical therapy told me to get up and start moving." She indicated the intervention after the fall was "resident education." A "Skilled Nursing Assessment and Data Collection" form dated [DATE] (no time) indicated "...Res placed on toilet, informed staff to be back was getting drsg (dressing) supplies. Upon return res calling out et (and) on floor in front of toilet. Res states she put herself back in her W/C (wheelchair) et leaned over to get TED (antithrombolytic devices) hose et fell out of W/C. Assist to W/C via 2 staff. Some pain to hips x 2 but 0 (no) increase (indicated by arrow) than normal once up (indicated by arrow) in W/C...Sat up (indicated by arrow) in W/C for ,[DATE] hrs (hours)..." At 11:30 A.M. "(Company name) here et xray done. Results are in et (and) (-) (negative)..." A physician's orders [REDACTED]. If (-) (negative) et cont c (with) increased (indicated by arrow) pain may send to hosp (hospital) for xray..." Nurses' notes indicated: [DATE] at 8:00 P.M. "Res cont (continues) to c/o (complain of) pain left leg. Leg has some general edema of that leg form hip down through the foot but only pitting on the inside of left knee...Res had good ROM for that left - given previous hip fx (fracture). Res stating pain 9 of 10 & whole leg tender to touch...Res has ice on left hip/thigh/knee..." Documentation was lacking related to the resident being sent to the hospital for additional x-rays. [DATE] at 9:00 A.M. "Res in bed. pp+ (pedal pulses positive) bil (bilateral) (L) upper (indicated by arrow) leg c (with) edema. N.O. (new order) received to xray femur & knee. (Company name) called...Xray results in femur fx to (L)...res c (with) cont (continuous) pain. Has diff (difficulty) moving (L) foot..." The resident was admitted to the hospital. A "Fall Circumstance, Assessment and Intervention" form dated [DATE] indicated "...Location of fall...Bathroom...Found on floor...transferring self...reaching for object...Resident has cognitive or memory impairment that effects safety and judgement? N (no)...Resident requires assistance to transfer? Y (yes)...Resident requires assistance to ambulate safely with or without assistive device? Y (yes)...Prevention update...Note in b/r (bathroom) @ (sic) reminder...PPA (personal alarms) to W/C et bed..." An x-ray report dated [DATE] indicated "...There is a fracture involving left mid to distal femur with modest displacement...Acute appearing left femur fracture..." A "Nursing Admission Assessment & Data Collection" form dated [DATE] indicated "...Has cognitive impairment that effects safety/judgement @ (at) times Y (yes)...Has a history of falls Y (yes)...Takes meds (medications) that may affect balance, cognition or gait Y (yes)...Non-compliant with safety measures @ times Y (yes)..." A resident care plan dated [DATE] indicated "...At risk for fall/injury...Additional approaches: Bed pad alarm, chair pad alarm..." The resident expired on [DATE]. Interview on [DATE] at 9:00 A.M. with the Medical Director indicated the resident had not expired due to the falls. He stated "she gave up and quit eating." Interview on [DATE] at 9:40 A.M. with the Director of Nursing indicated the resident had fallen at 7:00 A.M. She indicated she should not have been left alone in the bathroom. Review on [DATE] at 9:10 A.M. of a facility policy and procedure dated ,[DATE], provided by the Director of Nursing, identified as current, and titled "Fall/Safety Management Program Guidelines" indicated "...Care plan interventions should be implemented that address the resident's risk factors...Should the resident experience a fall the attending nurse shall complete the 'Fall Circumstance and Reassessment Form.' The form includes...interventions to reduce risk of repeat episode and a review by the IDT (interdisciplinary team) to evaluate thoroughness of the investigation and appropriateness of the interventions...Any orders received from the physician should be noted and carried out..." This federal tag relates to complaint IN 679. 3XXX,[DATE](a)(2)