Every finding on record at Crown Point Health Campus

Based on observation, interview, and record review, the facility failed to ensure hand hygiene was performed before and after resident care and failed to ensure a container of incontinence wipes were used for only one resident. (Residents N and D) The facility also failed to ensure correct Personal Protective Equipment (PPE) was used by a staff member (CNA 1) when providing care to a resident (Resident D) who was in Enhanced Barrier Precautions (EBP) for one random observation for infection control. This had the potiential to affect the 27 residents who resided on the [NAME]-C unit.Finding includes:During an observation on 8/24/26 at 8/24/26 at 4:27 a.m., there was a sign on the entry door to Resident D's room that indicated the resident was on EBP. CNA 1 entered the room with a package of incontinence wipes and placed them on Resident N's over the bed table and completed incontinence care on the resident. She removed the soiled brief and placed it in a plastic bag and removed her gloves. CNA 1 still had another pair of gloves on under the pair she removed. She then took the packet of wipes to Resident D's side of the room and place them on Resident D's over the bed table. There were three partial packs of wipes sitting on Resident D's window sill.CNA 1 then started to complete care on Resident D and was stopped. During an interview she indicated she had not washed her hands because she was wearing three pair of gloves and had removed the pair she used on Resident N. CNA 1 then removed the gloves and completed hand hygiene in the bathroom. CNA 1 returned to Resident D and completed incontinence care. She indicated the resident was on EBP. The resident was observed with a gastrostomy tube and a colostomy during the care. CNA 1 had worn gloves but had not worn a gown.During an interview after the care had been completed, CNA 1 indicated she would have to verify with the nurse if a gown should have been worn during the care to Resident D.There was a sign observed on the room door at that time indicating EBP which required a gown and gloves during care.Resident D's record was reviewed on 8/24/26 at 11:26 a.m. The diagnoses included, but were not limited to, stroke, gastrostomy, and colostomy.A Physician's order, dated 6/5/26, indicated Enhanced Barrier Precautions were to be implemented for all high contact resident care activities. An undated facility hand hygiene policy, received as current on 8/24/26 at 9:03 a.m. from Minimum Data Set (MDS) Nurse 1, indicated hand hygiene was to be completed, but not limited to, before and after having direct contact with a resident's skin, after contact with body fluids, and after glove removal.An undated facility EBP policy, received as current on 8/24/26 at 9 a.m. from MDS Nurse 1 indicated residents with indwelling medical devices, which included the gastrostomy tube were to be placed on EBP and gowns and gloves were to be worn with high-contact care activities, which included personal hygiene being provided and changing of incontinent briefs.410 IAC (Indiana Administrative Code) 3.1-18(b)

Based on record review and interview, the facility failed to ensure the resident's responsible party was notified timely after a fall occurred for 1 of 3 residents reviewed for accidents. (Resident C) Finding includes: Resident C's record was reviewed on 8/25/26 at 10:40 a.m. The diagnoses included, but were not limited to, COPD, heart disease, heart failure, diabetes, anemia, and anxiety. A Functional Abilities admission assessment, dated 8/12/26, indicated the resident's cognition, self-care, indoor mobility, and all other activities of daily living required dependent care. The resident was independent with eating. The resident was admitted on [DATE] and discharged home on 8/15/26. A Care Plan, dated 8/12/26, indicated the resident was admitted for respite stay on hospice support. A Care Plan, dated 8/12/26, indicated the resident was at risk for falls. Interventions were to offer and assist with non-skid footwear to bed and anticipate the resident's needs. A Care Plan, dated 8/12/26, indicated the resident had impaired cognitive function/dementia and impaired thought process with daily decision making. Interventions were to administer medications as ordered and communicate with the family/caregivers regarding the resident's needs and capabilities. A Nurse's Note, dated 8/13/26 at 11:00 p.m., indicated the resident was found on the floor lying on her back. The resident had bruises to the left arm which were now skin tears. The resident was confused and was talking to the television thinking it was her father. The physician was notified of the fall. There was no contact information available to contact the residents' family. A Nurses Note, dated 8/14/26 at 9:51 a.m., indicated the resident's daughter was visiting and was informed of the resident's fall and skin tear. During a telephone interview on 8/24/26 at 11: 38 a.m., Resident C's daughter indicated she was not notified of her mother's fall until the following day. During an interview on 8/25/26 at 3:01 p.m., RN Consultant 1 indicated they did not have the family's contact information at the time of the fall. A policy titled, Change in Condition Process, and received as current from the Director of Nursing on 8/25/26 at 3:30 p.m., indicated, .The facility must inform the resident, consult the resident's physician and notify the resident's family member or legal representative when there is a change requiring such notifications/ Situations requiring notification include .1. An accident involving the resident which .a. results in injury .b. Has the potential to require physician notification . This citation relates to Intake 3166895. 410 IAC (Indiana Administrative Code) 16.2-3.1--5(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a resident received meal set- up assistance to enable a resident to feed himself independently, for 1 of 5 residents observed for dining assistance. (Resident K) Finding includes:Facility staff were observed delivering the breakfast meal trays to the residents on Grace Point 1 on 8/24/26 at 7:40 a.m.During an observation on 8/24/26 at 8:00 a.m., Resident K was lying in bed. The head of the bed was at a 30 degree angle. The breakfast tray was on the over bed table, which was raised higher than the bed and placed over the resident in bed. The plate cover remained on the plate. The resident was attempting to take a drink of coffee from the full coffee cup. The oatmeal from the cereal bowl was spilled down the front of his clothing. He indicated he was messy. Permission was received to lift the plate cover off the plate. There were scrambled eggs and dry toast on the plate. The butter for the toast and jelly were sealed and sitting on the tray next to the plate.RN 2 entered the room and indicated she would assist the resident and began to clean the oatmeal off of the front of him and removed the napkin that had been placed over his chest. The resident indicated he did not want the scrambled eggs and accepted the toast. RN 2 then placed the butter on the toast, repositioned the resident in bed and elevated the head of the bed to enable the resident to feed himself the rest of the meal.Resident K's record was reviewed on 8/25/26 at 10:38 a.m. The diagnoses included, but were not limited to, subdural hemorrhage, diabetes mellitus, end stage renal disease, and the need for assistance with personal care.A Care Plan, dated 5/26/26, indicated a risk for impaired nutritional status. The interventions indicated the staff would provide assistance with meals as needed.An admission Minimum Data Set assessment, dated 5/29/26, indicated a moderately impaired cognitive status, no upper extremity impairments, and required set-up assistance for eating.A Physician's Order, date 6/3/26, indicated a regular consistency renal diet.The facility staff who passed the breakfast trays on 8/24/26 were interviewed on 8/26/26. At 8:05 a.m., RN 2 indicated she had not delivered the resident's tray. At 8:08 a.m. the Business Office Manager indicated she did not remember which resident breakfast trays she delivered. At 8:09 a.m., the Administrator in Training indicated she had not delivered the resident his tray. At 8:22 a.m., the Unit Manager indicated she did not remember if she delivered the resident's breakfast tray.This citation related to Intakes 3133315 and 3166895.410 IAC (Indiana Administrative Code) 16.2-3.1-38(a)(2)(D)

Based on record review, and interview, the facility failed to accurately assess a resident admitted for respite care and failed to implement medication and procedures applicable to their stay for 1 of 3 residents reviewed for pharmecutical services. (Resident C) Finding includes: Resident C's record was reviewed on 8/25/26 at 10:40 a.m. The diagnoses included, but were not limited to, copd, heart disease, heart failure, diabetes, anemia, and anxiety. A Functional Abilities admission assessment, dated 8/12/26, indicated the residents cognition, self-care, indoor mobility, and all other activities of daily living required dependent care. The resident was independent with eating. The resident was admitted on [DATE] and discharged home on 8/15/26. A History and Physical (H&P) report, dated 7/6/26, was uploaded into the facility system on 8/12/26. This indicated the resident had diabetes mellitus and received insulin lispro 2-5 units three times a day before meals and had blood sugar levels checked five times a day. A Care Plan, dated 8/12/26, indicated the resident required individualized comfort-based activity interventions to promote dignity, emotional support and quality of life. The resident was admitted for respite stay on hospice support. A Care Plan, dated 8/12/26, indicated the resident had impaired cognitive function/dementia and impaired thought process with daily decision making. Interventions were to administer medications as ordered and communicate with the family/caregivers regarding the resident's needs and capabilities. A Nurses Note, dated 8/12/26, indicated that the resident arrived via ambulance and medications were reconciled with the Nurse Practitioner (NP). The resident was able to make needs known and was admitted for respite care. There were no orders for insulin administration or blood sugar checks during the resident's stay. During a telephone interview on 8/24/26 at 11: 38 a.m., Resident C's daughter indicated her mother was on hospice and they had no power, so hospice had arranged for respite care at the facility. They had brought in her mother's insulin and she never received it her entire length of stay and they were also not doing blood sugar checks on her. She called and the facility told her they never had an order for insulin and blood sugar checks. The facility had her insulin because she had to go back and pick it up, it was in their refrigerator the entire time. During an interview on 8/25/26 at 10:58 a.m., the Director of Nursing (DON) indicated Resident C's son had brought the insulin later in the evening on the day she was admitted . There was no medication list provided by hospice upon admission. The hospice nurse had brought in the resident's pill bottles from home, and the medications were reconciled from the bottles. She would have expected the nurse to reconcile the insulin in the same manner as she reconciled the medication with the hospice nurse. They did not have any procedures in place for respite care. They conducted an in-service in the building, and they would no longer accept respite care unless a current medication list was provided to the facility. A physician would also need to see the resident at least once during their stay. They have not had any new residents admitted with respite care. During an interview on 8/25/26 at 11:36 a.m., RN consultant 1 indicated hospice had no power or ability to print a medication list. This admission occurred during an emergency disaster in the community. She had spoken with the resident's daughter after discharge with the DON also present, and the daughter informed them her mother was oriented and at baseline. During an interview on 8/25/26 at 2:45 p.m., RN 1 indicated she assumed all medications were reconciled in the system already when the son brought in the insulin. The son came in, handed her his mom's insulin and said, here's her insulin, can I go see my mother. This citation relates to Intakes 3044785 and 3166895. 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% for 2 of 5 residents observed during medication pass. Two errors were observed during 30 opportunities for errors during medication administration. This resulted in a medication error rate of 6.67%. (Residents L and M)Findings include:1. During a early morning Medication Pass Observation on 8/24/26 at 5:15 a.m., LPN 1 prepared Resident L's medication. She indicated the medication would be administered through the resident's gastrostomy tube (g-tube) (feeding tube). The Carb/Levo (Parkinson's disease medication) 25/100 mg (milligrams), one tablet was crushed and placed in 20 cc's (cubic centimeters) of water. LPN 1 pushed 20 cc's of water to flush the g-tube prior to administering the medication. She then pushed in the medication mixed in 20 cc's of water and pushed 20 cc's of water to flush after the medication administration.After the administration of the medication, LPN 1 indicated the flush and medication should have been administered by gravity and not pushed.LPN 1 then placed 10 cc's of lansoprazole suspension (stomach medication) three mg per milliliter (mg/ml) in a plastic medication cup. She pushed 20 cc's of water to flush the g-tube prior to the medicaton administration. The lansoprazole was administered by gravity and then the g-tube was flushed by gravity with 20 cc's of water after the medication was administered.Resident L's record was reviewed on 8/24/26 at 9:34 a.m. The diagnoses included, but were not limited to Parkinson's disease.A Physician's Order, dated 8/21/26, indicated the g-tube was to be flushed with 30 cc's of water before and after the medications were administered.A g-tube medication administration policy, dated 10/2014 and received as current from Minimum Data Set (MDS) Nurse 1, indicated water flushes were to be administered using gravity flow. The g-tube was to be flushed with 15-30 cc's of water or the prescribed amount. 2. During a morning Medication Pass Observation on 8/24/26 at 8:15 a.m., RN 2 indicated Resident M's blood sugar level was 188 and he received 10 units of humalog insulin routinely.RN 2 placed the needle on the humalog insulin pen, dialed in 10 units of insulin to be given, and indicated she was ready to administer the insulin. The insulin pen was not primed and she indicated she did not know what to prime it with. The insulin was then administered quickly with three seconds of the needle being inserted in the left arm.Resident M's record was reviewed on 8/24/26 at 9:40 a.m. The diagnoses included, but were not limited to, diabetes mellitus.A Physician's Order, dated, 8/11/26, indicated Lispro (humulog) insulin pen, 200 units per milliliter, 10 units were to be administered daily.An undated insulin pen usage policy, received as current from the Nurse Consultant 2 on 8/24/26 at 11:47 a.m., indicated the insulin pen was to be primed according to the manufacturer's instructions.The manufacturer's instructions, received on 8/25/26 at 10:34 a.m. from the Director of Nursing, indicated if the pen was not primed before each injection the resident may get too much or too little insulin. The pen was to be primed with 2 units prior to administration of the insulin. The needle was to be injected and the dose knob was to be pushed all the way in and held for a slow count to five before removing the needle from the skin.This citation relates to intakes 3044785 and 3166895.410 IAC (Indiana Administrative Code) 16.2-3.1-48(c)(1)

Based on observation, record review and interview, the facility failed to ensure infection control measures were in place and implemented related to correct isolation precautions in place for a resident on contact isolation, contracted staff not following enhanced barrier precautions during care and staff not cleaning a shared blood pressure cuff between residents. (Resident 6, phlebotomist and RN 1)Findings include:1.Resident 6 was observed in her bed on 3/16/26 at 11:15 a.m. There was an enhanced barrier precaution sign on the door and a PPE (personal protective equipment) bin next to the door. The resident's record was reviewed on 3/16/26 at 2:45 p.m. Diagnoses included, but were not limited to, cholecystitis (inflammation of the gallbladder) and urinary tract infection. The resident had been readmitted to the facility on [DATE] following a hospital stay. A Physician's Order, dated 3/13/26, indicated the resident was on contact isolation related to Strep A/ blood culture (Group A streptococcal infection). Contact sign outside resident's room. Gown and glove for high contact resident care activities. Face shield should be used for any tasks that have a high potential of splash or spray. On 3/16/26 at 2:54 p.m., the resident was observed with the Director of Nursing. She was made aware there was an order for contact isolation, but the resident was placed on enhanced barrier precautions. She indicated she would look into the issue. No further information was provided. 2.On 3/16/26 at 2:30 p.m., a phlebotomist was observed walking in the hallway toward resident's rooms. She was wearing a face mask and a blue protective gown. She entered room K, which had an enhanced barrier precautions sign on the door. Moments later she exited the room, still wearing the blue gown and face mask, and approached another resident in the common area. The resident and phlebotomist went into room [ROOM NUMBER] and closed the door. During an interview on 3/16/26 at 2:41 p.m., the Director of Nursing was made aware of the observation. She indicated the phlebotomist should have changed her gown and mask and immediately went to room [ROOM NUMBER]. The Enhanced Barrier Precautions sign, posted on the door of room K, indicated, Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: wear gloves and gowns for the following high contact resident care activities Device care or use: central lines, urinary catheters, feeding tube, tracheostomy. Wound care: any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more than one person. 3. On 3/19/26 9:09 a.m., RN 1 was observed preparing Resident 120's medications. Resident 120 had a sign on her door indicating that she was in enhanced barrier precautions. RN 1 obtained the blood pressure cuff from the top of the medication cart, entered the resident's room, and measured the resident's blood pressure. When the blood pressure reading was completed, she removed the blood pressure cuff and returned it to the top of the medication cart. RN 1 had not cleaned or disinfected the blood pressure cuff before or after use. RN 1 then continued on to prepare Resident 3's medications. Resident 3 had a sign on his door indicating that he was in enhanced barrier precautions. RN 1 obtained the blood pressure cuff from the top of the medication cart, entered the resident's room, and measured the resident's blood pressure. When the blood pressure reading was completed, she removed the blood pressure cuff and returned it to the top of the medication cart. RN 1 had not cleaned or disinfected the blood pressure cuff before or after use. RN 1 then continued on to prepare Resident 44's medications. Resident 44 had a sign on his door indicating that he was in enhanced barrier precautions. RN 1 obtained the blood pressure cuff from the top of the medication cart, entered the resident's room, and measured the resident's blood pressure. When the blood pressure reading was completed, she removed the blood pressure cuff and returned it to the top of the medication cart. RN 1 had not cleaned or disinfected the blood pressure cuff before or after use. During an interview on 3/19/26 at 10:27 a.m., the Administrator was made aware RN 1 had not cleaned the blood pressure cuff before or after use. A reuseable equipment cleaning policy was requested. A facility policy, titled Infection prevention and Control Program, indicated, .Cleaning and disinfection of environmental surfaces and reusable equipment: .b. The facility cleaning/disinfection policies include handling of equipment shared among residents [e.g. blood pressure cuffs, rehab therapy equipment etc.] c. Facility has policies and procedures to ensure that reusable medical devices are cleaned and reprocessed appropriately prior to use on another resident . 410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)

Based on observation, record review, and interview, the facility failed to keep the kitchen clean and in good repair related to dirty fans, trash cans, floors, and baseboards for 1 of 1 kitchen. (The Main Kitchen) The facility also failed to ensure a microwave and a refrigerator on 2 of 4 units were clean. (The Memory Care Unit and Independence Hall) Findings include:1. During the Kitchen Sanitation Tour on 3/16/26 at 9:20 a.m., with the Dietary Food Manager (DFM) the following was observed: a. A portable fan was observed on top of the garbage can located next to the handwashing sink. The fan had an accumulation of dirt and dried food spillage. During an interview at that time, the Dietary Food Manager (DFM) indicated the fan needed to be thrown out. b. A white garbage can located next to the handwashing sink had an accumulation of dried food spillage and debris on top of the lid and sides. c. An accumulation of dirt and debris was observed along the baseboards underneath the food prep counter.d. An accumulation of dirt and debris was observed on the floor in front of the oven.e. An accumulation of dried food spillage was observed on the white PVC pipes located underneath the food prep counter. During an interview at that time, the DFM indicated all of the above was in need of cleaning. 2. On 3/20/26 at 1:59 p.m., the microwave located in the Memory Care Unit pantry had an accumulation of dried food spillage.3. On 3/20/26 at 2:03 p.m., the refrigerator located on the Independence Hall had an accumulation of dried juice spillage on the shelves.During an interview on 3/20/26 at 2:30 p.m., the Director of Nursing indicated the microwave and the refrigerator would be cleaned. 410 IAC (Indiana Administrative Code) 16.2-3.1-19(f)

Based on observation, record review, and interview, the facility failed to ensure compression wraps were used for 1 of 1 resident with edema. The facility also failed to ensure physician's orders were in place for a biliary drain (abdominal drain inserted into the liver to assist with bile duct blockage) and the drain was monitored for 1 of 3 residents reviewed for catheters. (Residents 89 and 6)Findings include: 1. On 3/17/26 at 9:51 a.m., Resident 89 was seated in her wheelchair participating in an activity. No tubi grips (compression wraps) were visible to the resident's legs. At 11:51 a.m., the resident was seated in her wheelchair in the dining room. Again, there were no tubi grips visible to the resident's legs. At 3:05 p.m., the resident was seated in a chair in her room. Her pants were pulled down below her knees and her socks were visible. She was not wearing tubi grips on either leg. On 3/19/26 at 2:25 p.m., the resident was seated in her room watching television. During an interview at that time, the resident indicated she only had socks on and nothing else on her legs. At 3:22 p.m., LPN 1 entered the resident's room. She pulled up the resident's pant legs and pulled down her socks. She had no tubi grips in use to either leg. The record for Resident 89 was reviewed on 3/19/26 at 3:07 p.m. Diagnoses included, but were not limited to, vascular dementia and congestive heart failure. A Physician's Order, dated 2/12/26, indicated tubi grips were to be applied every morning and removed at bedtime for bilateral lower extremity edema (swelling). A Care Plan, dated 2/13/26, indicated the resident had edema to her bilateral lower extremities. Interventions included, but were not limited to, tubi grips as ordered. The Quarterly Minimum Data Set (MDS) assessment, dated 2/18/26, indicated the resident was cognitively impaired and required partial to moderate assistance with dressing. The March 2026 Treatment Administration Record (TAR) indicated the tubi grips were signed out as being applied on 3/17/26 and 3/19/26. During an interview on 3/19/26 at 3:30 p.m., the Director of Nursing ((DON) indicated the resident's tubi grips should have been applied as ordered. 2. On 3/16/26 at 11:15 a.m., Resident 6 was observed laying in her bed. There was biliary drain on the mattress next to her. The resident's record was reviewed on 3/17/26 at 2:45 p.m. Diagnoses included, but were not limited to, cholecystitis (inflammation of the gallbladder) and urinary tract infection. The resident had been readmitted to the facility following a hospital stay on 3/13/26. The Significant Change Minimum Data Set assessment, dated 1/29/26, indicated the resident had severe cognitive impairment and was dependent for toileting, bed mobility and eating. There were no physician's orders for the biliary drain or care of the drain. During an interview on 3/16/26 at 2:54 p.m., the DON was made aware there were no orders for the biliary drain or care of the drain. She indicated she would look into the issue. No additional information was provided. 410 IAC (Indiana Administrative Code) 16.2-3.1-37

Based on observation, record review, and interview, the facility failed to ensure a self-administration of medication assessment was complete and a physician's order to self-administer medication was in place, for 1 of 1 resident reviewed for self-administration of medication. (Resident 127)Finding includes:On 3/16/26 at 11:08 a.m., Resident 127 was observed sitting in the chair in his room. An unopened box of Salonpas patches (medicated pain relief patches) and a Breo Ellipta (respiratory medication) inhaler were on his overbed table.On 3/18/26 at 2:19 p.m., the resident was not in his room, but the Breo Ellipta inhaler remained on his overbed table.On 3/19/26 at 10:21 a.m., the resident was in his room preparing to leave for dialysis. The Breo Ellipta inhaler remained on his overbed table. The resident's record was reviewed on 3/20/26 at 9:23 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease. The resident was admitted to the facility on [DATE].A Physician's Order, dated 3/14/26, indicated fluticasone-salmeterol 100/25 micrograms (mcg) inhaler, inhale 1 puff two times a day. There was no Physician's Order to indicate the resident could self-administer the inhaler. There was no Physician's Order for the Salonpas patches.A Care Plan, dated 3/16/26, indicated the resident had a Physician's Order for self-administration of his inhalers.A Self-Administration of Medication Assessment, dated 3/16/26, indicated the resident wanted to self-administer some of his medications and those medications would be stored in the resident's room. The medications to be self-administered were not specified.During an interview on 3/19/26 at 1:23 p.m., the Administrator and Nurse Consultant indicated the resident had a care plan for self-administration of the inhaler, but the information had not been included in the physician's order or the medication assessment. The resident had brought in the Salonpas patches and there were no orders for the medication. The ADON had found them and taken them out of the room. A facility policy, titled, Self-Administration of Medication Program, indicated, .7. The admitting nurse or designee will complete the Self-Administration of Medication Evaluation and report the findings to the unit manager or designee. 8. a. Who will be responsible [the resident or the nursing staff] for storage [If medications are stored at the resident's bedside, a lockbox or locked drawer must be used to store the medications] .9. Once the resident has been deemed safe by the IDT an order will be obtained from the resident's physician or NP 410 IAC (Indiana Administrative Code) 16.2-3.1-11(a)

Based on observation, record review, and interview, the facility failed to ensure the current care plan was implemented related to documentation of food intake for 1 of 6 residents reviewed for nutrition and documentation of urinary catheter output for 2 of 3 residents reviewed for catheters. (Residents 32, 62 and 80)Findings include: 1. The record for Resident 32 was reviewed on 3/18/26 at 1:15 p.m. Diagnoses included, but were not limited to, Alzheimer's disease with late onset, dysphagia (difficulty swallowing) and protein calorie malnutrition. A Care Plan, dated 11/4/25 and reviewed on 1/5/26, indicated the resident had the potential for a nutritional problem related to the diagnoses of dementia, dysphagia, and protein calorie malnutrition. The resident received a mechanically altered diet and had a history of weight loss. Interventions included, but were not limited to, monitor meal consumption and record every meal. The Quarterly Minimum Data Set (MDS) assessment, dated 12/31/25, indicated the resident had short and long term memory problems and was severely impaired for daily decision making. She was also dependent on staff for eating, she had a history of weight loss, and received a mechanically altered diet. The Food Consumption documentation located in the Task section of the medical record, indicated there was no dinner intake documented on 2/20/26, 3/7/26, and 3/12/26. There was no breakfast and lunch intake documented on 2/21/26 and 3/8/26. During an interview on 3/19/26 at 4:01 p.m., the Director of Nursing (DON) indicated the resident did not have a true weight loss. She indicated the facility scale had not been calibrated in over two years and the weight loss was questionable. The DON also indicated the resident's food consumption was to be documented after each meal. 2. On 3/16/26 at 1:38 p.m., Resident 62 was observed in her room in bed. A Foley catheter was observed to be in use. The record for Resident 62 was reviewed on 3/19/26 at 9:35 a.m. Diagnoses included, but were not limited to, vascular dementia and neurogenic bladder (a dysfunction of the lower urinary tract). A Physician's Order, dated 4/13/25 and listed as current on the March 2026 Physician's Order Summary (POS), indicated the resident had a 16 French 30 milliliter (ml) Foley catheter for neurogenic bladder. The catheter was to be changed as needed for dislodgement, leakage, or blockage. A Care Plan, dated 11/5/25 and reviewed on 1/19/26, indicated the resident was at risk for complications secondary to requiring the use of an indwelling catheter related to neurogenic bladder. Interventions included, but were not limited to, monitor and document intake and output as per facility policy. The Quarterly Minimum Data Set (MDS) assessment, dated 1/19/26, indicated the resident was severely impaired for daily decision making and she had an indwelling catheter. The resident's urinary output documented in the Task section of the medical record indicated there was no urinary output documented on the following dates and shifts: Evening shift: 2/20/26, 2/25/26, 3/12/26, and 3/15/26. Day shift: 2/21/26, 2/28/26, 3/2/26, 3/8/26, and 3/11/26. Night shift: 2/22/26, 3/3/26, 3/9/26, 3/10/26, 3/11/26, and 3/14/26. During an interview on 3/19/26 at 3:40 p.m., the Director of Nursing indicated the resident's output should have been documented every shift. 3. Resident 80's record was reviewed on 3/18/26 at 1:38 p.m. Diagnoses included, but were not limited to, obstructive and reflux uropathy and neuromuscular dysfunction of the bladder. A Care Plan, revised on 3/21/24, indicated the resident had a suprapubic catheter (urinary catheter inserted directly into the bladder through the abdomen) related to neurogenic bladder and obstructive uropathy. Interventions included, but were not limited to, change suprapubic catheter monthly and as needed and record output every shift. The Quarterly Minimum Data Set (MDS) assessment, dated 12/17/25, indicated the resident was cognitively intact and had an indwelling urinary catheter. The resident was dependent on staff for toileting hygiene. The last 30 days of the CNA Tasks were reviewed. There was no documented urinary outputs in the record. During an interview on 3/19/26 at 11:15 a.m., the Nurse Consultant indicated the facility staff should not be routinely documenting urinary output and the care plan intervention should have been discontinued. 410 IAC (Indiana Administrative Code) 16.2-3.1-35(g)(2)

Based on record review and interview, the facility failed to ensure ADL (activities of daily living) care was provided to a dependent resident related to lack of documentation of incontinence care for 1 of 1 resident reviewed for ADL care. (Resident 4)Finding includes:During an interview on 3/16/26 at 11:28 a.m., Resident 4 indicated she was not receiving incontinence care routinely and would be left in a wet brief for long periods of time.Resident 4's record was reviewed on 3/19/26 at 9:44 a.m. Diagnoses included, but were not limited to, Charcot-Marie-Tooth disease (slowly progressive genetic disorders that damage peripheral nerves).A Care Plan, revised on 11/8/24, indicated the resident needed assistance with ADLs. Interventions included, but were not limited to, resident required a one staff assist for bathing and preferred bed baths.The Quarterly Minimum Data Set (MDS) assessment, dated 12/31/25, indicated the resident was cognitively intact and was dependent on staff for toileting hygiene.The CNA Task: B&B - Bladder Elimination, indicated there was no documentation of incontinence care provided on the following dates and shifts:-Day shift: 2/28/26, 3/8/26, 3/13/26, 3/15/26-Evening shift: 3/2/26, 3/6/26, 3/7/26-Night shift: 2/19/26, 2/21/26, 2/24/26During an interview on 3/19/26 at 3:44 p.m., the Director of Nursing indicated it was the expectation that the staff members were to document incontinence care at least once a shift (three times a day).410 IAC (Indiana Administrative Code) 16.2-3.1-38(a)(3)

Based on record review and interview, the facility failed to ensure a resident with a colostomy (opening in the colon that lets stools pass from the body) received appropriate treatment and services related to a lack of documentation of completed colostomy bag changes and stoma care for 1 of 1 resident reviewed for ostomies. (Resident 1)Finding includes:The record for Resident 1 was reviewed on 3/18/26 at 10:39 a.m. Diagnoses included, but were not limited to, history of cancer of the rectum, rectosigmoid, and anus, and colostomy status.A Care Plan, revised on 6/18/24, indicated the resident had an alteration in gastrointestinal status related to abdominoperineal resection (APR) (surgery that removes your sigmoid colon, rectum and anus) for rectal cancer. The resident had a colostomy. Interventions included, but were not limited to, monitor and record bowel movements (empty ostomy pouch), monitor and record peri-stoma condition, and provide and maintain appropriate ostomy supplies.The Quarterly Minimum Data Set (MDS) assessment, dated 2/24/26, indicated the resident was severely cognitively impaired. The resident had an indwelling catheter and ostomy.A Physician's Order, dated 2/26/26, indicated check colostomy pouch every shift for patency and if full, empty or change every shift and as needed.The March 2026 Medication and Treatment Administration Record indicated the colostomy pouch was monitored every shift as ordered.The record lacked documentation that the colostomy pouch was fully changed and/or stoma care was provided.During an interview with the DIrector of Nursing on 3/20 at 2:21 p.m., she had no information to provide when asked about the frequency of stoma care and complete bag changes.During an interview on 3/19/26 at 2:45 p.m., the Administrator indicated the resident's colostomy pouch was a one-piece system, meaning there was no separate wafer or pieces to the colostomy bag that needed to be changed out. There was no further information provided.A facility policy titled, Colostomy, Urostomy, or Ileostomy Care, indicated, .I. Protecting the skin around the stoma 1. Use the right size pouch and skin barrier opening. 2. Change the pouching system regularly to avoid leaks and skin irritation. 3. Be careful when pulling the pouching system away from the skin and don't remove it more than once a day unless there's a problem. Remove the skin barrier gently by pushing your skin away from the sticky barrier rather than pulling the barrier away from the skin. 4. Clean the skin around the stoma with water. Dry the skin completely before putting on the skin barrier or pouch. Watch for sensitivities and allergies to the adhesive, skin barrier, paste, tape, or pouch material.III.3. When to change the pouching system May change every day, or weekly as needed, depends on the type of pouch used.410 IAC (Indiana Administrative Code) 16.2-3.1-47(a)(3)

Based on observation, record review and interview, the facility failed to ensure G-tube (gastrostomy tube, a tube inserted directly into the stomach) flushes were instilled via gravity for 1 of 9 residents observed for medication administration. (Resident 9)Finding includes: On 3/28/26 at 3:03 p.m., LPN 2 was observed preparing Resident 9's medication. She crushed the pill and placed it in a medication cup. She entered the resident's room, washed her hands, donned a gown and gloves, filled the water bottle with tap water, put the tube feeding on hold, and checked for residual. She inserted the G-tube syringe into the water bottle and drew up 30 cc of water. She opened the G-tube and placed the syringe directly into the tube and pushed the 30 cc of water down the tube using the plunger. She diluted the medication in 30 cc of water and administered the medication and remaining flush by gravity.During an interview on 3/18/26 at 3:15 p.m., LPN 2 indicated she had not administered the initial G-tube flush by gravity. She would always administer the medications by gravity but would sometimes push the flushes in. She was unsure what the facility policy was.During an interview on 3/18/26 at 3:35 p.m., the Director of Nursing was made aware the G-tube flush had not been administered by gravity. She indicated the facility policy did not specify to administer flushes by gravity.A current facility policy, titled Placement and Residual Volume Check of Enteral Feeding Tubes indicated, .7. If acceptable placement and gastric residual volume is verified, flush feeding tube with 30 cc of water or as ordered by the physician. 8. Administer feeding and or medications as ordered, followed by flush, as appropriate .An article titled, Flushing Your Feeding Tube, published by Ohio State University Medical Center, dated 1/23/25, indicated .Steps for Flushing Your Feeding Tube.7. Pour the water into the syringe. Raise the syringe above your stomach. Let the water flow into your feeding tube by gravity.410 IAC (Indiana Administrative Code) 16.2-3.1-44(a)(2)

Based on observation, record review, and interview, the facility failed to ensure clinical records were complete and accurately documented related to clarification orders for diet and assistive devices for 1 of 6 residents reviewed for nutrition. The facility also failed to ensure urinary catheter care was accurately documented for 1 of 3 residents reviewed for catheters. (Residents 41 and 6)Findings include:1. On 3/17/26 at 11:42 a.m., Resident 41 was served a bowl of chicken and rice soup. The soup contained chunks of carrots and chicken. During an interview at that time, CNA 1 indicated the resident had orders for a pureed diet but she thought she could have soup. The CNA indicated the soup had chunks of carrots and chicken and she proceeded to take the soup from the resident. At 11:51 a.m., the resident was served thickened juice in a clear plastic cup. On 3/18/26 at 11:35 a.m., the resident was seated in her wheelchair in the dining room. She was served her lunch and a glass of thickened juice in a clear plastic cup. On 3/19/26 at 11:51 a.m., the resident was seated in her wheelchair in the dining room. She was asking for soup but was told that she couldn't have any due to the chunks of meat. She received her meal and was given thickened juice in a clear plastic cup. The record for Resident 41 was reviewed on 3/19/26 at 2:43 p.m. Diagnoses included, but were not limited to, Alzheimer's disease with late onset and dysphagia (difficulty swallowing). The Annual Minimum Data Set (MDS) assessment, dated 1/8/26, indicated the resident was moderately impaired for daily decision making and she received a mechanically altered diet. A Physician's Order, dated 2/17/26, indicated the resident was to receive a pureed diet with nectar thickened liquids. The resident was to use a scoop plate and Provale cup (a sippy cup) for meals. During an interview on 3/17/26 at 3:30 p.m., the Director of Nursing (DON) provided the resident's speech therapy discharge summary which indicated the resident could have mechanical soft pleasure feeds. The DON indicated the resident's diet order needed to be updated. During an interview on 3/19/26 at 4:01 p.m., the DON indicated the Provale cup was used when the resident was not receiving thickened liquids. The cup couldn't be used for thickened liquids and the order should have been updated. 2.On 3/16/26 at 11:15 a.m., Resident 6 was observed lying in her bed. There was biliary drain on the mattress next to her, and there was no urinary catheter observed hanging on the bed. On 3/16/26 at 2:54 p.m., the resident was observed with the DON. The DON removed her covers and indicated there was no urinary catheter, it must have been removed while in the hospital. The resident's record was reviewed on 3/17/26 at 2:45 p.m. Diagnoses included, but were not limited to, cholecystitis (inflammation of the gallbladder) and urinary tract infection. The resident had been readmitted to the facility following a hospital stay on 3/13/26. The Significant Change Minimum Data Set assessment, dated 1/29/26, indicated the resident had severe cognitive impairment and was dependent for toileting, bed mobility and eating. A Physician's Order, dated 3/13/26, indicated the resident had a urinary catheter, size 16 French with a 10-milliliter balloon, catheter care every shift. The March 2026 Treatment Administration Record indicated catheter care had been completed 3/13, 3/14, 3/15 and 3/16. During an interview on 3/18/26 at 3:15 p.m., the Administrator was made aware staff had been documenting catheter care when no catheter was present. No additional information was provided. 410 IAC 16.2-3.1-50(a)(2)

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) comprehensive assessment was accurately completed related to a Wanderguard alarm (wearable device that alarms when approaching a restricted area) not documented for a resident with history of wandering for 1 of 23 MDS assessments reviewed. (Resident 30)Finding includes: The record for Resident 30 was reviewed on 3/18/26 at 2:34 p.m. Diagnoses included, but were not limited to, dementia.A Care Plan, revised on 6/13/25, indicated the resident was an elopement risk/wanderer related to diagnosis of dementia. Interventions included, but were not limited to, check Wanderguard placement (right ankle) and function.The Physician's Order, dated 12/4/25, indicated Wanderguard to right ankle. Check placement each shift.The Quarterly Minimum Data Set (MDS) assessment, dated 12/18/25, indicated the resident had moderate cognitive impairment. The Wander/elopement alarm assessment was marked as 0 indicating not used.During an interview on 3/19/26 at 11:42 a.m., the Administrator indicated an MDS modification was going to be submitted. No further information was provided.410 IAC (Indiana Administrative Code) 16.2-3.1-31(i)

Based on record review and interview, the facility failed to ensure a resident's family/Responsible Party was notified for a new medication order, for 1 of 3 residents reviewed for family/Responsible Party notification. (Resident O)Finding includes:Resident O's record was reviewed on 8/18/25 at 1:06 p.m The diagnoses included, but were not limited to, osteomyelitis and schizophrenia.A Nurse Practitioner's Progress Note, dated 8/12/25 at 12:29 p.m., indicated the resident voiced she was not able to fall asleep at night and when she does fall asleep, she has difficulty staying asleep. A Nurse Practitioner's Order, dated 8/12/25, indicated melatonin three milligrams was to be administered every night for insomnia.There was no documentation that indicated the resident's Responsible Party/family had been notified of the change in medication.During an interview on 8/19/25 at 3:10 p.m., the Regional Nurse Consultant indicated the Responsible Party/family had not been notified of the medication order.This citation relates to Intake 2590825.3.1-5(a)(3)

Based on observation, record review and interview, the facility failed to ensure adequate supervision was in place to prevent elopement of a resident with diagnoses of dementia and bipolar in a manic state with psychotic features. The resident had indicators of being an elopement risk and behaviors of wanting to exit the facility. The facility was unaware of the resident's where abouts and the resident was found by a Good Samaritan standing in the road, approximately 0.15 miles from the facility, on a highly traveled road. The resident was returned to the facility by the Good Samaritan. (Resident E) The Immediate Jeopardy began on 6/24/25, when the facility was unaware the resident had exited the facility without supervision. The resident walked independently and was found standing on the road that runs in front of the facility at approximately 4:50 a.m. by a Good Samaritan, who assisted the resident back to the facility. The Administrator, Executive Director (ED), and the Director of Nursing (DON), were notified of the immediate jeopardy on 7/22/25 at 2:52 p.m. The immediate jeopardy was removed on 7/23/25, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility also failed to ensure a resident who had falls had documentation of a fall, assessments after the fall, family and Physician notification, investigation of the fall, assessments and follow up assessments after the falls, for 1 of 1 resident reviewed for falls. (Resident H) Findings include:1. During an interview on 7/22/25 at 5:05 a.m., the Administrator and DON indicated there had been no current elopements from the facility. The Administrator indicated if there had been an elopement, she would have reported it to the Indiana Department of Health (IDOH). During an interview on 7/22/25 at 5:21 a.m., RN 1 indicated a person from the outside community had found Resident E outside of the building on 6/24/25 and brought her back to the facility. She had not been the nurse assigned to the resident that night. The resident was last seen in the lounge across from the Nurses' Station drinking coffee and was gone from the facility approximately 30 minutes. The DON had been notified of the incident. During an interview on 7/22/25 at 5:24 a.m., LPN 2 indicated she had been the nurse assigned to Resident E. On 6/24/25, early morning, the resident was in the Dining Room/Lounge, across from the Nurses' Station, and requested coffee. She drank the coffee and said she was going back to her room. The resident was brought back to the facility through the [NAME] Unit Doors by a community person. LPN 2 indicated one of the staff members from the [NAME] Unit called the DON and the DON called the Grace Unit and directed her to go to the [NAME] Unit to assist the resident back up to the Grace Unit. There were no injuries observed. She was missing from the building about 30 minutes from the last time she was observed. She left through the front door. The Front door had been slid open and would not close when attempts were made to reset the door. LPN 1 indicated she was instructed not to document the incident. The resident had not been at the facility very long and kept her belongings packed and made statements she was going home. She also had other behaviors. During an interview on 7/22/25 at 5:33 a.m., CNA 3 indicated Resident E would make comments she was ready to go and she was not going to stay at the facility. She would wander the hallways and was exit-seeking. She never stayed in her room very long. The staff had to keep a close eye on the resident. During an interview on 7/22/25 at 6:20 a.m., the Executive Director (ED) indicated the incident had not been reported to the Indiana Department of Health (IDOH). They had not considered this event an elopement. The resident was oriented to person, place and time and was assessed as safe to be out in the community. The Administrator indicated the resident was not off the facility grounds and she had been found at the edge of the parking lot. During a telephone interview on 7/22/25 at 8:17 a.m., the Good Samaritan indicated she was driving west on the road in front of the facility about 4:50 a.m. on 6/24/25 and saw a woman who was kind of hunched over standing in the road. She indicated it was just getting light outside. She turned her car around and came back to get the resident. She indicated the resident was about a quarter of a mile down the road from the main entrance and was at the end of the turn in lane into the facility parking lot. The resident was not hesitant about getting in the car and just wanted a cup of coffee. The resident gave her a home address and informed her she did not want to go back to the facility. The resident was returned to the unit at the back of the building and the Good Samaritan indicated she had spoken to the DON on the phone. The resident had indicated her knees were hurting. On 7/22/25 at 8:45 a.m., the pathway from the front door to the approximate area where the resident was found, through the grass and not the parking lot, was walked. Once in the grassy area, it was downhill, then uphill closer to the road. The distance was measured with a sports watch and registered at 0.15 mile. A longer distance would have been walked if the resident used the driveway. There were several cars observed driving on the road. There were no sidewalks or shoulder areas along the road. Resident E's closed record was reviewed on 7/22/25 at 9:09 a.m. The diagnoses included, but were not limited to dementia, bipolar with current manic episodes with psychotic features, and unsteadiness on her feet. The admission date was 6/20/25. A Hospital History and Physical, dated 6/11/25, indicated the resident was confused at times. A Guardianship Physician's Report, dated and signed by the Physician on 6/18/25 and downloaded into the resident's record on 6/23/25, indicated the resident was impulsive and had unsafe behaviors. She was confused but able to follow commands and instructions. She had good social skills and could communicate well. She was delusional and at times and made unsafe decisions due to the confusion and delusions. The resident would likely need a long-term nursing home and eventually, as her dementia progressed, a locked memory care. Changes in the routine could cause more confusion, triggering an aggressive episode. A Guardian was needed for personal and financial needs.A Nurse's Progress Note, dated 6/20/25 at 11:30 p.m., indicated the resident packed her belongings and said she was leaving. She attempted to leave out the locked front door. The resident indicated she was not staying and wanted an Uber notified. LPN 4 informed the resident she would need to stay at least for the night and in the morning, she could notify her family. The resident calmed.An admission Clinical Observation, dated 6/20/25 at 11:45 p.m., indicated a baseline Care Plan for a risk for falls. The interventions included to educate the resident about safety reminders and what to do if a fall occurred and Physical and Occupational Therapy. The Neurological Observation indicated the resident was oriented to person. The Elopement section indicated she was able to ambulate independently, was not oriented to person, place, time. Statements were made by the resident of dissatisfaction or intention to leave. The resident was physically able to leave the facility independently. There was no Base Line Care Plan for the risk of elopement nor for resident behaviors. There was no admission/arrival to the facility note located in the record. During an interview on 7/23/25 at 2:10 p.m., the Administrator indicated the resident was admitted to the facility at 8:00 p.m. on 6/24/25, but the admission Clinical Observation note was entered in the electronic record at 11:45 p.m. on 6/24/25. An attempt was made to contact LPN 4 for clarification of the resident's orientation on 7/23/25 at 10:57 a.m. and a voicemail was left to return the call. There was no return call from LPN 4. The DON also attempted to contact LPN 4 with no return call at the time of exit on 7/24/25 at 4:15 p.m.A Skilled Evaluation, dated 6/21/25 at 10:36 a.m., indicated the resident was oriented to person, place, and time (x3), though was disoriented to person and time. During an interview on 7/23/24 at 11:33 a.m., LPN 5 indicated the resident had periods of confusion and she was forgetful at times. She was not oriented at all times and the oriented x3 may have been marked by accident. LPN 5 could not recall the status of the resident on 6/21/25.A Nurse's Progress Note, dated 6/21/25 at 11:59 a.m., indicated a family member was notified per phone at the resident's request. The family member indicated he could not pick the resident up and informed the nurse the resident was confused. The resident continued to pack her belongings and brought them to the Nurses' Station. There were no documented interventions for behavior management or to prevent elopement.During an interview on 7/23/25 at 11:33 a.m., LPN 5 indicated the family member was notified by her at the resident's request because she wanted to leave the facility. The family member had not wanted to speak to the resident and informed LPN 5 he was not coming to pick the resident up and the resident was confused.A Nurse's Progress Note, dated 6/21/25 at 4:15 p.m., indicated the resident demanded a soda and a candy bar. She was informed by the nurse that they would try to get them for her. The resident shouted she would get them herself and attempted to open the Emergency Exit and set off the alarm. There were no documented interventions for behavior management or to prevent elopement. A Nurse's Progress Note, dated 6/21/25 at 8:20 p.m., indicated the resident approached the Nurses' Station with her belongings packed and indicated she was taking the items to make up for the things that were stolen from her. The resident was redirected back to her room and after a few minutes of conversation, she calmed down and returned to her room.A Nurse's Progress Note, dated 6/21/25 at 8:56 p.m., indicated the resident was not found in her room and was located in the Bistro pulling dishes out of the cabinets, saying they were hers and they were stolen from her. LPN 4 indicated she explained to the resident that the dishes belonged to the facility. After speaking with the resident, she calmed down and returned to her room.There were no Care Plans with interventions implemented for the elopement risk and the behaviors on 6/21/25.A Nurse's Progress Note, dated 6/22/25 at 9:30 p.m., indicated aggressive and destructive behavior was exhibited. The resident entered the front foyer area and destroyed a plant, a glass vase, and the Check-In Stand. She was agitated and verbally upset. One-on-one supervision was implemented.There were no Care Plans and/or interventions implemented for the elopement risk and behaviors on 6/22/25. A Cognitive Status Assessment, dated 6/23/25 at 7:06 a.m. and completed by the Social Service Director (SSD), indicated an intact cognitive status. A Skilled Evaluation, dated 6/23/25 at 12:57 p.m., indicated the resident was anxious, agitated, and restless, had confusion and was forgetful.A Nurse Practitioner's (NP) Progress Note, dated 6/23/25 at 1:25 p.m., indicated the resident had a flight of ideas, seemed anxious and was ready to go home. The resident had dementia and needed monitored for any exit seeking behaviors. There was no Care Plan or interventions implemented for the monitoring of the exit-seeking behaviors.There were no further Elopement Assessments completed from 6/20/25 until 6/23/25.An Elopement Assessment, dated 6/23/25 at 4:04 p.m. and completed by the Social Services Director (SSD), indicated there was no history of wandering and/or elopement. There was a diagnosis of dementia and/or severe mental illness. There were no reported or documented episodes of elopement and/or attempts to elope. There were no behaviors of wandering, hanging around exits or stairways, verbalizing a strong intent to leave the facility. There was no agitation, confusion and/or disorientation and there was no display of poor judgement or engaging in theme behavior. The resident had the ability to leave the facility and the score was a 2, which indicated there was not risk for an elopement. A Nurse's Progress Note, dated 6/24/25 at 7:30 a.m. and written by the DON on 6/24/25 at 1:51 p.m., indicated the resident was banging on the front door and tried to open the door. She was verbalizing she wanted to leave. The staff were unable to redirect. One-on-one care was provided, the family was notified and arrived at the facility. The Nurse Practitioner was notified and the resident was transferred to the hospital for further evaluation. During an interview on 7/22/25 at 9:16 a.m., the DON indicated she had spoken with the person who brought the resident back to the facility and was told the resident was walking in the grass out front. Discussed this with the Administrator and ED and it was decided it was not an incident. She indicated she was unsure if it was an unusual occurrence. She indicated no one had told her not to document the event but was told what to document. During an interview on 7/22/25 at 10:44 a.m., the Administrator provided an undated investigation/timeline of the incident. The investigation indicated the resident had an intact cognitive status and was oriented to person, place, time, and situation. Behaviors were displayed on 6/22/25. On 6/23/25, staff discussed behaviors with family. On 6/24/25 at 1:29 a.m., there were no behaviors and the resident was in bed, she received a Tylenol at 3:33 a.m. for a headache and remained in bed. At approximately 3:45 - 4 a.m., she was in the Dining Room/Lounge, dressed and watching TV. At 4:35 a.m., the Nurse followed up on the Tylenol and the resident said it was effective. At 4:55 a.m., the resident was returned to the facility and she stated she was trying to go home. She was immediately placed on one-on-one's. The family arrived at the facility and decided to take the resident to the hospital. There were no employee written statements in the investigation. The Administrator indicated the investigation had been started on 6/24/25.The ED, SSD, Administrator, and DON were interviewed together on 7/22/25 at 11:35 a.m.:The ED indicated the resident had been at the facility for a short time. They were unaware of the Guardianship paper. The resident would visit with her and there was no confusion. The nurse was told not to document at that time because they wanted to make sure the documentation was factual. The SSD indicated that the resident was admitted on a Friday and she completed the Elopement Assessment and other assessments on the following Monday (6/23/25). The cognitive assessment indicated her cognition was intact and she was consistent. There was no confusion when the assessment had been completed. She did not recall looking at the Nurses' Progress Notes when she completed the assessments. She was aware of the behaviors. The Administrator indicated she had spoken to the resident, and she was talking about wanting to leave and to go home. The family had not been concerned about any other diagnoses other than the bipolar diagnosis. She indicated the administrative staff wanted to discuss the event and ensure the documentation was objective and not subjective. She indicated she did not have the name or phone number for the community person who brought the resident back to the facility and had not spoken with her to get a statement. The DON indicated she had spoken to the community person on the phone when she brought the resident back to the facility. She did not recall the name of the person. She indicated she had informed the nurse not to document because they wanted to make sure the verbiage was correct. She indicated the 6/24/25 at 7:30 a.m. entry was her own documentation. She assumed the resident was pounding on the door and saying she wanted to go home but she had not witnessed the event. She indicated it was the family who decided to transfer the resident to the hospital. During an interview on 7/24/25 at 8:56 a.m., the DON indicated the elopement assessment was to be done on admission and if the staff saw signs of a risk for elopement. There was no care plan or interventions put into place for the resident when she had signs of being an elopement risk. It was the responsibility of the nurse to do the assessment and put interventions in place until Social Service evaluated the resident. A facility elopement policy, dated 2/12/24 and received from the Administrator as current, indicated it was the intent of the facility to be aware of the residents' locations as reasonably practicable. The Immediate Jeopardy that began on 6/24/25 was removed on 7/23/25 when the facility inserviced 172 out of 179 staff members on the facility resident at risk for elopement, elopement, and missing resident policy and procedures. Staff were interviewed and indicated residents who exhibited signs of possible elopement would be reported to the Charge Nurse, DON, and Administrator. Care Plans would be implemented and interventions followed. If a resident was unable to be found, a code pink would be called and an immediate search of the building would be completed. The Administrator would be immediately notified. The Wanderguard bracelets were to be checked every shift for placement. Residents' behaviors would be reviewed by the interdisciplinary team to ensure residents at risk for elopement had appropriate interventions in place and the care plan would be revised. The non-compliance remained at a lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility will continue to inservice all new staff and all staff who have not been educated prior to their next working day. An audit was initiated for all residents in the facility and elopement risk assessments were updated. All residents who were identified as a risk were reassessed by social service and the care plan interventions were reviewed and revised if needed. The Maintenance Director checked all exit doors for proper functioning. An Elopement Drill was completed and will be completed on alternate shifts. The Social Service Director was provided education to ensure all behaviors are reviewed and appropriate interventions were in place. 2. Resident H's record was reviewed on 7/23/25 at 1:56 p.m. The diagnoses included, but were not limited to, gastrostomy tube, dysphagia, and malignant breast cancer. A Care Plan, dated 5/27/25, indicated the resident was a fall risk. The interventions indicated on 6/28/25 bolsters were added to the bed, needed items/frequently used items were within reach, and the call light would be kept in reach. An admission Minimum Data Set (MDS) assessment, dated 5/28/25, indicated a severely impaired cognitive status, no impairment of the upper and lower extremities, dependent for all activities of daily living, had a feeding tube which provided 51% or more of daily nutrition and 502 milliliters (ml) or more of fluids daily, and had a pressure reducing mattress for the bed. a. A Nurse's Progress Note, dated 6/15/25 at 8:41 a.m., indicated the resident's roommate informed the nurse that the resident had fallen from the bed on 6/14/25 on the evening shift. The resident complained of pain and discomfort of the bilateral lower extremities and grimaced in pain upon movement. There was slight swelling of the left knee with redness. The physician and the responsible party were notified. The resident was transferred to the Emergency Room. A Nurse's Progress Note, dated 6/15/25 at 3:15 p.m., indicated the resident returned from the emergency room and there were no fractures. The responsible party had been notified. There was no documentation on 6/14/25 evening shift of the fall, nursing assessment after the fall, or that the Physician and Responsible Party had been made aware of the fall. There were no follow-up assessments after the fall or return from the hospital. During an interview on 7/23/25 at 8:56 a.m., the DON indicated she was aware the resident's roommate reported the resident had fallen on 6/14/25 on the evening shift. She was unsure if the fall had actually occurred. There was no documentation of the fall or an investigation of the fall. There was no assessment of the resident after the fall. She had attempted to notify the nurse who was on duty the evening of the alleged fall and the nurse never got back with her and then she forgot to follow up on the call. She had not interviewed the CNA's who were on duty. There were no follow-up assessments after the reported fall or hospital visit. b. A Fall Progress Note, dated 6/28/25 at 1:30 a.m., indicated Resident H was found on the floor next to the bed. She had stated she was reaching for her lotion and slipped out of the bed. There were no visible injuries, and she was able to move her extremities. She denied pain or discomfort. She was assisted back to bed and vital signs and neuro checks were initiated. There were no follow-up assessments completed on 6/28/25 until 11:30 p.m. There were no follow-up assessments completed from 6/28/25 at 11:30 p.m. to 6/29/25 at 3:01 p.m. There were no follow-up assessments completed from 6/28/25 at 11:30 p.m. to 6/29/25 at 3:01 p.m. and 9:18 p.m. There were no follow-up assessments completed from 6/29/25 at 9:18 p.m. to 6/30/25 at 10:20 a.m. and 3:13 p.m. There were no follow up assessments completed from 6/29/25 at 9:18 a.m. to 6/30/25 at 10:20 a.m. There were no follow-up assessments completed from 6/30/25 at 6:30 p.m. to 7/1/25 at 6:36 p.m. c. A Fall Follow-up assessment, dated 7/18/25 at 11:53 a.m., indicated a recent fall, no report of pain, no injury, no change in cognition or mental status, no change in activity of daily living status or mobility, and no changes in physician's orders related to the event. A Change of Condition Summary, dated 7/18/25 at 11:58 a.m., indicated the resident had fallen, vital signs were obtained. There were no changes in mental status and the Nurse Practitioner was notified. There were no neurological assessments completed after the fall. There were no post fall follow-up assessments documented. During an interview on 7/23/25 at 8:56 a.m., the DON indicated the nurse had documented the fall in the electronic record on a change of status form instead of a fall event, so it had not transferred over to the report sheet. There were no neurological assessments completed and there was no documentation about the fall, the location or the cause of the fall. There were no witnesses to the fall so neurological assessments should have been completed. A facility policy for fall management, dated 1/13/25 and received form the Corporate Regional RN as current, indicated a post-fall assessment was to be completed, which included vital signs, neurological assessment for all unwitnessed falls and if the resident hit their head. The post fall documentation was to include the circumstances and location of the fall, range of motion status, injuries observed, vital signs, neurological status, and post-fall interventions. A post-fall assessment was to be completed on each shift for 72 hours and documented in the medical record. This citation relates to Complaint 1811008. 3.1-45(a)(2)

Based on observation, record review and interview, the facility failed to ensure residents received necessary care and services, related to, treatments to surgical sites were not completed, glucometer monitoring (blood sugar checks) were not completed and orders not clarified for the glucometer monitoring, a thorough admission assessment was not completed, a elopement risk assessment was not completed accurately, insulin was not administered as ordered, and bruising un unknown cause was not investigated and monitored, for 4 of 12 residents reviewed for quality of care. (Residents D, E, F, and M)Findings include:1. During an observation on 7/23/25 at 2:42 p.m., the Wound Nurse indicated Resident D had two surgical wounds located on the left ischium and on the sacral area. There was a dressing on each of the areas with the date of 7/21/25. Both areas were washed and patted dried, covered with calcium alginate (wound treatment) and covered with foam dressings. She indicated the wounds were improving. Resident D’s record was reviewed on 7/24/25 at 10:13 a.m. The diagnoses included, but were not limited to, osteomyelitis, stroke, and post-surgical closure and debridement of stage four (full thickness) pressure ulcers. The admission date was 6/20/25. A Care Plan, dated 6/24/25 and revised on 7/17/25, indicated there were surgical wounds on the left ischium and sacrum area. The interventions included the treatment would be completed as ordered. An admission Minimum Data Set assessment, dated 6/26/25, indicated an intact cognitive assessment, surgical wounds were present, was receiving an antibiotic, and had intravenous (IV) medications and access. a. A Skin/Wound Note, dated 6/20/25 at 4:30 p.m., indicated the resident had been admitted from an acute care facility. A head-to-toe assessment was completed. There was an IV line in the left upper arm, a feeding tube, colostomy, and urinary catheter present. There was a surgical site observed on the right hip with 10 sutures and 24 staples. The coccyx and left ischium both had six sutures, and the right ischium had eight sutures. There were pressure ulcers on the bilateral heels. New orders were received from the Nurse Practitioner and skin would be re-assessed in a week. There was no admission Assessment completed at the time of admission other than the Skin and Wound Note. A facility policy for the admission assessments, dated 9/1/24, and received from the Administrator as current, indicated the residents were to have a comprehensive assessment upon admission to identify each resident’s physical, emotional, psychological, and social needs. b. The Physician’s admission Orders indicated an order on 6/20/25 to monitor the blood glucose four times a day and on 6/21/25 there was also an order to complete blood sugar glucose testing twice a day. There was no clarification of the blood sugar monitoring orders. The blood sugars had not been completed on the Medication and Treatment Administration Records from 6/21/25 to 7/24/25. c. A Physician’s Order, dated 6/21/25 and discontinued on 7/8/25, indicated the coccyx (sacrum) surgical site was to be cleansed with normal saline, patted dry, and a foam dressing was to be applied every day shift and as needed for dislodgement/soilage. The Treatment Administration Record (TAR), dated 7/2025, indicated the treatment had not been completed on 7/5/25 A Physician’s Order, dated 6/21/25 and discontinued on 7/8/25, indicated the left ischium surgical site was to be cleansed with normal saline, patted dry, and a foam dressing was to be applied every day shift and as needed for soilage/dislodgement. The TAR, dated 7/2025, indicated the treatment had not been completed on 7/8/25. During an interview on 7/24/25 at 1:33 p.m., the Director of Nursing indicated the blood sugar monitoring had not been completed. The order had not been transcribed correctly so it had not been transferred over to the Medication Administration Record. She indicated the resident was not diabetic. She acknowledged the treatment had not been completed as ordered and an admission Assessment should have been completed. 2. Resident E’s closed record was reviewed on 7/22/25 at 9:09 a.m. The diagnoses included, but were not limited to dementia, bipolar with current manic episodes with psychotic features, and unsteadiness on her feet. The admission date was 6/20/25. A Nurse’s Progress Note, dated 6/20/25 at 11:30 p.m., indicated the resident packed her belongings and stated she was leaving the facility. An admission Clinical Observation was dated 6/20/25 at 11:45 p.m. The Neurological Observation indicated the resident was oriented to person. The Elopement section indicated she was able to ambulate independently, was not oriented to person, place, time. Statements were made by the resident of dissatisfaction or intention to leave. The resident was physically able to leave the facility independently. A Skilled Evaluation, dated 6/21/25 at 10:36 a.m., indicated the resident was oriented to person, place, and time (x3), though was disoriented to person and time. During an interview on 7/23/24 at 11:33 a.m., LPN 5 indicated the resident had periods of confusion and she was forgetful at times. She was not oriented at all times and the “oriented x3” may have been marked by accident. LPN 5 could not recall the status of the resident on 6/21/25. A Nurse’s Progress Note, dated 6/21/25 at 11:59 a.m., indicated the resident had packed her belongings and was wanting to leave. A family member indicated the resident was confused. A Nurse’s Progress Note, dated 6/21/25 at 4:15 p.m., indicated she had attempted to exit the facility using the Emergency Exit due to wanting to get a soda and candy bar and the alarm was activated. A Nurse’s Progress Note, dated 6/21/25 at 8:20 p.m., indicated she had packed her belonging and thought someone was stealing from her. A Nurse’s Note, dated 6/21/25 at 8:56 p.m., indicated she was pulling plates from a cabinet in the Bistro and telling staff they were hers and someone had stolen them. A Nurse’s Note, dated 6/22/5 at 9:30 p.m., indicated the resident was in the front foyer area and had aggressive and destructive behavior. A Cognitive Status Assessment, dated 6/23/25 at 7:06 a.m., indicated an intact cognition status. A Skilled Evaluation, dated 6/23/25 at 12:57 p.m., indicated the resident was agitated, anxious, and restless. She had confusion and was forgetful. A Nurse Practitioner’s Progress Note, dated 6/23/25 at 1:25 p.m., indicated the resident had a flight of ideas, seemed anxious and was ready to go home. She had dementia and needed to be monitored for any exit seeking behaviors. The Elopement Risk Assessment, dated 6/23/24 at 4:04 p.m. and completed by the Social Service Director, included the following questions: - Is there a history (prior to admission) of wandering/elopement and/or does the resident verbalize a strong desire to leave? This was marked no. - Is there a diagnosis of dementia and/or severe mental illness? This was marked yes - Was there any reported/documented episodes of elopement and/or attempts to elope? This was marked no. - Are there signs of compromised decision capacity and substantially impaired judgement and/or physical status limitations that would place the resident at risk in the community? This was marked no. The Behavioral Observations indicated if 6 or more triggers, makes the resident a possible elopement risk: - Does the resident, hang around the facility exits and/or stairways? (if yes, score 2 points). This was marked no - Does the resident verbalize a serious/strong intent to leave the facility in the absence of an appropriate discharge plan? (if, yes, score 3 points). This was marked no - Does the resident have the physical ability to leave the building? (if yes, score 1 point). This was marked yes. - Does the resident become agitated, confused, and/or disoriented or displays consistently poor judgement (i.e would not be able to safely care for hi/herself outside of the facility)? (if yes, score 2 points) This was marked no. The assessment indicated the combined score was 2 and the resident was not a risk for elopement. The Nurse’s Progress Notes indicated the above questions would have been a yes, making the score 8 and the resident was at risk for elopement. During an interview on 7/22/25 at 11:35 a.m., the Social Service Director indicated she did not recall if she reviewed the Nurses’ Progress and Skilled Notes prior to the completion of the Elopement Risk Assessment. 3. Resident F’s record was reviewed on 7/23/25 at 9:23 a.m. The diagnoses included, but were not limited to, dementia, long term use of insulin, depression, diabetes, and hypertension (high blood pressure). The 5/27/25 admission Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making and he received insulin. A Care Plan, dated 6/3/25, indicated the resident was at risk for complications related to diagnosis of diabetes. Interventions included, but were not limited to, administer diabetes medication as ordered and monitor/document for side effects and effectiveness. A Physician’s Order, dated 5/21/25, indicated the resident was Insulin Dependent. A Physician’s Order, dated 5/23/25, indicated the resident received a Humalog Injection (insulin injection) per sliding scale (amount of medication needed is based on blood sugar levels) subcutaneously (applied under the skin) before meals and at bedtime. A Physician's Order, dated 7/1/25, indicated the resident received 5 units of Insulin Glargine subcutaneously at bedtime. The June 2025 Medication Administration Record (MAR) indicated the Humalog was not signed out as given and no blood sugar level was documented on 6/24/25 at 11:00 a.m., and 6/27/25 at 9:00 p.m. The July 2025 Medication Administration Record (MAR) indicated the Insulin Glargine was not signed out as given and no blood sugar level was documented on 7/1/25 at 9:00 p.m. During an interview on 7/23/25 at 4:00 p.m., the nurse consultant indicated she had no answer as to why insulin was not given or documented on 6/24, 6/27, and 7/1/25. 4. Resident M’s record was reviewed on 7/24/25 at 9:00 a.m. The diagnoses included, but were not limited to, dysphagia (difficulty swallowing), parkinsonism, gastrostomy status, diabetes, and chronic respiratory failure. The 5/19/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was severely impaired for daily decision making. A Care Plan, dated 6/2/25, indicated the resident had diabetes. Interventions included, but were not limited to, administer diabetes medication as ordered and monitor for adverse effects, monitor/document/report signs of hyperglycemia and hypoglycemia. A Physician’s Order, dated 7/3/25, indicated the resident received 20 units of Lantus insulin subcutaneously two times a day. The June 2025 Medication Administration Record (MAR) indicated the Lantus was not signed out as given on 6/6, 6/7, 6/13, 6/14, and 6/15/2025 for the 8:00 p.m. dose. The July 2025 Medication Administration Record (MAR) indicated the Lantus was not signed out as given on 7/12/25 for the 8:00 p.m. dose. During an interview on 7/24/25 at 10:18 a.m., the Director of Nursing indicated she did not have an answer to why Resident M’s insulin was not given and signed out. No further information was provided. This citation relates to Complaints 1810989, 1811010, and 1811012. 3.1-37(a)

Based on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act related to an allegation of physical and sexual abuse for 1 of 1 resident reviewed for abuse. (Resident E) Finding includes:Resident E's closed record was reviewed on 7/22/25 at 9:09 a.m. The diagnoses included, but were not limited to dementia, bipolar with current manic episodes with psychotic features, and unsteadiness on her feet. The admission date was 6/20/25. A Nurse's Progress Note, dated 6/20/25 at 11:30 p.m., indicated the resident voiced an allegation that she had been both physically and sexually assaulted the day earlier.During an interview on 7/22/25 at 11:35 a.m., the Administrator indicated the allegation had not been investigated or reported immediately to the Administrator, Indiana Department of Health (IDOH), the resident's previous facility, physician, responsible party, or local law enforcement.A Reported IDOH Incident, dated 7/22/25, indicated the Administrator was notified of a Progress Note that indicated an allegation of physical and sexual abuse. LPN 4 had indicated she thought the resident was in a manic state and the allegation was related to the mental state at the time the allegation was voiced. The Resident's family and Physician were notified on 7/22/25.The facility abuse policy, dated 9/1/24 and received as current from the Administrator, indicated the employees were required to report any allegation of abuse to the Administrator immediately or to the immediate supervisor. Any allegation of abuse was to be investigated and reported to the IDOH.3.1-28(c)

Based on observations, record review, and interview, the facility failed to ensure a resident's tube feeding was infusing at the correct flow rate for 1 of 3 residents reviewed for feeding tube usage. (Resident H)Finding includes:During an observation on 7/22/25 at 3:03 p.m., the liquid tube feeding for Resident H was not infusing.During an observation on 7/23/25 at 11:51 a.m., the liquid tube feeding of Jevity 1.5 was infusing at 60 cc/hr (cubic centimeters per hour).Resident H's record was reviewed on 7/23/25 at 1:56 p.m. The diagnoses included, but were not limited to, gastrostomy tube and dysphagia.A Care Plan, dated 5/26/25, indicated a feeding tube was present. The interventions indicated the tube feeding and water flushes were to be administered as ordered by the Physician.An admission Minimum Data Set assessment, dated 5/28/25, indicated a severely impaired cognitive status and had a feeding tube and it provided 51% or more of daily nutrition and 502 milliliters or more of fluids daily. A Physician's Order, dated 7/17/25, indicated a liquid feeding of Jevity 1.5 at 60 cc/hr for 18 hours. Turn the feeding off at 8:00 a.m. and turn the feeding on at 2:00 p.m. The Medication Administration Record, dated 7/2025, indicated the enteral feeding order was one time per day of Jevity 1.5 at 60 cc/hr for 18 hours for a total of 1350 cc's. Turn feeding off at 8:00 a.m. and on at 2:00 p.m. The time was documented as 5:30 p.m. and was being checked off as done. During an interview on 7/23/25 at 4:46 p.m., the Director of Nursing indicated she would re-write the feeding tube orders to make the orders clearer. This citation relates to Complaint 1811010.3.1-44(a)(2)

Based on record review and interview, the facility failed to notify a resident's Physician in a timely manner, related to a change in status of a skin abrasion, for which a resident was admitted to a hospital due to infection of the area to be treated with intravenous antibiotics, for 1 of 3 residents reviewed for Physician notification in a total sample of 3. (Resident #B) Finding includes: Resident B's record was reviewed on 09/02/16 at 10 a.m. The resident's [DIAGNOSES REDACTED]. A Nurses' Progress Note, dated 08/18/16 at 7:41 a.m. indicated an abrasion to the left elbow was found, cleaned and a Duoderm ([MEDICATION NAME] dressing for wounds) dressing was applied. A Skin Condition form, dated 08/18/16, indicated an area on the left elbow, which measured 4 centimeters (cm) by 4 cm was found by nursing and the resident's Physician was notified. A physician's orders [REDACTED]. A Nurses' Progress Note, dated 08/22/16 at 3:59 p.m., a late entry for 08/21/16 (no time documented) indicated, the left elbow had a border gauze (absorbs drainage) in place and a dressing change to the left outside elbow had been completed with a duoderm dressing being placed over the left elbow area. The note indicated a normal saline flush was used to loosen the border gauze dressing and the area was open on the edges of the wound with a dark red area in the center of the wound. The note indicated, .Area measured 9 cm x (by) 5 cm with darker red area 6 cm x 2 1/2 cm @ widest part . A Wound Care Specialist Note, dated 08/23/16, indicated the resident had an unstageable necrotic pressure area on the left outer elbow, which measured 6.3 cm by 2.5 cm, with redness and induration (hardening) with the surrounding area of the wound purple/maroon colored. The left elbow had heavy serous (clear) drainage and the wound was 60% covered with necrotic tissue. Additional information on the note, indicated, Wound debrided .considerable swelling and watery discharge, large amount necrotic tissue debrided but concerned with extent of induration and infection. Feel wisest to admit to hospital . An emergency room History and Physical, dated 08/23/16, indicated the resident had an odorous and draining wound to the left elbow, with purulent (contains pus) drainage, surrounded by redness and swelling to the left elbow and forearm. The differential [DIAGNOSES REDACTED]. A Hospital Admission History and Physical, dated 08/25/16, indicated, .A local doctor tried to do debridement but could not .examined by the ER (emergency room ) physician, and he agreed that she has a pretty badly infected wound on the left elbow that needs debridement and IV antibiotics .Final Impression: 1. Decubitus ulcer, quite large, stage 3 (full thickness skin loss involving damage or necrosis of subcutaneous tissue), infected, left elbow. Needs debridement and intravenous antibiotics . During an interview on 09/02/16 at 2:10 p.m., the Unit Manager indicated when she observed the area on 08/22/16 (Monday), there were two areas on the left elbow which were red and swollen with drainage and she immediately notified the Physician. The Unit Manager continued to indicate an investigation was started on 08/22/16 because of the change in condition of the left elbow. She indicated the area on the left elbow was found on 08/18/16 (Thursday) and was classified as an abrasion, the Nurse Practitioner was notified and an order for [REDACTED].#1 had not notified the Physician in the change of condition of the area. The Unit Manager indicated on 08/21/16 (Sunday), RN #2 replaced the border gauze with a Duoderm dressing. The investigation, dated 08/29/16, indicated on 08/21/16 at 2:55 p.m., RN #2 completed a dressing change to the left elbow and used normal saline to remove the border gauze dressing. The area was draining, red and swollen, and one area measured 9 cm by 5 cm and the second area measured 6.5 cm by 2 cm. RN #2 left the wound open to air until it dried then re-applied a Duoderm dressing. The Unit Manager indicated the Physician had not been notified of the change in condition. A statement, dated 09/01/16, indicated a review of the events from 08/18/16 and 08/19/16 with LPN #1 had occurred. LPN #1's statement indicated on 08/18/16 she observed an unopened abrasion on the left elbow, notified the Physician and a Duoderm dressing was ordered. LPN #1 indicated on 08/19/16 the Duoderm had come off the left elbow and the area was crusty, red and had started to bleed LPN #1 indicated she cleaned the area and applied [MEDICATION NAME] and border gauze. LPN #1 indicated she did not remember if she called the Physician. During an interview on 09/02/16 at 3:20 p.m., LPN #1 indicated she did not remember if the Physician had been notified of the change in condition of the left elbow on 08/19/16. LPN #1 indicated the facility policy was to notify the Physician with a change in condition. A facility policy, dated 12/07/11, titled, Change of Condition, received from the Director of Nursing as current, indicated, .The physician/responsible party will be notified when: a. The change is sudden in onset, OR b. Represents a marked changed (sic) in relation to usual signs and symptoms .Symptoms of an infectious process .need to significantly alter the resident's treatment .The nurse will document in the clinical record. Documentation and assessment will be ongoing until condition has stabilized . This Federal tag relates to Complaint IN 664. 3.1-5(a)(2)

Based on record review and interview, the facility failed to ensure a resident received necessary treatment and services to promote healing of pressure sores and prevention of infections, related to a treatment without a physician's orders [REDACTED]. (Resident #B) Finding includes: Resident B's record was reviewed on 09/02/16 at 10 a.m. The resident's [DIAGNOSES REDACTED]. A Nurses' Progress Note, dated 08/18/16 at 7:41 a.m. indicated an abrasion to the left elbow was found, cleaned and a Duoderm ([MEDICATION NAME] dressing for wounds) dressing was applied. A Skin Condition form, dated 08/18/16, indicated an area on the left elbow, which measured 4 centimeters (cm) by 4 cm was found by nursing and the resident's Physician was notified. A physician's orders [REDACTED]. There were no assessments of the left elbow area in the Nurses' Progress Notes on 08/19/16. The Daily Skilled Note, dated 08/19/16 at 10:11 p.m., indicated the resident had no skin conditions. There were no assessments of the left elbow area in the Nurses' Progress Notes on 08/20/16. The Daily Skilled Note, dated 08/20/16 at 10:02 a.m., indicated the resident had a left elbow dressing, the note was signed and dated 08/23/16. There was no assessment of the area. The Daily Skilled Note, dated and signed 08/21/16 at 3:46 p.m., indicated the resident had a left elbow dressing. There was no assessment of the area. A Nurses' Progress Note, dated 08/22/16 at 3:59 p.m., a late entry for 08/21/16 (no time documented) indicated, the left elbow had a border gauze (absorbs drainage) in place and a dressing change to the left outside elbow had been completed with a Duoderm dressing being placed over the left elbow area. The note indicated a normal saline flush was used to loosen the border gauze dressing and the area was open on the edges of the wound with a dark red area in the center of the wound. The note indicated, .Area measured 9 cm x (by) 5 cm with darker red area 6 cm x 2 1/2 cm @ widest part . A Wound Care Specialist Note, dated 08/23/16, indicated the resident had an unstageable necrotic pressure area on the left outer elbow, which measured, 6.3 cm by 2.5 cm, with redness and induration (hardening) with the surrounding area of the wound purple/maroon colored. The left elbow had heavy serous (clear) drainage and the wound was 60% covered with necrotic tissue. Additional information on the note indicated, Wound debrided .considerable swelling and watery discharge, large amount necrotic tissue debrided but concerned with extent of induration and infection. Feel wisest to admit to hospital . A Nurses' Progress Note, dated 08/23/16 at 5:17 p.m., indicated an order was received to transfer the resident to the Hospital emergency room for evaluation and treatment of [REDACTED]. An emergency room History and Physical, dated 08/23/16, indicated the resident had an odorous and draining wound to the left elbow, with purulent (contains pus) drainage, surrounded by redness and swelling to the left elbow and forearm. The differential [DIAGNOSES REDACTED]. A Hospital Admission History and Physical, dated 08/25/16, indicated, .A local doctor tried to do debridement but could not .examined by the ER (emergency room ) physician, and he agreed that she has a pretty badly infected wound on the left elbow that needs debridement and IV antibiotics .Final Impression: 1. Decubitus ulcer, quite large, stage 3 (full thickness skin loss involving damage or necrosis of subcutaneous tissue), infected, left elbow. Needs debridement and intravenous antibiotics . During an interview on 09/02/16 at 2:10 p.m., the Unit Manager indicated when she observed the area on 08/22/16 (Monday), there were two areas on the left elbow which were red and swollen, and had drainage and she immediately notified the Physician. The Unit Manager continued to indicate an investigation of the change of condition of the left elbow was started on 08/22/16. She indicated the area was found on 08/18/16 (Thursday) and was classified as an abrasion, the Nurse Practitioner was notified and an order for [REDACTED].>The Unit Manager indicated on 08/19/16 (Friday), LPN #1 removed the Duoderm dressing and applied a border gauze dressing and indicated the left elbow was open and draining. The Unit Manager indicated LPN #1 had not notified the Physician in the change of condition of the area and there had not been a physician's orders [REDACTED]. The Unit Manager indicated on 08/21/16 (Sunday), RN #2 replaced the border gauze with a Duoderm dressing. The investigation, dated 08/29/16, indicated on 08/21/16 at 2:55 p.m., RN #2 completed a dressing change to the left elbow and used normal saline to remove the border gauze dressing. The area was draining, red and swollen and one area measured 9 cm by 5 cm and the second area measured 6.5 cm by 2 cm. RN #2 left the wound open to air until it dried then re-applied a Duoderm dressing. A statement, dated 09/01/16, indicated a review of the events from 08/18/16 and 08/19/16 with LPN #1 had occurred. LPN #1's statement indicated on 08/18/16 she observed an unopened abrasion on the left elbow, notified the Physician and a Duoderm dressing was ordered. LPN #1 indicated on 08/19/16 the Duoderm had come off the left elbow and the left elbow area was crusty, red and had started to bleed LPN #1 indicated she cleaned the area and applied [MEDICATION NAME] and border gauze. LPN #1 indicated she did not remember if she called the Physician to obtain an order for [REDACTED].>During an interview on 09/02/16 at 3:20 p.m., LPN #1 indicated she did not remember if the Physician had been notified of the change in condition of the left elbow on 08/19/16. LPN #1 indicated she could not remember if she had a physician's orders [REDACTED]. A facility policy, dated 01/14/14, titled, Wound Management, received as current from the Clinical Documentation Specialist, indicated, .Daily Skin Observation - to be done by RN/LPN or CNA daily during routine care .An assessment will be used to provide a consistent means of wound evaluation .The wound will be treated according to physician's orders [REDACTED]. This Federal tag relates to Complaint IN 664. 3.1-40(a)(2)

Based on record review, and interview the facility failed to ensure interventions and treatments were obtained for pressure ulcers, resulting in worsening of the pressure ulcers for 1 of 3 residents reviewed for pressure ulcers of the 8 who met the criteria for pressure ulcers. This failure resulted in the deterioration of a right outer ankle wound from a Stage 2 pressure ulcer to an Unstageable pressure ulcer and a right ear wound from a Stage 2 pressure ulcer to a Stage 4 pressure ulcer. (Resident #19) Findings include: 1. The closed record for Resident #19 was reviewed on 6/8/16 at 9:15 a.m. The resident's [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The 4/7/16 Quarterly Minimum Data Set (MDS) assessment indicated the resident was at risk for pressure ulcers, currently had one unstageable pressure ulcer and one stage 4 pressure ulcer that were present on admission. A care plan dated 4/1/16 indicated the resident had a pressure ulcer to her left hip and her ankle. The interventions included: .administer treatments as ordered and monitor for effectiveness .low air loss mattress with bolsters . The intervention of protective foam boots to BLL (bilateral lower extremities). Offload pressure from R (right) ankle wound when possible was added on 4/6/16. The intervention of waffle foam or neck roll when in bed to offload pressure from Rt(right) ear was added on 4/21/16. Review of the Admit/Readmit Screener, dated 3/31/16, indicated the resident had a stage 2 pressure ulcer to her right outer ankle measuring 3 cm (centimeters) x (by) 3 cm, a stage 4 pressure ulcer to left hip, and two stage 2 pressure ulcers to the left buttocks. Review of the Weekly Wound Flow Sheet, dated 3/31/16, indicated the resident had a stage 2 pressure ulcer to her right ear measuring 0.75 cm x 0.5 cm. The following note was written under the additional comments section: Discovered small pressure area upper R (right) ear after resident admitted and family had left the building. Review of a Progress Note, dated 3/31/16 at 11:30 p.m., indicated .Noted small pressure sore to R (right) inner ear, notified (name) NP (nurse practitioner) and resident's daughter . Review of the Physician Admission Note, dated 4/1/16, indicated the resident had a pressure ulcer of the left hip with a wound vac and the wound doctor was to consult. Review of the Wound Care Specialist Evaluation, dated 4/5/16, indicated the resident had a stage 4 pressure ulcer to the left lateral hip and the pressure ulcer to the right lateral ankle was now an unstageable due to necrosis (dead tissue) measuring 2 x 0.8 x 0.2 cm. The right ankle wound was 100% necrotic tissue. The Wound Doctor performed surgical debridement of the right ankle wound and recommended a treatment to the area of hydrogel, [MEDICATION NAME], and a protective dressing daily. Review of the Wound Care Specialist Evaluation, dated 4/12/16, indicated the pressure ulcer to the right lateral ankle was now a stage 3 and measured 1 x 1 x 0.2 cm. The wound was 30% yellow necrotic tissue and 70% granulation tissue. Surgical debridement was performed to the area and the same treatment was continued. Review of the Wound Care Specialist Evaluation, dated 4/19/16, indicated the right lateral ankle pressure ulcer was a stage 3 measuring 1.7 x 1.5 x 0.2 cm and was 100% granulation tissue. The Wound Doctor indicated there was a generalized decline of the resident's health. The resident now also had a stage 4 pressure ulcer to the right ear measuring 2.2 x 0.7 x 0.2 cm. The evaluation indicated the area had exposed cartilage and was unavoidable secondary to rapid clinical and nutritional decline of the resident. The Wound Doctor recommended a treatment of [REDACTED]. Review of the Weekly Wound Flow Sheet, dated 4/19/16, indicated the resident had a stage 4 pressure ulcer to the right ear measuring 2.2 x 0.7 x 0.2 cm with an onset date of 3/30/16. Review of a physician's orders [REDACTED]. Review of the Hospice physician's orders [REDACTED]. Review of the March 2016 and April 2016 Medication Administration Records (MAR) and Treatment Administration Records (TAR) lacked documentation the resident had received any treatment to the right lateral ankle pressure ulcer until 4/5/16 after the Wound Doctor had evaluated the area. The record lacked documentation the resident had received any treatment or intervention to the right ear pressure ulcer until 4/16/16 when ordered by Hospice. Interview with the Director of Nursing (DON) on 6/10/16 at 11:21 a.m. indicated she had spoken to the admitting nurse and she did not remember the resident having a pressure ulcer to her right ear on 3/31/16. She indicated she had spoken to the Wound Nurse and she did not remember finding the pressure ulcer to the resident's right ear on 3/31/16 and was unsure as to why she would have charted that. She indicated the Wound Nurse told her I don' t know what to tell you and if the resident had the area to her right ear on 4/5/16 they (the Wound Nurse and the Wound Doctor) would have assessed it on the Wound Doctor's initial visit. She indicated the Wound Nurse indicated to her the first time she was aware of the area to the resident's right ear was 4/19/16. She further indicated there was no treatment to the right lateral ankle pressure area from 3/31/16 until 4/5/16. She indicated the resident was provided a low air loss mattress on admission and the facility had provided her with foam boots prior to 4/5/16 but it had not been documented anywhere. A policy titled Wound Management, dated 1/14/14, received from the DON as current on 6/10/16 at 12:16 p.m. indicated .3 .A. Pressure Ulcers .Pressure ulcers are staged to determine the extent of tissue damage. treatment of [REDACTED]. 3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to provide adequate supervision to prevent accidents related to transferring a resident with assistance and assistive devices per the resident's plan of care for 1 of 3 residents reviewed for fractures in the sample of 13. This deficient practice resulted in an ankle fracture. (Resident #C) (CNA #3) Finding include: On 2/12/13 at 10:00 a.m., CNA #1 and CNA #2 were observed transferring Resident #C from the bed into a recliner chair in her room. The resident was transferred using a mechanical left. There was a dressing on the resident's right ankle area. The record for Resident #C was reviewed on 2/12/13 at 11:00 a.m. The resident's [DIAGNOSES REDACTED]. Review of the 1/2/13 Orthopedic physician progress notes [REDACTED]. Review of the 10/3/12 Minimum Data Set (MDS) significant change assessment indicated the resident required extensive assistance of two or more staff members for transfers. Review of the 12/2012 Physician orders [REDACTED]. Review of the 2/2013 Physician order [REDACTED]. The 12/2012 Nurses' Notes were reviewed. An entry made on 12/3/12 at 10:30 a.m., indicated the Nurse was called to the resident's room and observed the resident lying in a supine position on the floor. The entry also indicated a deformity to the right ankle with active bleeding was observed. The entry also indicated the resident complained of pain and rated the pain at a severity level of ten based on a scale of one to ten. An entry made at 10:50 a.m. indicated the Paramedics arrived at the facility and the resident was transferred to the hospital at 11:00 a.m. An "Incident and Accident Report" dated 12/3/12 was received from the Director of Nursing and reviewed 2/12/13 at 2:00 p.m. The report indicated Resident #C was transferred from a bedside commode to a recliner, became dizzy, and fell to the floor. The report indicated a deformity to the resident's right ankle was observed and the resident was sent to the hospital. An "Investigation Conclusion" form was attached to the above "Incident and Accident Report". The form indicated the Nurse observed the resident lying on the floor in the supine position. The form also indicated blood and a deformity were noted to the right ankle. The form also indicated the IDT (Inter Disciplinary Team) determined the cause of the fall was related to a CNA not utilizing a gait belt and not having assistance when transferring the resident. The resident's care plan and care card were also attached to the above "Incident and Accident Report." A care plan initiated on 10/5/12 indicated the resident was at risk for falls related to a history of a fall, obesity impairing mobility, and a history of stating "My knees give out." Care plan interventions included staff to transfer the resident with a full mechanical lift if the resident felt weak, dizzy, or fatigued. The care card indicated the resident was to be transferred with two assist and a gait belt was to be used when transferring the resident. When interviewed on 2/12/13 at 2:35 p.m., the Director of Nursing indicated CNA #3 transferred the resident from the bed to the bedside commode and then when transferring the resident from the bedside commode to the chair the resident started to get up and fell . The Director of Nursing indicated Resident #C was to be transferred with the assistance of two staff members and the staff were to use a gait belt when transferring the resident. The Director of Nursing indicated the resident stood up with the CNA standing next to her and the CNA turned to move the bedside commode and the resident fell . The Director of Nursing indicated the CNA transferred the resident by herself and did not use a gait belt as per the resident's plan of care. This federal tag relates to Complaint IN 369. 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a resident with a known history of exit seeking behavior was supervised to prevent elopement from the facility resulting in the resident going down two flights of stairs and out into the parking lot and falling sustaining multiple abrasions with the potential for serious harm (Resident #175) and failed to assess and apply interventions in a timely manner for a resident at risk for elopement (Resident #31) for 2 of 3 residents residing on the Reclaim unit who were at risk for elopement. This immediate jeopardy began on 3/23/12 when the resident eloped from the facility. The Administrator and Director of Nurses were notified of the immediate jeopardy at 4:30 p.m. on 4/12/12. The immediate jeopardy was removed on 4/15/12, but noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: Resident #175's record was reviewed on 4/11/12 at 11:00 a.m. Resident #175's [DIAGNOSES REDACTED]. A nurse's note, dated 3/14/12 at 1:30 p.m., indicated "...Repeatedly requested to leave. CNA's walked with her and attempted to redirect. Called daughter (name) res (resident) told daughter that she will slit her throat if she doesn't get out of here. Res then preceded to curse at daughter..." A nurse's note, dated 3/14/12 at 6 p.m., "(name) ambulance here to pick up resident and send to (name of hospital) ER (emergency room )..." A hospital psychiatric evaluation, dated 3/14/12, indicated "...History of present illness:...female who has been living with her adopted daughter for the past 7 years. The adopted daughter was able to care for her initially but lately she has been wandering away from the house, started falling and her dementia got worse...The patient has been agitated, upset, being at the nursing home and she wants to go home...So yesterday when the daughter called her, apparently she was threatening to harm herself if she let her stay at the nursing home..." Resident #175 was readmitted to the facility on [DATE]. An elopement assessment, dated 3/16/12, indicated the resident was physically able to leave the building on their own, had a [DIAGNOSES REDACTED]. The assessment indicated "resident's are at High Risk for Elopement when "Yes" is answered to both questions in section A (physically able to leave the building on their own and a [DIAGNOSES REDACTED]." The resident's score was 9. The comments section indicated "Resident expressing anger toward placement. Resident states that she want (sic) to go home. Exit seeking." An admission MDS (minimum data set) assessment, dated 3/27/12, indicated the resident had severe cognitive impairment. The resident had wandered daily which had placed the resident at significant risk of getting to a potentially place (stairs/outside of the facility). The resident required extensive assistance of one staff member for transfers and limited assistance of one staff member for ambulation. A care plan, dated 3/9/12, indicated the "Resident exhibits exit seeking behav (behaviors) and no safety awareness, wanderguard...Interventions...maintain functioning of device...monitor whereabouts...initiate psych services, provide 1:1 services prn (as needed)." Nurses' notes on the following dates and times indicated: 3/16/12 at 6:15 p.m., "...wanderguard is on resident..." 3/17/12 at 4:47 p.m., "Res (resident) continues to be a 1:1 at all times..." 3/19/12 at 2:30 p.m., "...safety (check mark) (checks) cont (continue)..." 3/20/12 at 1:40 p.m., "res (resident) non-compliant c/ (with) safety ambulating and transferring self..." 3/20/12 at 11 p.m., "...Res tries to leave facility, and wanders in other res rooms...requires 1:1 care while awake to promote safety...encouraged to remain in w/c (wheelchair), or have a staff member walk with Res at all times." 3/21/12 at 9 p.m., "...Resident has been trying to leave facility and becomes combative to staff. Requires 1:1 care while awake for safety...staff member needs to be with resident." 3/23/12 at 7:15 p.m., "...Wanderguard is in place. Res continously (sic) tries to wander off unit. Res resists and becomes combative when staff tries to retrieve her." 3/23/12 at 7:50 p.m., "Alarm began to sound. I looked down hall to see Res wc (wheelchair) near exit door. I went downstairs and looked outside. Res had been found by 1st floor staff. Res stated she was leaving and was going home. Staff was able to calm Res and she returned to unit cooperatively..." Social Services notes on the following dates and times indicated: 3/20/12 at 11 a.m., "Writer met c/ (with) Resident in hallway sitting in w/c (wheelchair) asking staff to take her outside and requesting to go home..." 3/22/12 at 10:05 a.m., "...Resident discussed of her cont. (continue) to wish leaving (sic) and going home. On elopement risk..." 3/26/12 at 9:30 a.m., "Writer informed by Administrator, of Res. exit out of bldg (building). over wk-end (weekend), all measures were in place at @ time of exit...Met c/ (with) Resident RE: above incident, could not recall, was asking writer how to get out of facility..." An Incident/Accident Report, dated 3/23/12 at 7:50 p.m., indicated "I began to hear an alarm. I look into hallway, res chair was at end of hall. I checked outside. Res was found by first floor staff w (with) abrasions to left knee, shin, elbow, pinky and Rt (right) palm...Immediate intervention implemented to prevent re-occurrence: Alarm in place. 1 on 1 with aide. The Investigation Conclusion indicated "...Summary of Comprehensive Investigation: Res was observed lying on the ground in the parking lot. Fall occurred secondary to elopement from building. Res had self ambulated down 2 flights of stairs et (and) out the yard in rain when she was located. Res was assessed multiple abrasions noted. Res assisted back into facility s/ (without) further incident no (indicated by O) other injuries noted at this time...Nurse alerted to hallway where exit door alarm was sounding Nurse noted w/c parked by exit door. Nurse went down the stairway to the Eden Unit where staff was alerted to door alarm...Plan of Action to Prevent Reoccurrence: Fall was R/T (related to) elopement no (indicated by O) new interventions will be put into place at this time." The investigation indicated the DoN (Director of Nursing) interviewed RN #1 and LPN #2 on 3/24/12. The form indicated "...(RN #1) left the nurse's station to provide care in a resident's room at the end of Reclaim 2 when she heard the Reclaim 2 back door alarm sound. She immediately exited the room and observed an empty wheelchair at the end of the hall next to the back door. (RN #1) informed another nurse to call Eden Unit (the downstairs unit) to look for (Resident #175). (RN #1) entered the stairwell and walked down the stairs and out the door. It was raining outside. (Resident #175) had been located by the Eden staff. (Resident #175) had fallen in the parking lot. (Resident #175) cooperatively returned with staff to the facility. (Resident #175) informed (RN #1) that she was trying to leave and go home. 15 minute safety checks initiated...(LPN #2) stated he went outside looking for (Resident #175). He observed (Resident #175) in the parking lot on the ground...(Resident #175 ) was assisted up and willingly came into the facility as it was raining outside..." During an interview with the DoN, on 4/12/12 at 12:20 p.m., she indicated "The door (exit door at the end of Reclaim Unit) will sound when it is open. It is locked for fire safety and will unlock after 15 seconds. The nurse was 2 or 3 rooms down from where the resident went out the door. She heard the alarm, seen the empty wheelchair and told the other nurse to call downstairs. She indicated "When (Resident #175) wants to, she can move fast." During an observation with the DoN, on 4/12/12 at 12:35 p.m., of the door to the stairwell where Resident #175 went down 2 flights of stairs, the DoN pushed on the door which then began a faint beep. After 15 seconds the door opened and a louder alarm sounded. The door opened to 2 flights of stairs which led to a foyer with 2 doors, one leading outside and one going into the Eden Unit. The door leading outside did not have any type of alarm on it. Outside the door there was a sidewalk that led to a parking lot. The DoN identified the area where the resident had fallen in the parking lot. This took approximately 1 1/2 minutes. During an interview at the time of the observation, the DoN indicated she did not inservice the staff because they followed the elopement policy. She indicated the resident was put on every 15 minute safety checks. She indicated the day the resident eloped, the resident was not on one to one with staff. She indicated the resident was not put in the Haven Unit (locked Alzheimer's unit) because the resident was "claustrophobic." During an interview with the DoN, on 4/12/12 at 2:30 p.m., she indicated there were times the resident was on one to one. She indicated the resident's physician wanted the resident to be placed on the locked Alzheimer's Unit (Haven Unit). She indicated the Haven Unit was not discussed with the family until after the elopement. During an interview with the Administrator, on 4/12/12 at 4:25 p.m., she indicated the door alarm drills were not done, "I would have been the one that done it." During an observation and interview on 4/13/12 at 9:20 a.m.,with Maintenance Staff Member #3 present at the nurses' station, the bar on the door on the reclaim unit was pushed upon and after 5 seconds a faint beep was heard and then the alarm sounded which was not able to be heard at the nurses' station. Maintenance Staff Member #3 indicated the alarm was not able to be heard because it had been set to bypass. He indicated to turn the alarm off the staff had to place the alarm on bypass. He indicated the staff had to push the button again to reset the alarm. He indicated he was not sure if the staff were aware of the need to push the button again to reset the alarm. During an interview on 4/13/12 at 3 p.m. with LPN #5, she indicated the night Resident #175 exited the building, "I was at break. I eat in the dayroom across from the nurses station, I don't leave the floor. I did not hear the door alarm go off." During an interview on 4/13/12 at 9:30 a.m., the DoN indicated she had not checked to see if the alarm had been set to bypass or if it had been turned on when the resident had eloped on 3/23/12. The DoN acknowledged she was aware the resident was at risk for elopement and the stairway door had no wanderguard alarm system. During an interview on 4/13/12 at 9:45 a.m., the Corporate Regional Vice President acknowledged a resident with exit seeking behaviors should have been placed on one on one with staff. During an observation and interview on 4/13/12 at 9:50 a.m., Maintenance Staff Member #3 indicated the west emergency exit door (the stairwell door the resident had eloped through) on the reclaim unit did not show up on the door panel indicator, located in the reclaim nurses' station, to let the staff know the door had been opened. A facility policy titled "Missing Resident Elopement," dated 2/3/12, indicated "Policy...Door Alarm Drills will be utilized to ensure exit doors are functioning properly and verify staff competency in door alarm response and elopement prevention...Residents Identified At Risk for Elopement...1...an alarm bracelet will be placed on the resident to audibly alert staff of attempts by the resident to exit...Residents with an elopement incident from the facility either on or off the grounds shall be considered at higher risk for further attempts at elopement. These residents will have the following precautionary measure implemented to prevent repeat incidents of elopement. 1. Resident will wear an alarm bracelet...The bracelet will be checked weekly to assure that it is functional, and checks will be logged...Door Alarm Drills 1. The facility will conduct a door alarm drill on each shift each quarter. 2. The drills will be coordinated by the administrator and unannounced..." The immediate jeopardy that began on 3/23/12 was removed on 4/15/12 when the facility implemented every 15 minute safety checks on exit doors until the wanderguard alarm is installed, revised elopement policy, the staff were educated on the revised elopement policy prior to working. Staff were interviewed on the revised elopement policy and were able to verbalize what they are to do if a resident was a wonder risk, exit seeking, and/or if the resident elopes from the building. The facility had inserviced 94 out of 254 employees. Door checks were being completed every 15 minutes and monitored by the designee and elopement drills had been conducted. 2. Resident #31's record was reviewed on 4/13/12 at 9:10 a.m. Resident #31's [DIAGNOSES REDACTED]. An Admission MDS assessment, dated 2/09/12, indicated the resident was alert and oriented. The MDS assessment indicated the resident was extensive assistance of one staff member for transfers. The MDS assessment indicate the resident used a walker and wheelchair for mobility. An elopement assessment, completed on 2/2/12 indicated the resident was not at risk for elopement from the facility. A nurses' note, dated 2/17/12 at 3:40 a.m., a late entry for 2/16/12 at 3:50 p.m., indicated the front desk secretary came to the nurse and indicated the resident was very confused and wanted to call her sister. The nurses' note, indicated the resident wanted her sister to come and get her and that she had walked to the facility and did not know where she was at. The note indicated the nurse went to the front desk, located on the same floor as the Reclaim unit, and redirected the resident and wheeled the resident back to her room. There was a lack of documentation in the nurses' notes of any further behaviors or of the resident being off of the Reclaim Unit. There was a lack of documentation of another elopement assessment being completed on the resident. A Social Service note, dated 4/5/12, indicated "Writer heard concerns the res. (resident) may try to exit seek. Not noted in Nsg (Nursing) notes. Spoke to rcc (resident care coordinator) - who will speak c/ (with) floor nurses. Elopement assessment updated score does not warrant wanderguard." An elopement assessment, completed on 4/5/12, indicated a score of four a score of five indicates high risk. The comment section of the elopement assessment indicated "Res. recently attempted to exit. Wanderguard applied." During an interview on 4/13/12 at 9:52 a.m., the Social Service Designee indicated she was not aware of the resident being up at the front desk on 2/16/12. She indicated that nursing staff had come to her about the concerns of the resident wandering. She indicated the nursing staff had requested she complete an elopement assessment. She indicated the resident had a wanderguard placed on her on 04/05/12. During an interview on 4/13/12 at 9:55 a.m., the Social Service Supervisor indicated she was unaware of the resident going to the front desk on 02/16/12. During an interview on 4/13/12 at 10:05 a.m., the DoN indicated she was aware the resident made it to the front desk on 2/16/12. The DoN indicated she didn't know the resident was wanting to go home. She indicated she was not aware of the nursing staff concerns to social services about the resident.. The DoN indicated residents were allowed to go to the Bistro for coffee but "to go to the front lobby to the front door is elopement." 3.1-45(a)(2)

Based on record review and interviews, the facility failed to ensure Physical Therapy's recommendation/evaluation for the use of a Hoyer lift was utilized for resident transfers to and from the wheelchair and failed to ensure the leg brace was in place, which resulted in a fracture of the left hip for 1 of 4 fractures reviewed in the sample of 7. (Resident #B) Findings include: The closed record for Resident #B was reviewed on 9/27/11 at 1:55 p.m. The resident was admitted to the facility on [DATE] from the hospital. The resident's [DIAGNOSES REDACTED]. Review of Physician order [REDACTED]." Further review of Physician Orders, dated 8/24/11, indicated brace to left leg on in the morning and off at night. Physician orders [REDACTED]. Review of the Initial Plan of Care, dated 8/24/11, indicated Surgical wound left leg, pain related to left femur fracture. The nursing approach was to ensure the resident wore a brace to the left leg at all times. Review of the Physical Therapy Evaluation, dated 8/25/11, completed by a Physical Therapist, indicated the resident was completely dependent on staff for transfers related to her impairments of weakness, pain, balance, cognition, range of motion and weight bear restriction of the left lower extremity. The assistive device to be used for transfer was to be a Hoyer lift. Review of the Weekly Physical Therapy Progress Note by the Physical Therapy Assistant, dated the week of 8/26/11-9/1/11, indicated the resident required the use of the Hoyer lift for transfers and was completely dependent on staff for transfer. The resident had impairments with cognition, left lower extremity pain, poor activity tolerance, and decrease balance. The resident's precautions were weight bear restriction of left lower extremity of toe touch weight bear, brace for left lower extremity to be worn during the day time, confusion and macular degeneration. The resident was educated on her weight bearing status when working with parallel bars in which the resident needed maximum visual cues and assistance to be compliant. Physical Therapy was on hold as of 8/31/11 due to a new fracture. Review of Nursing Progress Notes, dated 8/29/11, indicated the resident was verbally alert with confusion. Nursing Progress Notes dated 8/30/11, at 4:30 p.m., indicated "Resident complaints of increased pain to left leg and pelvic area, after being transferred to bed. PRN (as needed) medication given, no relief after hour, new orders received, daughter made aware. Review of Physician order [REDACTED]. Review of the Radiology Report, dated 8/30/11, indicated there was a displaced periprosthetic fracture involving the margin of the femoral stem on the left. The conclusion was left hip periprostthetic fracture. Review of Nursing Progress Notes, dated 8/30/11, at 7:00 p.m., indicated mobile X-ray were at the facility to obtain the X-rays. At 9:00 p.m., the results were received and the resident's physician was notified. The resident's orthopedic physician was notified and indicated the resident's leg brace was to be worn at all times. The Orthopedic Physician indicated he wanted a copy of the disc with the X-rays sent to his office so he could compare them to older ones. Review of Physician Orders, dated 8/31/11, indicated bed rest, turn and reposition every two hours, and full leg brace. Review of Nursing Progress Notes, dated 9/1/11, indicated the resident was febrile with complaints of pain. The resident's Physician was notified and the resident was directly admitted to the hospital with [REDACTED]. Review of the Investigation of the fracture of the left hip, dated 8/31/11, indicated CNA #2 indicated Resident #B wanted to go to bed. At that time, CNA #3 placed the gait belt around her waist and they both assisted her to bed. She indicated the resident turned and pivoted and sat on the bed. CNA #3 picked up her legs and placed them into the bed. After sitting down, the resident screamed, "You broke my leg." The resident did not have on her leg brace at the time of the transfer. CNA #2 indicated CNA #3 told the resident not to bear weight on her leg. CNA #3 indicated she had seen the resident's leg brace in the chair by the wall after the transfer. The CNA indicated she did not realize it was not on until after the transfer. The resident's roommate indicated to staff that Resident #B took her leg brace off by herself. Review of the Rehab Addendum Note by the Physical Therapy Assistant, dated 8/31/11, indicated "patient continued to complain of pain in left lower extremity just above the knee with standing in the parallel bars. Patient needs constant reminders of left lower weight bearing status of toe touch weight bear." Interview with the Physical Therapist on 9/28/11, at 11:00 a.m., who completed the initial evaluation indicated she had recommended the Hoyer lift for transfers on the day the resident was evaluated. She indicated at the time of evaluations they would instruct the staff working with the resident what should be used to transfer for each resident. She indicated she recalled the resident was very confused and was only toe touch weight bear. She further indicated the therapists only worked with her for five days and with maximum assist were working with her on the parallel bars with only toe touch weight bear. Interview with LPN #1 on 9/28/11, at 11:05 a.m., indicated she recalled the resident and had taken care of her. She indicated the resident was a two person transfer with a gait belt. She indicated she was not aware of the recommendation from the therapy department for the Hoyer lift to be used for transfers. Interview with CNA #1 on 9/28/11, at 11:15 a.m., indicated she had worked with the resident while she was there at the facility. She indicated the resident was a two person transfer with a gait belt. She indicated she was unaware the resident was supposed to be transferred with the Hoyer lift. Interview with the Physical Therapist and the Therapy Manager on 9/28/11, at 12:10 p.m., indicated she had recommended the Hoyer lift at the time of the evaluation and only for that day 8/25/11. She further indicated the case was passed onto a physical therapy assistant. Further review of the Physical Therapy weekly progress notes, dated 8/26/11-9/1/11, indicated there was no documentation indicating the Hoyer lift was only recommended on the first day of the evaluation. There was no further documentation or other assessments for the resident's transfer status and the use of the Hoyer lift. Interview with the Director of Nursing on 9/28/11, at 11:25 a.m., indicated she was completely unaware the Physical Therapist had indicated during her evaluation the assistive device for transfers was to be a Hoyer lift. She indicated the therapists were to inform the nursing staff of their recommendations. This Federal Tag related to Complaint Number IN 027. 3.1-45(a)(2)

Based on record review, observation and interview, the facility failed to ensure interventions were in place for a resident who was observed with her head positioned over the gap between the mattress and side rail with her feet on the floor and failed to assess the resident's need for side rails after the observation, resulting in the resident subsequently having an incident with her head getting wedged between the mattress and the side rail and her feet out of the bed and on the floor, for 1 of 2 residents reviewed who had an air mattress and side rails in a sample of 8. (Resident #E) In addition to the resident in immediate jeopardy, the facility failed to assess the need for side rails after a different resident was found with his face on the side rail for 1 or 3 residents reviewed with half side rails and an air mattress in a supplemental sample of 3. (Resident #M) The immediate jeopardy began on 10/06/11 when Resident #E was observed with her head over the gap between the mattress and the side rail and with her feet out of the bed and on the floor, and no interventions were put into place for resident's safety. The Executive Director and Director of Nursing were notified of the immediate jeopardy at 2:35 p.m. on 10/25/11. The immediate jeopardy was removed on 10/26/11 at 10:50 a.m., but non compliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. On 10/24/11 at 2:27 p.m. Resident #E was observed lying on her back slightly to the left side of the bed with a body pillow on each side of the bed and bilateral half side rails in the up position. The resident was sleeping. On 10/25/11 at 1:35 p.m. the resident was observed lying in the middle of the bed on her right side. There were body pillows on both sides of the bed and bilateral half side rails were in the up position. There was a 3.5 cm space between the air mattress and the side rails. The resident had a light brown scabbed area to the middle of her right shin and a scratch to her upper right cheek with a pin point scab at the bottom portion of the scratch. Resident #E's record was reviewed on 10/25/11 at 12:30 p.m. The resident's [DIAGNOSES REDACTED]. A nursing note dated 10/6/11 at 11:00 p.m., indicated the entry was documented by RN #2. The writer was walking down the hall and observed, when looking in the room, that Resident #E was turned to the left side of the bed and appeared to be very close to the edge of the bed. The resident was found to have her feet off the bed and on the floor mat. Her arms were crossed on her chest. Her face was between the mattress and the side rail. The rest of her body was angled with her feet on the floor. The bed was in the low position and a body pillow was off of the bed to the left side. CNA #1 and LPN #1 slowly brought the resident out from between mattress and side rail to lying on her back in bed. The resident was assessed fully at that time. She was able to do range of motion to all extremities with no distress noted. There were red areas noted to the resident's bilateral cheeks and a reddened area along her temple. Her skin was slightly red in the right arm pit and along the right side of her chest along the right arm pit. When found, the resident's arms had been across her chest, with her left hand under her right arm. There were no other red areas found on the resident. There were no skin tears and no bruising at this time. The physician was paged twice with no return call, and a call was made to her daughter with no answer or answering machine. A nursing note dated 10/7/11 at 7:30 a.m., indicated the resident was up in her wheelchair with no signs or symptoms of distress noted. The resident was up at breakfast eating well. There was no redness noted to her cheeks or right temple. Her chest was clear from marks or redness. There were no skin tears or bruises noted. A nursing note dated 10/20/11 at 10:45 p.m. indicated the entry was documented by RN #1. During last rounds, the resident was observed with half of her body on the floor mat, arms folded, and legs contracted with her left leg resting on top of her right leg. Her neck and head were wedged between the half side rail and air mattress. The resident's eyes were open and there were no signs of loss of consciousness. The resident was unable to verbalize how this occurred. The resident's neck and head were carefully removed from wedged position with assist of two CNAs. The resident showed no signs of pain. The resident said, "Is it gum." She was assessed prior to moving with no obvious signs of fractures or dislocations. The resident did not follow commands. Her lower extremities were severely contracted with limited range of motion. The resident's ear lobes were red with redness extending from the left base of the neck to the right base of the neck. Her cheeks were flushed. She was assisted in to bed. Her body was assessed and noted were a left mid thigh bruise, light purple in color measuring 4.5 cm (centimeters) by 0.5 cm; a left mid rib abrasion which was superficial, red in color, measuring 1.6 cm by 0.8 cm; a right shin abrasion, measuring 1.8 cm by 1 cm; and a right forearm bruise that was bright red in color, measuring 3 cm by 3.2 cm. She squeezes eyes tightly for pupil check, her blood pressure was 140/70, apical pulse 80, respirations 20, temperature 97.1, and oxygen saturation of 97%. The resident was in the center of the air mattress on the right side with body pillows on each side under the sheet to secure. The bed was in the low position, with floor mats in place on each side of the bed. The physician was paged due to being unable to contact by phone. The resident's daughter was notified by phone. Fifteen minute safety checks were initiated and staff were informed. A nursing note dated 10/21/11 at 4:30 a.m., indicated the resident was resting comfortably in bed and was easily aroused. Staff were unable to check pupils due to the resident being uncooperative. Her blood pressure was 122/70, pulse was 72, respirations were 18 and temperature was 98.0. Her range of motion was limited related to the resident being unable to follow directions. The physician was notified of the resident's condition. There were no signs or symptoms of pain or discomfort. A Significant Change Minimum Data Set Assessment ((MDS) dated [DATE], indicated the resident was sometimes understood and sometimes understands. She scored a 0 on her Brief Interview for Mental Status (BIMS), which indicated she was severely impaired cognitively. She required extensive assistance (resident involved in activity, staff provide weight-bearing support) with one person physical assist for bed mobility and extensive assistance with two plus person physical assist for transfers. A care plan initiated on 6/20/11 indicated a problem of requiring assist for all aspects of her Activities of Daily Living (ADLs). The approaches included, but were not limited to, offer verbal cues and/or hand over hand assist to encourage resident to use half side rails. Staff may have to place her right hand on the rail and tell the resident to hold on. A Side Rail Evaluation form indicated a side rail assessment was completed on 9/7/11. The form indicated the evaluation could be completed for admission, re-admission, quarterly, annual, significant change or other. The resident was to have left and right half side rails to serve as an enabler. The Proper Use of Side Rails policy was provided by the Executive Director on 10/25/11 and reviewed on 10/26/11 at 9:20 a.m. The policy indicated, "Side Rails will be used only to ensure the safety of the resident and as a mobility aid. Side rails may never be used as a restraint unless necessary to treat a resident's medical condition and with an order from the physician." The General Guidelines included, but were not limited to, side rails may be used to assist in mobility and transfer of residents, an assessment will be made to determine the resident's symptoms or reason for using side rails (When used for mobility or transfer, an assessment will include a review of the resident's: bed mobility and ability to transfer between positions, to and from bed or chair, to stand and toilet.), the resident will be checked frequently for safety, and when side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk of entrapment. Interview with the Executive Director and the Director of Nursing on 10/25/11 at 12:00 p.m., indicated there had been an incident with Resident #E on 10/20/11, and the information they had been given on the incident was not the same as what had been documented in the resident's record. They indicated the supervisor had been informed the resident just rolled over in bed. The supervisor assessed the resident and found no issues at that time. They then indicated on 10/24/11 they were informed of the incident of the resident being wedged between the mattress and the side rail. When further interviews were completed, the nurse documenting the incident on 10/20/11 indicated the resident was wedged between the mattress and the side rail, and the supervisor indicated she had been informed the resident just rolled over. Interview with RN #1 on 10/25/11 at 3:25 p.m. indicated the resident's head was wedged between the mattress and the side rail on 10/20/11. The bottom half of her head was between the mattress and the side rail and her face was above the mattress. The resident would not have been able to remove herself from the position. She further indicated she cradled the resident's head and pushed on the mattress to remove the resident's head from between the mattress and the side rail. Interview with RN #2 on 10/25/11 at 5:45 p.m., indicated the resident was never stuck or wedged between the mattress and side rail on 10/6/11. The resident's head was laying on the space between the side rail and the mattress. Interview with the DoN on 10/25/11 at 1:40 p.m. indicated the incident had not been reported to Indiana State Department of Health. Interview with the Executive Director on 10/25/11 at 2:00 p.m., indicated she had not been aware of the incident that occurred on 10/6/11. She further indicated the only interventions put into place were fifteen minute checks which were started on 10/20/11. 2. On 10/25/11 at 4:20 p.m. Resident #M was observed in his room in bed. The head of the resident's bed was elevated and two half side rails, which were padded, were in the upright position. The record for Resident #M was reviewed on 10/25/11 at 4:40 p.m. The resident's [DIAGNOSES REDACTED]. An entry in the Nursing Progress Notes dated 9/25/11 at 12:00 a.m., indicated the resident was observed lying on his right side with his face on the side rail. A red area to the right side of the resident's nose with an indentation was observed. An entry in the Nursing Progress Notes dated 9/30/11 at 4:30 a.m., indicated the resident received a left forearm skin tear from the side rail which measured 2.5 centimeters (cm) x 1.5 cm (upper forearm) and 1.0 cm x 1.0 cm (lower forearm). Documentation in the Nursing Progress Notes dated 10/21/11 at 3:30 a.m., indicated the resident was turned sideways in bed with the pad alarm under his back and the left abdominal area was under the side rail. The resident was repositioned in bed and three skin tears were observed to the lower left abdomen. There was no incident/accident investigation summary related to the resident's face against the side rail on 9/25/11. The incident/accident investigation summary dated 10/3/11, related to the skin tear to the left forearm, indicated the resident's side rails would be padded. A Side Rail Evaluation dated 9/24/11, indicated the resident had 1/2 side rails to the left and right side of his bed, and the side rails were being used as an enabler to promote independence. The next Side Rail Evaluation was dated 10/25/11, which indicated the resident's side rails were not indicated at this time and would be removed. Interview with the Director of Nursing on 10/26/11 at 10:35 a.m., indicated the resident should have been re-assessed for the need of the side rails after the incident on 9/25/11. She further indicated an incident/accident investigation summary had not been completed for the incident on 9/25/11. The immediate jeopardy that began on 10/6/11 was removed on 10/26/11 when the facility had completed side rail assessments on all residents, side rails were removed for residents who did not demonstrate mental and physical capabilities to utilize the side rails, and staff was educated on no side rails were to be placed on residents' beds without the Administrators or Director of Nursing approval, re-educated on the abuse and reporting of unusual occurrences and side rail safety, and nurses were re-educated on the policy for reporting unusual occurrences to the Administration immediately twenty four hours a day regardless of the time of day. The clinical team will be reviewing all residents with side rails on their beds weekly for four weeks and share the list with the facility QA (Quality Assurance) team. The QA team will monitor side rail use during daily QA rounds to assure no side rails are placed without proper assessment and review their findings with the QA team for six months. To assure the education on abuse, reporting, and unusual occurrences was successful, random interviews will be conducted. The random interviews will be submitted to the quality assurance committee. Noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because of the need for continued reviewing and monitoring of side rail use. This Federal Tag related to Complaint IN 027. This deficiency was cited on 9/28/11. The facility failed to implement a systemic plan of correction to prevent recurrence. 3.1-45(a)(1) 3.1-45(a)(2)