Every finding on record at Envive of Brookville

Based on interview and record review, the facility failed to routinely document physician-ordered daily weights for 1 of 3 residents reviewed for following physician care orders. (Resident B) Findings include: The clinical record of Resident B was reviewed on 6-30-26 at 11:10 a.m. His diagnoses included, but were not limited to congestive heart failure (CHF), diabetes, chronic pulmonary (lung) disease (COPD) and morbid obesity (very overweight). His most recent Minimum Data Set (MDS) assessment, dated 4-8-26, indicated he was cognitively intact and was non-ambulatory, required the use of a wheelchair for mobility. Resident B's current order summary, dated 6-30-26, indicated an order was placed on 3-30-26 to obtain daily weights. The order for the daily weights failed to have parameters to notify the physician for weight gain or loss within a defined time period. Weights for Resident B were documented in the clinical record on 3-18-26, 3-30-26, 3-31-26 and 6-3-26. The majority of the dates in which weights were not obtained failed to have any documentation reflective of the resident's refusal to have his weight checked or the notification to the attending physician or nurse practitioner (NP) of the weight not being obtained or the resident's refusal to have the weight obtained. In an interview with Resident B on 6-30-26 at 11:05 a.m., he denied he he had ever had daily weights obtained at facility. In an interview with LPN 3 on 6-30-26 at 10:50 a.m., she indicated she was unaware of any current residents who were to have daily weights checked.In an interview on 6-30-26 at 10:55 a.m., with LPN 4 she indicated she was aware of one current resident, Resident B, who was to have daily weights conducted.In an interview with the Director of Nursing (DON) on 6-30-26 at 12:55 p.m., indicated she was familiar with Resident B. She was unsure if Resident B had refused daily weights the resident had a history of noncompliance with his care, specific to refusing to have daily weights obtained by the staff. She added his weights should be documented in his resident record to reflect at least his monthly weights. The doctor and nurse practitioners were aware of his non-compliance with the fluid restrictions, weights and medication or treatments.In an interview on 6-30-26 at 2:50 p.m., with RN 5, she indicated she was unaware of any residents who required daily weights.In an interview on 6-30-26 at 2:35 p.m., with the Registered Dietitian (RD), she indicated she was familiar with Resident B. She noted, I thought the order for the daily weights had been discontinued after he signed the waiver for the fluid restrictions. He tended to be non-compliant with many aspects of care. He did not follow the fluid restrictions. He would not allow the staff to get his weights and sometimes would refuse medications or other treatments. To the best of her knowledge, he was the only resident in a long time that has been on daily weights. Our new [resident] admissions would be followed for the first 4 weeks with weekly weights to trend how they were doing. Some of the residents with CHF may end up on daily weights, depending on the severity of their situation and to monitor them closely. Daily weights were not something I see ordered in this building very often.In an interview with the DON on 7-1-26 at 1:45 p.m., she clarified she had spoken with the nurse practitioner today about Resident B's daily weights and his continued refusals and his not following the fluid restriction guidelines. She specified the nurse practitioner wanted to continue with both orders and planed to continue to monitor those values and his labs, with a change to the daily weights to weekly weights every Monday morning, to notify the provider for a weight gain of five (5) pounds or more and to document all refusals in the progress notes.A review of Resident B's care plans identified on 3-19-26, and revised on 5-5-26, non-compliance with various aspects of his medical care. Interventions recommended included, but were not limited to, educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care; encourage as much participation/interaction by the resident as possible during care activities; give clear explanation of all care activities prior to and as they occur during each contact.In an interview with the DON on 7-1-26 at 2:57 p.m., indicated the facility did not have a specific policy or procedure regarding implementation of physician orders. The facilities expectation would be that all physician orders were followed.On 7-1-26 at 2:13 p.m., the facility electronically provided a copy of a policy entitled, Weight Assessment and Intervention, with a revision date of 8/2024. This policy indicated, Resident weights were monitored for undesirable or unintended weight loss or gain .weights were recorded in each unit's weight record chart and in the individual's medical record .The physician and the multidisciplinary team identify conditions and medications that may be causing anorexia, weight loss or increasing risk of weight loss .Care planning for weight loss or impaired nutrition is a multidisciplinary effort and includes the physician, nursing staff, the dietitian, the consultant pharmacist, and the resident or resident's legal surrogate. Individualized care plans shall address, to the extent possible, the identified causes of weight loss, goals and benchmarks for improvement; and time frames and parameters for monitoring and reassessment.On 7-1-26 at 2:13 p.m., the facility electronically provided a copy of a policy entitled, Provider Notification Guidelines, with a revision date of 8-2022. This policy indicated, To ensure the resident's physician or practitioner (may include NP, PA or clinical nurse specialist) were aware of all diagnostic testing results or change in condition in a timely manner to evaluate condition for need of provision of appropriate interventions for care.This Federal tag relates to Intake 3044279.410 IAC (Indiana Administrative Code) 3.1-46(a)(1)

Based on interview and record review, the facility failed to offer and provide education on the 2025-2026 Covid-19 vaccination and maintain documentation of such for 5 of 5 residents reviewed. (Residents 3, 7, 9, 10, and 12) Findings include: 1. The clinical record for Resident 3 was reviewed on 3/27/26 at 1:15 p.m. Her diagnoses included, but were not limited to, chronic obstructive pulmonary disease (a progressive, treatable lung disease, mainly caused by smoking or long-term irritant exposure, that restricts airflow and causes breathing difficulties) and hypertensive heart disease with heart failure (condition that occurs when chronic high blood pressure forces the heart to work harder, leading to thickened or weakened heart muscle that cannot pump effectively). She was admitted to the facility on [DATE]. There was no 2025-2026 Covid-19 vaccination information in the clinical record to indicate she accepted or refused the vaccination or was provided education regarding the vaccination. 2. The clinical record for Resident 7 was reviewed on 3/27/26 at 1:15 p.m. Her diagnoses included, but were not limited to, diabetes (a chronic condition characterized by high blood sugar levels caused by insufficient insulin production or ineffective insulin use) and hypertension (a chronic condition where blood force against artery walls is consistently too high, forcing the heart to work harder). She was admitted to the facility on [DATE]. There was no 2025-2026 Covid-19 vaccination information in the clinical record to indicate she accepted or refused the vaccination or was provided education regarding the vaccination. 3. The clinical record for Resident 12 was reviewed on 3/27/26 at 1:15 p.m. His diagnoses included, but were not limited to, chronic obstructive pulmonary disease (a progressive, treatable lung disease mainly caused by smoking or long-term irritant exposure that restricts airflow and causes breathing difficulties) and chronic kidney disease (the long-term, irreversible loss of kidney function, preventing the filtration of blood, waste buildup, and blood pressure regulation). He was admitted to the facility on [DATE]. There was no 2025-2026 Covid-19 vaccination information in the clinical record to indicate he accepted or refused the vaccination or was provided education regarding the vaccination. 4. The clinical record for Resident 10 was reviewed on 3/27/26 at 1:15 p.m. His diagnoses included, but were not limited to, chronic obstructive pulmonary disease and hypertension. He was admitted to the facility on [DATE]. There was no 2025-2026 Covid-19 vaccination information in the clinical record to indicate he accepted or refused the vaccination or was provided education regarding the vaccination. 5. The clinical record for Resident 9 was reviewed on 3/27/26 at 1:15 p.m. Her diagnoses included, but were not limited to, emphysema (a chronic, progressive lung disease, typically caused by smoking or long-term exposure to air pollution, that destroys the alveoli, leading to severe shortness of breath,) and hypertension. She was admitted to the facility on [DATE]. There was no 2025-2026 Covid-19 vaccination information in the clinical record to indicate she accepted or refused the vaccination or was provided education regarding the vaccination. An interview was conducted with the Infection Preventionist on 3/27/26 at 11:34 a.m. She indicated they offered the Covid-19 vaccination to all residents on a yearly basis and provided the CDC (Centers for Disease Control) Fact Sheet on Covid-19 vaccination to residents at that time. An interview was conducted with the Director of Nursing (DON) on 3/27/26 at 3:00 p.m. She indicated there was no documentation to indicate the residents were offered the 2025-2026 Covid-19 vaccination to the above five residents or staff provided the residents with education on the vaccination. The facility had offered vaccination consents in the past in the residents admission packet, but the facility no longer did that. The 2025-2026 COVID-19 Vaccination Guidance from the CDC (Centers for Disease Control,) effective 11/4/25, indicated, For Health Care Providers.The 2025-2026 COVID-19 vaccine is recommended for people ages 6 months and older based on individual-based decision-making (also known as shared clinical decision making). The recommended vaccine and number of doses are based on age and vaccination history. People can self-attest to factors that increase their risk for severe COVID-19 and receive COVID-19 vaccination.COVID-19 vaccination is recommended for all adults ages 65 years and older based on individual-based decision-making (also known as shared clinical decision-making). For people ages 6 months-64 years, vaccination is recommended based on individual-based decision-making (also known as shared clinical decision-making) with an emphasis that the risk-benefit of vaccination is most favorable for individuals who are at an increased risk for severe COVID-19 disease and lowest for individuals who are not at an increased risk, according to the CDC list of COVID-19 risk factors. In addition to the CDC list, the Moderna (Spikevax) package insert states that prematurity (birth at <37 weeks gestational age) has been associated with COVID-19-related hospitalizations in children ages 6-23 months. Additionally, some people may be at increased risk for SARS-CoV-2 infection including healthcare workers and residents and employees in long-term care facilities and other residential congregate settings.The Covid-19 Vaccination Education and Administration policy was provided by the Administrator on 3/25/26 at 11:34 a.m. It indicated, To protect LTC [long term care] residents from COVID-19, this facility shall adhere to the following procedures in effort to meet each resident's, resident representative, and staff member's information/educational needs and provide vaccines to all residents that elect them. Education.All residents and/or resident representatives and staff shall be educated on the COVID-19 vaccine they are offered, in a manner they can understand, including information on the benefits, risks, and common reactions (i.e., aches, fevers, and, in rare cases, anaphylaxis) consistent with CDC and/or FDA [Food and Drug Administration] information and shall be provided the FDA COVID-19 EUA [emergency use authorization] Fact Sheet before being offered the vaccine. If the vaccination recommends multiple doses of vaccine, the resident or resident representative and staff shall again be provided with education regarding the benefits and potential side effects of the vaccine and current information regarding those additional doses, including any change in the benefits or potential side effects, before requesting consent for administration of any additional doses. Offering Vaccinations.This facility shall offer residents and staff vaccination against COVID-19. Screening individuals prior to offering the vaccination for prior immunization, medical precautions and contraindications shall be conducted to determine whether they are appropriate candidates for vaccination at any given time. The vaccine may be offered and provided directly by this facility or indirectly, such as through an arrangement or referral to a local vaccination site or local health department.If a resident or staff requests vaccination against COVID-19 but missed earlier opportunities for any reason, this facility shall offer the vaccine to that individual as soon as possible. If the vaccine is unavailable in the facility, the facility shall provide information on obtaining vaccination opportunities (e.g., health department or local pharmacy) to the individual. This facility shall provide evidence, upon request, of efforts made to make the vaccine available to its residents and staff. Like influenza vaccines, if there is a manufacturing delay, the facility shall provide evidence of the delay, including efforts to acquire subsequent doses, as necessary. Indications and contraindications for COVID-19 vaccination are evolving, and this facility shall remain alert to any new or revised guidelines/recommendations issued by the CDC, FDA, vaccine manufacturers, or other expert stakeholders.Documentation of Resident Vaccination.The resident's medical record shall include documentation that indicates, at minimum, that the resident or resident representative was provided education regarding the benefits and potential side effects of the COVID- 19 vaccine, and that the resident ( or representative) either accepted and received the COVID-I9 vaccine or did not receive the vaccine due to medical contraindications, prior vaccination, or refusal.

Based on observation, interview, and record review, the facility failed to store respiratory supplies correctly at the bedside for 1 of 1 resident reviewed for respiratory care. (Resident 21) Findings include:The clinical record for Resident 21 was reviewed on 3/25/2026 at 1:12 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD/a progressive, irreversible lung disease that restricts airflow and makes breathing difficult) hypothyroidism (underactive thyroid gland producing insufficient hormones), and anxiety disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 2/24/26, indicated Resident 21 was cognitively intact. During an observation on 3/24/26 at 11:40 a.m., Resident 21 had an oxygen nebulizer with tubing and mask openly lying on an empty bed. The oxygen mask was not in a bag. During an observation and interview on 3/25/26 at 1:23 p.m., Resident 21 had the nebulizer and oxygen tubing and mask lying on an empty bed, covered with a blanket. Resident 21 indicated the nebulizer and mask usually always lay on the bed close to her and that she gets breathing treatments twice a day, once in the morning and again at bedtime. A physician's order, dated 8/14/25, indicated Budesonide Suspension 0.25 mg (milligrams)/2ml (milliliters), 2 ml inhale orally every 12 hours for copd. A plan of care, dated 8/29/25, indicated Resident 21 had copd. The interventions included, but were not limited to, give aerosol or bronchodilators as ordered. During an interview with the Director of Nursing (DON) on 3/27/26 at 11:10 a.m., indicated the nebulizer and supplies should all be in a bag at the bedside and the tubing gets changed weekly. A Respiratory Policy was provided by the Administrator on 3/27/26 at 11:38 a.m. It indicated .2. Oxygen administration. j. keep oxygen cannula and tubing used prn (as needed) in a plastic bag when not in use. 410 IAC (Indiana Administrative Code) 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to schedule an oral surgeon appointment, as referred, and follow-up on a recommendation for a new toothbrush and water flosser for 1 of 1 resident reviewed for dental status and services. (Resident 12) Findings include: The clinical record for Resident 12 was reviewed on 3/26/26 at 2:26 p.m. His diagnoses included, but were not limited to, chronic obstructive pulmonary disease (a progressive, treatable lung disease mainly caused by smoking or long-term irritant exposure that restricts airflow and causes breathing difficulties) and nicotine dependence (a chronic brain disorder where tobacco use becomes compulsory, causing intense cravings, failed quit attempts, and severe withdrawal symptoms). An interview was conducted with Resident 12 on 3/24/26 at 2:20 p.m. He indicated he needed to see the dentist, because he had holes in his teeth. He thought he was supposed to have an appointment scheduled already. The dental consultation, dated 3/18/26, indicated a recommendation for a specific type of rechargeable toothbrush and water flosser. It included a referral to a specific oral surgeon for extraction of two teeth. There was no information in the clinical record to indicate follow-up to the recommendation for a rechargeable toothbrush and water flosser or that an appointment was scheduled for an oral surgeon for Resident 12. An observation and interview were conducted with Resident 12 on 3/27/26 at 12:03 p.m. He indicated no one had followed up with him on an appointment for teeth extractions or a new rechargeable toothbrush and water flosser. He wanted the extractions completed. Resident 12 pointed to the right side of his mouth and indicated his teeth hurt when he chewed on that side of his mouth, so he avoided chewing on that side. An interview was conducted with the SSD (Social Services Director) on 3/27/26 at 11:35 a.m. She indicated the nursing department was responsible for follow-up on the recommendation for a rechargeable toothbrush and water flosser as well scheduling an appointment for the oral surgeon. An agency nurse was working when Resident 12 returned from his dental appointment on 3/18/26, and they did not follow up on any of the recommendations. The Dental Services policy was provided by the Regional Clinical Consultant on 3/27/26 at 12:07 p.m. It indicated, Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Social services representatives will assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible. 410 IAC (Indiana Administrative Code) 3.1-24(b)

Based on observation, interview, and record review, the facility failed to assist a resident with feeding who had weight loss for 1 of 4 residents reviewed for nutrition. (Resident 8) Findings include:The clinical record for Resident 8 was reviewed on 03/25/2026 at 2:23 p.m. The diagnoses included, but were not limited to, dementia, epilepsy, dysphagia (difficulty swallowing), eating difficulties, and schizoaffective disorder (chronic mental health condition combining hallucinations, delusions, and disorganized speech with mania or depression). The Quarterly Minimum Data Set (MDS) assessment, dated 12/30/25, indicated Resident 8 had severe cognitive impairment though usually understood others, had no behaviors for rejection of care, needed partial/moderate assistance to use suitable utensils to bring food and/or liquid to the mouth and swallow. Resident 8 had a loss of liquids/solids from mouth when eating or drinking, held food in mouth/cheeks or residual food in mouth after meals, and coughed or choked during meals or when swallowing medications. The Electronic Health Record (EHR) indicated Resident 8 had a 9.15% weight loss from 12/29/25 to 3/16/26. During an observation on 3/24/26 at 1:30 p.m., Resident 8 was sitting in the dining room being fed pureed food by the Social Service Director (SSD). The SSD was sitting to the right of the resident. A physician's order, dated 1/2/26, indicated Resident 8 was to be fed on left side for left head turn; feed in an upright position; small bites and sips at slow rate; 1:1 feed. During an observation on 3/26/26 at 12:30 p.m., Resident 8 was sitting at a table alone in the dining room. He had a pureed diet tray in front of him. Resident 8 was feeding himself. No staff observed assisted or observing Resident 8 while he ate. During an observation on 3/27/26 at 12:24 p.m., Resident 8 was sitting at a table alone in the dining area, feeding self. Observed Resident 8 having trouble putting his two handled cup up to his mouth. No staff assisting or observing resident while he ate. A Nutritional Risk Assessment, dated 3/10/26, indicated Resident 8 was at risk for malnutrition and received dietary supplements due to weight loss. An interview with the Director of Nursing on 3/27/2026 at 12:35 p.m., indicated Resident 8 was supposed to be a 1:1 (one staff member continuously observation of one resident) feed and was to be assisted on his left side with all meals. Nursing was who was responsible to ensure Resident 8 was assisted with feeding for every meal. An Assistance with Meals policy was provided by the Administrator on 3/27/26 at 2:08 p.m. It indicated .Residents shall receive assistance with meals in a manner that meets the individual needs of each resident.Dining Room Residents: 2. Facility staff will help residents who require assistance with eating.3. Residents who cannot feed themselves will be fed with attention to safety.Residents who may benefit from adaptive devices: 2. Assistance will be provided to ensure that residents can use and benefit from special eating utensils. A Food and Nutritional Services policy was provided by the Administrator on 3/27/26 at 2:08 p.m. It indicated .5. The food and nutrition staff will be available and adequately staffed to assist residents with eating as needed. Nurse Aides and feeding assistants will provide support to enhance the resident experience. 410 IAC (Indiana Administrative Code) 3.1-46

Based on interview and record review, the facility failed to ensure a resident's right to be free from misappropriation of their narcotic medication for 1 of 1 resident reviewed for misappropriation. (Resident B) Findings include:A facility reported incident, dated 1/29/26, indicated a nurse noted a sleeve of 6 narcotic pills were missing from the narcotic box that belonged to Resident B. The clinical record for Resident B was reviewed on 3/25/2026 at 2:21 p.m. The diagnoses included, but were not limited to, chronic pain syndrome, irritable bowel syndrome (chronic functional gastrointestinal disorder affecting the large intestine, characterized by abdominal pain, bloating, and diarrhea or constipation), and idiopathic chronic gout (a severe, long-term form of inflammatory arthritis). The Quarterly Minimum Data Set (MDS) assessment, dated 1/8/26, indicated Resident B was cognitively intact for decision making, used opioid medication, received scheduled and prn (as needed) pain medications, had pain frequently, and occasionally their pain would interfere with daily activities. A physician's order, dated 8/14/25, indicated Resident B had Percocet 5-325 mg (milligram) oral tablet, give one tablet by mouth every 8 hours as needed for neck pain. During an interview with the Administrator on 3/26/26 at 1:05 p.m., they indicated they were notified 1/29/26 in the afternoon by the Director of Nursing (DON) that a sleeve of 6 Percocet were missing from the narcotic lock box and the narcotic sheet was missing from the binder for Resident B. The Administrator indicated Registered Nurse (RN) 2 received the medication 1/28/26, signed off for them from the pharmacy, locked the 6 Percocet in the locked box, created a narcotic sheet, and placed it in the narcotic binder. On 1/29/26, Resident B had called out for pain medication. Licensed Practical Nurse (LPN) 4 went to the medication cart and there were no Percocet in the narcotic box nor a narcotic sheet in the narcotic binder. LPN 4 then informed the Administrator and DON about the missing medication. The Administrator indicated RN 3 was the last nurse to care for Resident B when the count was correct, then was incorrect. RN 3 told her that she knew the sleeve of medication had been in the locked box because she had given two pills throughout the night. RN 3 did not document giving the medication or assess Resident B's pain. Resident B indicated to the Administrator that she had not taken any pain medication the night of 1/28/26. The Administrator indicated through investigation and narcotic audits, they came to the conclusion that RN 3 was taking the medication, so she was ultimately terminated. RN 3 did not return to the facility after 1/29/26. During an interview with RN 2 on 3/26/26 at 1:25 p.m., they indicated they received a sleeve of 6 Percocet from the pharmacy for Resident B on 1/28/26. RN 2 indicated they put the 6 Percocet pills into the narcotic box on the medication cart and filled out a narcotic sheet and placed it in the narcotic binder. RN 2 indicated they did a narcotic count and handoff with RN 3 at the end of their shift and everything was correct. During an interview with LPN 4 on 3/26/26 at 5:23 p.m., they indicated they were going through the Electronic Health Record (EHR) to re-check who had pain medications due next for the day. LPN 4 noticed that Resident B did not have any pain medicine due and normally after lunch they would ask for a pain pill. LPN 4 indicated they thought maybe the resident was out of their Percocet and waited a little bit to see if pharmacy had a delivery when they came in that day. Pharmacy came in to the facility and informed LPN 4 that 6 Percocet were delivered the day before on 1/28/26 to RN 2 who signed off for them with a witness. LPN 4 indicated the pills along with the narcotic sheet were gone. LPN 4 indicated they did a narcotic report sheet sign off with RN 3 the morning of 1/29/26. LPN 4 indicated they counted all of the narcotic cards with RN 3 at shift change that morning and the hand off sheet did not look abnormal because it said there were 10 narcotic cards, which was what was counted and it should have been 11, but RN 3 had not added a card after a pharmacy delivery the night prior, she just removed the Percocet card from the drawer, so the sign off sheet said 10 and there were 10 cards, because throughout the night she did not add one to the hand off sheet, just placed the card in the drawer. RN 3 wrote 10 so it looked like nothing was added or subtracted. LPN 4 indicated they were supposed to sign out medication in pcc (point click care), but RN 3 would only sign the medication off on the narcotic sheet and not pcc. LPN 4 indicated on the computer it showed RN 3 had not given any pain medication, but on the report hand off sheet, they documented they gave a pain pill, but there was no documentation because the narcotic sheet was missing, but on the report sheet they indicated they gave it. During an interview with the DON on 3/27/26 at 11:00 a.m., they indicated on 1/29/26 they were informed by LPN 4 that a card of Percocet 5mg with a quantity of 6 were missing from the narcotic drawer and the narcotic sheet from the binder was also missing. The DON immediately notified the Administrator and they initiated a search through all med carts, med rooms, and the nurse's station, but the search was unsuccessful. The DON indicated when she spoke with RN 3 who worked the prior night, she indicated she gave 3 Percocet that night. The DON indicated Resident B did not go without any pain medication and RN 3 was then placed on suspension. The DON indicated once a card was complete, the empty card and narcotic sheet was removed from the binder and it was given to the DON or Assistant DON. When pharmacy comes into the facility, we sign off on the medications that were delivered and get a copy for the facility. We then add the card count to the report sign off sheet so we know how many narcotic cards should be in that designated drawer. The January Medication Administration Record (MAR) indicated Resident B had not received any Percocet the night or early morning of 1/28/26 and 1/29/26. A plan of care, dated 3/17/25, indicated Resident B had acute/chronic pain. The interventions included, but were not limited to, administer analgesia per MD (physician) orders. The Abuse, Neglect, Exploitation and Misappropriation Prevention Program Policy was provided by the Administrator on 3/25/26 at 10:04 a.m. It indicated .Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.to protect residents from misappropriation by anyone including facility staff. This Citation relates to intake 2730371 410 IAC (Indiana Administrative Code) 3.1-28(a)

Based on interview and record review, the facility failed to ensure residents maintained dignity by answering call lights in a timely manner, resulting in incontinence leading to residents feeling uncomfortable and embarrassed for 2 of 4 residents reviewed for resident rights. (Resident F and Resident E) Findings include: 1. The record for Resident F was reviewed during the survey. The diagnoses included, but were not limited to, obstructive uropathy (a structural or functional blockage of urine flow anywhere along the urinary tract, from the kidneys to the urethra) and weakness. The most recent care plan for Resident F indicated they needed assistance with moderate assistance with toileting. The interventions for their bowel continence included, but were not limited to, assisting to sit on the toilet and providing toileting at the same time every day. The most current minimum data set assessment indicated Resident F was cognitively intact, did not exhibit behaviors, and was frequently incontinent of bowel. An interview completed during the survey with Resident F indicated they needed assistance with toileting needs. In the weekend prior to the survey, they had turned on their call light to use the bathroom and had to wait over an hour to get assistance. Because of the prolonged wait time, Resident F became incontinent of their bowels which made Resident F feel .uncomfortable and embarrassed . 2. The clinical record for Resident E was reviewed on 03/25/2026 at 12:57 p.m. The diagnoses included, but were not limited to Multiple Sclerosis (a chronic autoimmune disease of the central nervous system), generalized anxiety disorder, chronic pain syndrome, and neuromuscular dysfunction of the bladder (a condition where nerve damage disrupts brain-bladder communication, causing overactive or underactive bladder behavior). A Quarterly Minimum Data Set (MDS) assessment, dated 1/9/26, indicated Resident E was cognitively intact for daily decision making, had no behaviors exhibited for rejection of care, had impairments to bilateral upper extremities, and used a wheelchair for ambulation. Resident E was dependent lying to sitting and sitting to stand, depended on chair transfers, and was on a scheduled pain medication regimen. During an interview with Resident E on 3/24/26 at 10:07 a.m., they indicated a couple nights prior they started to get really uncomfortable lying in bed and the only thing that usually helped was repositioning or getting out of bed. Resident E indicated she turned her call light on and twenty minutes later a Certified Nursing Assistant (CNA) entered the room, her body was turned toward the door, so she did not know who it was. Resident E told the CNA she was hurting bad and needed to get up and reposition. The CNA then told Resident E that she did not have time for that right now because her partner was on break and walked out of the room. Resident E indicated it then took 40 more minutes to come back into the room to help her get up and reposition. Resident E indicated she timed it on her clock and it took a total of an hour before her needs were addressed. Resident E was very upset and worried about other residents who do not have the capability to speak up for themselves and thought that if they were ignoring her that much, then how much are they ignoring the residents who cannot speak up for themselves and were they getting the care they deserved either. A plan of care, dated 4/25/25, indicated Resident E had acute/chronic pain related to fibromyalgia. The interventions included, but were not limited to, anticipate the resident's need for pain relief and respond immediately to any complaint of pain and to attempt non-pharmacological interventions. A Resident's Rights policy was provided by the Administrator on 3/25/26 at 10:10 a.m. It indicated .The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident. This Citation relates to intake 2961693 and 2700913 410 IAC (Indiana Administrative Code) 3.1-3(a) 410 IAC 3.1-38(a)(2)(C)

Based on interview and record review, the facility failed to monitor for side effects of psychotropic medications, as ordered, for 5 of 5 residents reviewed for unnecessary medications. (Residents C, G, 7, 9, and 36) Findings include: 1. The clinical record for Resident 7 was reviewed on 2/25/25 at 12:47 p.m. His diagnoses included, but were not limited to, depression. The 1/29/25 care plan indicated he used an antidepressant medication related to depression. An intervention was to administer the medication as ordered by the physician and monitor/document side effects and effectiveness every shift. The physician's orders indicated to administer one 50 milligrams (mg) tablet of sertraline daily, starting 1/9/25, for depression. They indicated to monitor for side effects of psychotropic medications every shift, starting 1/1/25. The February 2025 TAR (treatment administration record) indicated he was not monitored for side effects of psychotropic medications on night shift the entire month. 2. The clinical record for Resident 9 was reviewed on 2/27/25 at 11:14 a.m. Her diagnoses included, but were not limited to, depression, anxiety, mood disturbance, pseudobulbar effect, and dementia. The 1/22/25 care plan indicated she had a diagnosis of depression and at times, may display triggers such as being short tempered, easily annoyed, trouble concentrating, and poor appetite. An intervention was to monitor/document for side effects and effectiveness. The 1/22/25 care plan indicated she used anti-anxiety medication related to anxiety and impulse disorder. The goal was for her to be free from adverse reactions related to anti-anxiety therapy through the review date. The physician's orders indicated to administer one 0.5 mg tablet of alprazolam daily, effective 1/18/25, for anxiety, and one 12.5 mg tablet of sertraline, starting 12/30/24, for depression. They indicated to monitor for side effects of psychotropic medications every shift, starting 12/30/24. The February 2025 TAR indicated she was not monitored for side effects of psychotropic medications on night shift the entire month. 45291 3. The clinical record for Resident 36 was reviewed on 2/26/2025 at 11:30 a.m. The medical diagnoses included Parkinson's disease, anxiety disorder, and depression. A Quarterly Minimum Data Set assessment, dated 11/27/2024, indicated Resident 36 was cognitively intact. A psychotropic medication care plan, dated 11/18/2024, indicated Resident 36 utilized antidepressant medication. Interventions were listed as monitoring for adverse side effects and for behaviors. A psychotropic medication care plan, dated 11/18/2024, indicated Resident 36 utilized antianxiety medication. Interventions were listed as monitoring for adverse side effects and for behavior. A physician order, dated 12/31/2024, indicated Resident 36 to receive antianxiety medication daily. A physician order, dated 1/23/2025, indicated Resident 36 received an antidepressant medication daily. Review of the February 2025 TAR for Resident 36 indicated the night shift administrations for monitoring side effects of psychotropic medications was not documented as completed. 4. The clinical record for Resident C was reviewed on 2/25/2025 at 11:38 a.m. The medical diagnoses included depression and anxiety disorder. A Quarterly Minimum Data Set assessment, dated 12/23/2024, indicated Resident C was cognitively intact. A psychotropic care plan, revised 12/10/2024, indicated Resident C utilized antidepressant medication. Interventions were listed as monitoring for adverse side effects and for behavior. A psychotropic care plan, revised 12/10/2024, indicated Resident C utilized antianxiety medication. Interventions were listed as monitoring for adverse side effects and for behavior. A physician order, dated 12/31/2024, indicated for Resident C to receive an antidepressant medication daily. A physician order, dated 12/31/2024, indicated for Resident C to receive an antianxiety medication daily. Review of the February 2025 TAR for Resident C indicated the night shift administrations for monitoring side effects of psychotropic medications was not documented as completed. 50436 5. The clinical record for Resident G was reviewed on 2/26/25 at 10:02 a.m. The diagnoses included, but were not limited to, dementia and peripheral vascular disease. Physician orders for Resident G, dated 12/30/24, indicated Resident G was ordered divalproex sodium. A physician's order, dated 12/31/24, indicated Resident G was ordered sertraline and aripiprazole. Psychotropic side effect monitoring every shift was indicated in the physician's orders for all three of these medications. The TAR was reviewed on 2/26/25 at 11:30 a.m. The TAR indicated no monitoring of side effects for psychotropic medications were being done on night shift from 2/1/25 to 2/25/25. During an interview with the Director of Nursing (DON) on 2/26/25 at 12:05 p.m., they indicated the computer system should flag if nurses were not charting what they are supposed to be charting and checking off. They did not know why there was no documentation recorded for treatments on night shift. The treatments are not popping up on the nightly scheduled medication pass on the Medication Administration Record (MAR). The DON indicated it was found the night shift nurses did not have access to the TAR when they transitioned from one electronic health record (EHR) computer system to another EHR computer system on 1/1/25. During an interview with the Chief Nursing Officer (CNO) on 2/26/25 at 1:52 p.m., they indicated the night shift nurses did not have the ability to see the night shift TAR due to a security issue. He wasn't sure if they were doing it. The nurses can see the MAR, but not the TAR. It was on the label, and he would expect a competent nurse to look at the label and order to know to administer it. The CNO indicated they did not know it was an issue until today, 2/26/25, when it was discovered. A Psychotropic Medication Use policy was provided by the CNO on 2/27/25 at 2:15 p.m. It indicated, .2. Drugs in the following categories are considered psychotropic medications: a. Anti-psychotics; b. Anti-depressants; c. Anti-anxiety medications; and d. Hypnotics .13. Residents receiving psychotropic medications are monitored for adverse consequences, including: j. anticholinergic effects- flushing, blurred vision, dry mouth, altered mental status, difficulty urinating, falls, excessive sedation and constipation; k. cardiovascular effects- irregular heart rate or pulse, palpitations, lightheadedness, shortness of breath, diaphoresis, chest/arm pain, increased blood pressure, orthostatic hypotension; l. metabolic effects- increased cholesterol and triglycerides, poorly controlled or unstable blood sugar, weight gain; m. neurologic effects- agitation, distress, extrapyramidal symptoms, neuroleptic malignant syndrome, Parkinsonism, tardive dyskinesia, cerebrovascular events; and n. psychosocial effects- inability to perform ADLs or interact with others, withdrawal or decline from usual social patterns, decreased engagement in activities, diminished ability to think or concentrate . 3.1-48(b)(1) 3.1-48(b)(2)

Based on interviews, observations, and record reviews, the facility failed to provide a diet that was palatable and attractive to 9 of 9 residents reviewed. (Residents G, H, J, 1, 14, 30, 35, 36, and 37) Findings include: 1. The clinical record for Resident 36 was reviewed on 2/26/2025 at 11:30 a.m. The medical diagnoses included Parkinson's disease. A Quarterly Minimum Data Set (MDS) assessment, dated 11/27/2024, indicated Resident 36 was cognitively intact and had no significant weight changes. A physician order, dated 12/30/2024, indicated Resident 36 received a regular diet. During an interview on 2/25/2025 at 12:35 p.m., Resident 36 indicated the food was terrible. The food was often too mushy to eat, has poor to no taste, and she goes without eating because of the quality of the food, or will just eat peanut butter and jelly sandwiches. She stated, Last night they gave us pea soup over mashed potatoes with Jello. It was so bad that I couldn't even eat it, so I just had candy that my [family] brings in. There was some yellow stuff on the side. I think it was supposed to be a vegetable, but I couldn't make out what it was. A test tray of the facility lunch meal was provided by the Clinical Support on 2/25/25 at 12:10 p.m. It included a frittata, diced potatoes, broccoli, and a roll. Three out of four of the foods were yellow in color and did not appear appetizing. The frittata had a bland taste with an unappealing texture. The diced potatoes were bland tasting and lacked any flavor. The broccoli was overcooked, mushy, and bland tasting. The roll was soggy on the bottom from the broccoli juices. During an observation on 2/25/2025 at 12:55 p.m., Resident 36 was served a tray with what she described as an egg omelet, a piece of bread, and mashed broccoli, with some kind of pastry. Resident 36 attempted one bite of the eggs, broccoli, and roll before she indicated she could not eat the food provided because the eggs tasted awful, the broccoli was just mush, and the dessert was too dry. Resident 36 then ate part of her roll and then retrieved ice cream from her freezer to eat. 30344 2. An interview was conducted with Resident 14 on 2/25/25 at 11:25 a.m. They indicated the facility food was not good. A test tray of the facility lunch meal was provided by the Clinical Support on 2/25/25 at 12:10 p.m. It included a frittata, diced potatoes, broccoli, and a roll. Three out of four of the foods were yellow in color and did not appear appetizing. The frittata had a bland taste with an unappealing texture. The diced potatoes were bland tasting and lacked any flavor. The broccoli was overcooked, mushy, and bland tasting. The roll was soggy on the bottom from the broccoli juices. An interview was conducted with Resident 14 on 2/25/25 at 2:02 p.m. He indicated the above lunch meal was not good at all. He didn't eat the diced potatoes, because he didn't like them, and didn't eat the roll, because he didn't want it. 3. An interview was conducted with Resident 30 on 2/25/25 at 11:54 a.m. She indicated the facility food was horrible. Dinner last night was terrible, and she couldn't eat it. A test tray of the facility lunch meal was provided by the Clinical Support on 2/25/25 at 12:10 p.m. It included a frittata, diced potatoes, broccoli, and a roll. Three out of four of the foods were yellow in color and did not appear appetizing. The frittata had a bland taste with an unappealing texture. The diced potatoes were bland tasting and lacked any flavor. The broccoli was overcooked, mushy, and bland tasting. The roll was soggy on the bottom from the broccoli juices. An interview was conducted with Resident 30 on 2/25/25 at 1:56 p.m. She indicated, in regards to the frittata, I don't know what that egg thing was. There was no taste at all, and she wasn't sure if there was broccoli or spinach in it. Every meal is bad. She didn't eat all of any of the above lunch meal. The potatoes were bland, but most stuff was. There was no spice or much flavor. The broccoli was dull with no flavor, no nothing, like they poured it in a pan and served it. She stated, I'm just hoping they can do better. How can it be so hard to fix a halfway decent meal. 4. An interview was conducted with Resident 37 on 2/24/25 at 1:23 p.m. He indicated some of the facility food was not fit to eat and poor quality. A test tray of the facility lunch meal was provided by the Clinical Support on 2/25/25 at 12:10 p.m. It included a frittata, diced potatoes, broccoli, and a roll. Three out of four of the foods were yellow in color and did not appear appetizing. The frittata had a bland taste with an unappealing texture. The diced potatoes were bland tasting and lacked any flavor. The broccoli was overcooked, mushy, and bland tasting. The roll was soggy on the bottom from the broccoli juices. An interview was conducted with Resident 37 on 2/25/25 at 1:54 p.m. He indicated, in regard to the above lunch meal, the potatoes were not flavorful, and the frittata was bland and of different texture. 5. An interview was conducted with Resident J on 2/25/25 at 11:35 a.m. She indicated the facility food taste and quality was horrendous and inedible. It practically turns my stomach and I'm not a picky eater. The facility did not cook the food correctly and needed cooking lessons. Either they didn't know or didn't care. It had been this way for over a year. They discussed it in resident council, but nothing was ever done about it. It's very frustrating. She went to bed hungry many times, because the food was so bad, and she would eat pretty much anything. A test tray of the facility lunch meal was provided by the Clinical Support on 2/25/25 at 12:10 p.m. It included a frittata, diced potatoes, broccoli, and a roll. Three out of four of the foods were yellow in color and did not appear appetizing. The frittata had a bland taste with an unappealing texture. The diced potatoes were bland tasting and lacked any flavor. The broccoli was overcooked, mushy, and bland tasting. The roll was soggy on the bottom from the broccoli juices. 50436 6. The clinical record for Resident 1 was reviewed on 2/26/25 at 10:29 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease and chronic pain syndrome. During an interview with Resident 1 on 2/25/25 at 10:03 a.m., Resident 1 indicated the food had no taste, and was barely warm. A test tray of the facility lunch meal was provided by the Clinical Support on 2/25/25 at 12:10 p.m. It included a frittata, diced potatoes, broccoli, and a roll. Three out of four of the foods were yellow in color and did not appear appetizing. The frittata had a bland taste with an unappealing texture. The diced potatoes were bland tasting and lacked any flavor. The broccoli was overcooked, mushy, and bland tasting. The roll was soggy on the bottom from the broccoli juices. During an interview on 2/25/25 at 12:47 p.m., Resident 1 indicated lunch was just plain lousy. It had no taste and he only took a few bites of it. Resident 1 indicated he would not eat it again, and also indicated he says that about every meal he received. A Quarterly MDS assessment, dated 1/2/25, indicated Resident 1 was cognitively intact. A physician's order, dated 1/1/25, indicated Resident 1 was ordered a regular diet, chopped meats texture, regular/thin consistency for mechanical soft. 7. The clinical record was reviewed for Resident G on 2/26/25 at 10:02 a.m. The diagnoses included, but were not limited to, dementia and chronic kidney disease. A Quarterly Minimum Data Set assessment, dated 2/18/25, indicated Resident G was cognitively intact. During an interview on 2/25/25 at 10:27 a.m., Resident G indicated he refused dinner the night before. He indicated the food had no taste. A test tray of the facility lunch meal was provided by the Clinical Support on 2/25/25 at 12:10 p.m. It included a frittata, diced potatoes, broccoli, and a roll. Three out of four of the foods were yellow in color and did not appear appetizing. The frittata had a bland taste with an unappealing texture. The diced potatoes were bland tasting and lacked any flavor. The broccoli was overcooked, mushy, and bland tasting. The roll was soggy on the bottom from the broccoli juices. During an interview with Resident G on 2/25/25 at 12:49 p.m., he indicated his lunch had no taste or flavor. Resident G indicated he did not eat much because the taste was so bad. A physician's order, dated 12/30/24, indicated Resident G was ordered a regular diet, mechanical soft texture, regular/thin consistency. 8. The clinical record for Resident H was reviewed on 2/26/25 at 9:54 a.m. The diagnoses included, but were not limited to, Parkinson's disease and diabetes mellitus. A Quarterly Minimum Data Set assessment, dated 1/9/25, indicated Resident H was cognitively intact. During an interview with Resident H on 2/25/25 at 11:44 a.m., he indicated the food was terrible. Resident H indicated the food did not have much taste and was very bland. A test tray of the facility lunch meal was provided by the Clinical Support on 2/25/25 at 12:10 p.m. It included a frittata, diced potatoes, broccoli, and a roll. Three out of four of the foods were yellow in color and did not appear appetizing. The frittata had a bland taste with an unappealing texture. The diced potatoes were bland tasting and lacked any flavor. The broccoli was overcooked, mushy, and bland tasting. The roll was soggy on the bottom from the broccoli juices. During an interview with Resident H on 2/25/25 at 12:52 p.m., he indicated lunch tasted horrible, it had no taste, and was a bunch of mush. During an interview with Resident H on 2/26/25 at 12:51 p.m., he indicated lunch was not good and he did not know what he was eating. Resident H indicated the food was mushy and he had to request a replacement meal. A physician's order, dated 12/29/24, indicated Resident 24 was ordered a no added salt diet. 9. The clinical record for Resident 35 was reviewed on 2/26/25 at 10:09 a.m. The diagnoses included, but were not limited to, acute respiratory failure with hypoxia and anorexia. An Annual Minimum Data Set assessment, dated 12/22/24, indicated Resident 35 was severely cognitively impaired. During an interview with Resident 35's husband, also her roommate, on 2/25/25 at 10:03 a.m., they indicated the food had no taste, was bland, and was barely warm when it arrived to them. A test tray of the facility lunch meal was provided by the Clinical Support on 2/25/25 at 12:10 p.m. It included a frittata, diced potatoes, broccoli, and a roll. Three out of four of the foods were yellow in color and did not appear appetizing. The frittata had a bland taste with an unappealing texture. The diced potatoes were bland tasting and lacked any flavor. The broccoli was overcooked, mushy, and bland tasting. The roll was soggy on the bottom from the broccoli juices. During an interview with Resident 35's husband on 2/25/25 at 12:47 p.m., he indicated Resident 35 had barely touched her food. He indicated the food tasted lousy today. During an interview with the Dietary Manager (DM) on 2/26/25 at 3:19 p.m., she indicated she had residents' voice concerns that they do not care for the food. The DM indicated the menu changed, on 1/1/25, and she thinks that was part of the concerns. The DM also indicated she has noticed a request for a lot more alternative foods since changing the menu. A General Food Preparation and Handling policy provided by the Chief Nursing Officer, on 2/26/25 at 3:40 p.m., indicated, .13. All food will be prepared by methods that preserve nutritive value, flavor, and appearance. Food will be attractively served at the appropriate temperature and in a form to meet the individual needs of the resident . This citation relates to Complaint IN00440035. 3.1-21(a)(1) 3.1-21(a)(2)

Based on interview and record review, the facility failed to monitor and document target behaviors for 5 of 5 residents reviewed for unnecessary medications. (Residents C, G, 7, 9, and 36) Findings include: 1. The clinical record for Resident 7 was reviewed on 2/25/25 at 12:47 p.m. His diagnoses included, but were not limited to, depression and insomnia. The 1/29/25 care plan indicated he used an antidepressant medication related to depression. An intervention was to administer the medication as ordered by the physician and monitor/document side effects and effectiveness every shift. The 2/11/25 care plan indicated he had a diagnosis of insomnia. The physician's orders indicated to administer one 50 milligrams (mg) tablet of sertraline daily, effective 1/9/25, for depression and one 5 mg tablet of melatonin at bedtime, starting 1/8/25, for insomnia/sleeplessness. They indicated to monitor for the following behaviors related to depression, starting 1/1/25: tearfulness, withdrawn, agitation, excessive crying, or social isolation, and at the end of each shift, mark the frequency of how often the behavior occurred, the intensity of the behaviors, and how he responded to redirection; and related to insomnia, starting 1/1/25, at the end of each shift, mark the frequency of how often the behavior occurred, the intensity of the behavior, and how he responded to redirection. The February 2025 TAR (treatment administration record) indicated the above behaviors related to Resident 7's depression and insomnia were not monitored and documented for frequency, intensity, and response to redirection on night shift the entire month. 2. The clinical record for Resident 9 was reviewed on 2/27/25 at 11:14 a.m. Her diagnoses included, but were not limited to, depression, anxiety, mood disturbance, pseudobulbar effect, and dementia. The 1/22/25 care plan indicated she required the use of anticonvulsant medication related to mood disturbance. The 1/22/25 care plan indicated she had a diagnosis of depression and, at times, may display triggers such as being short tempered, easily annoyed, trouble concentrating, and poor appetite. An intervention was to monitor/document for side effects and effectiveness. The 1/22/25 care plan indicated she used anti-anxiety medication related to anxiety and impulse disorder. The physician's orders indicated to administer one 0.5 mg tablet of alprazolam daily, effective 1/18/25, for anxiety; four 125 mg capsules of Depakote sprinkles every day, starting 2/10/25 and three 125 mg capsules of Depakote sprinkles every day, starting 2/10/25; and one 12.5 mg tablet of sertraline, starting 12/30/24, for depression. They indicated to monitor for psychosis, delusions, and hallucinations, starting 1/3/25, and at the end of each shift, mark the frequency of how often the behavior occurred, the intensity of the behavior, and how she responded to redirection; the following behaviors related to depression, starting 1/3/25: tearfulness, withdrawn, agitation, excessive crying, or social isolation, and at the end of each shift, mark the frequency of how often the behavior occurred, the intensity of the behaviors, and how she responded to redirection; and the following behaviors related to anxiety, starting 1/3/25: self reported nervousness, restlessness, sleeplessness, etc., and at the end of each shift, mark the frequency of how often the behavior occurred, the intensity of the behavior, and how she responded to redirection. The February 2025 TAR indicated that the above behaviors were not monitored and documented for frequency, intensity, and response to redirection on night shift the entire month. 45291 3. The clinical record for Resident 36 was reviewed on 2/26/2025 at 11:30 a.m. The medical diagnoses included Parkinson's disease, anxiety disorder, and depression. A Quarterly Minimum Data Set assessment, dated 11/27/2024, indicated Resident 36 was cognitively intact. A psychotropic medication care plan, dated 11/18/2024, indicated Resident 36 utilized antidepressant medication. Interventions were listed as monitoring for adverse side effects and for behavior. A psychotropic medication care plan, dated 11/18/2024, indicated Resident 36 utilized antianxiety medication. Interventions were listed as monitoring for adverse side effects and for behavior. A physician order, dated 12/31/2024, indicated to monitor Resident 36 for target behaviors of depression every shift. A physician order, dated 12/31/2024, indicated to monitor Resident 36 for target behaviors of anxiety every shift. Review of the February 2025 TAR for Resident 36 indicated the night shift administrations for monitoring for target behaviors of psychotropic medications was not marked as completed. 4. The clinical record for Resident C was reviewed on 2/25/2025 at 11:38 a.m. The medical diagnoses included depression and anxiety disorder. A Quarterly Minimum Data Set assessment, dated 12/23/2024, indicated Resident C was cognitively intact. A psychotropic care plan, revised 12/10/2024, indicated Resident C utilized antidepressant medication. Interventions were listed as monitoring for adverse side effects and for behavior. A psychotropic care plan, dated revised 12/10/2024, indicated Resident C utilized antianxiety medication. Interventions were listed as monitoring for adverse side effects and for behavior. A physician order, dated 12/31/2024, indicated to monitor Resident C for target behaviors of depression every shift. A physician order, dated 12/31/2024, indicated to monitor Resident C for target behaviors of anxiety every shift. Review of the February 2025 TAR for Resident C indicated the night shift administrations for monitoring for target behaviors of psychotropic medications were not indicated as completed. 50436 5. The clinical record for Resident G was reviewed on 2/26/25 at 10:02 a.m. The diagnoses included, but were not limited to, dementia and peripheral vascular disease. Physician orders for Resident G, dated 12/30/24, indicated Resident G was ordered divalproex sodium for mood and behaviors. A physician's order, dated 12/31/24, indicated Resident G was ordered sertraline for depression and aripiprazole for depression. Behavior monitoring every shift was indicated in the physician's orders for all three of these medications. They indicated to monitor for the following behaviors related to depression, starting 12/30/24: tearfulness, withdrawn, agitation, excessive crying, or social isolation, and at the end of each shift, mark the frequency of how often the behavior occurred, the intensity of the behaviors, and how he responded to redirection; and related to psychosis, delusions and hallucinations starting 1/3/25, at the end of each shift, mark the frequency of how often the behavior occurred, the intensity of the behavior, and how he responded to redirection. The TAR was reviewed on 2/26/25 at 11:30 a.m. The TAR indicated no monitoring of behaviors were being done on night shift from 2/1/25 to 2/25/25. During an interview with the Director of Nursing (DON) on 2/26/25 at 12:05 p.m., they indicated the computer system should flag if nurses were not charting what they were supposed to be charting and checking off. They did not know why there was no documentation recorded for treatments on night shift. The treatments were not popping up on the nightly scheduled medication pass on the Medication Administration Record (MAR). The DON indicated it was discovered the night shift nurses did not have access to the TAR when they transitioned from one electronic health record (EHR) computer system to another EHR computer system on 1/1/25. During an interview with the Chief Nursing Officer (CNO) on 2/26/25 at 1:52 p.m., they indicated the night shift nurses did not have the ability to see the night shift TAR due to a security issue. He wasn't sure if they were doing it. The nurses can see the MAR, but not the TAR. It was on the label, and he would expect a competent nurse to look at the label and order to know to administer it. The CNO indicated they did not know it was an issue until today, 2/26/25, when it was discovered. During an interview with the CNO on 2/27/25 at 11:13 a.m., they indicated, It's our expectation that physician's orders are followed, it's a standard of care. A Behavioral Assessment, intervention and Monitoring policy was provided by the CNO on 2/27/25 at 2:15 p.m. The policy indicated, .6. The nursing staff will identify, document, and inform the physician about specific details regarding changes in the individual's mental status, behavior, and cognition, including . i. onset, duration, intensity, and frequency of behavioral symptoms . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure treatments were completed and documented on night shift and a resident had a fall intervention in place for 5 of 5 residents reviewed for unnecessary medications and 1 of 2 residents reviewed for falls. (Residents C, G, 7, 9, 24, and 36) Findings include: 1. a) The clinical record 7 was reviewed on 2/25/25 at 12:47 p.m. His diagnoses included, but were not limited to, Parkinson's disease. The 1/12/25 Accident & Incident Report and Investigation indicated Resident 7 had a fall from his wheelchair at the nurse's station on 1/12/25 at 6:51 p.m. He attempted to stand up. A CNA (Certified Nurse Aide) ran to try and catch him but was unable to reach him in time. He fell , striking his head on a bedside table. He suffered a laceration to the top of his head, a laceration to his top lip, and was sent to the emergency room . The 1/12/25 emergency department notes indicated he had a large laceration to his scalp that was repaired with a total of nineteen staples and a smaller laceration to his upper lip that was repaired with four stitches. The 1/13/25 at risk for falls care plan indicated an intervention was hipsters/padded undergarments to be worn when up, initiated 1/13/25. An observation of Resident 7 was made on 2/27/25 at 2:34 p.m. He was sitting in his wheelchair in front of the nurse's station. An interview was conducted with the DON (Director of Nursing) and CNA 5 on 2/27/25 at 2:34 p.m. The DON indicated she didn't know Resident 7 was supposed to wear hipsters when up. The DON inquired with the ADON (Assistant Director of Nursing) via telephone, and indicated the ADON didn't know anything about it either. CNA 5 indicated he wasn't currently wearing hipsters and didn't wear anything like that. The Assessing Falls and Their Causes policy was provided by the DON on 2/27/25 at 3:10 p.m. It indicated, Review the resident's care plan to assess for any special needs of the resident . Assemble the equipment and supplies as needed. 1. b) The clinical record for Resident 7 was reviewed on 2/25/25 at 12:47 p.m. His diagnoses included, but were not limited to, Parkinson's disease, heart disease, and hypertension. The 1/29/25 care plan indicated Resident 7 had impaired skin integrity related to decreased mobility, fragile skin, and incontinence. The 2/10/25 anticoagulant medication care plan indicated he had the potential for hemorrhage due to his use of Eliquis. The goal was for him to have no signs or symptoms of hemorrhage through the next review. An intervention was to monitor for signs and symptoms of adverse reactions. The physician's order for Resident 7 indicated to monitor for signs and symptoms of bruising and bleeding, and to notify medical provider with complications, every shift starting 1/1/25; to apply house barrier cream to peri-area and buttocks every shift, starting 1/1/25; and to float heels while in bed every shift, starting 1/1/25. The February 2025 TAR (treatment administration record) indicated the signs and symptoms of bruising and bleeding were not monitored every night shift the entire month; the house barrier cream was not applied to his peri-area and buttocks every night shift the entire month; and his heels were not floated while in bed the entire month. 2. The clinical record for Resident 9 was reviewed on 2/27/25 at 11:14 a.m. Her diagnoses included, but were not limited to, peripheral vascular disease and chronic obstructive pulmonary disease (COPD). The 1/22/25 COPD care plan indicated the goal was for her to have optimal breathing patterns daily with an intervention for the head of her bed to be elevated to her preference. The 1/22/25 care plan indicated she had the potential for skin breakdown related to incontinence and assistance required for bed mobility. The physician's orders for Resident 9 indicated to apply moisture barrier to bilateral buttocks at bedtime for prevention, starting 12/30/24; apply skin prep to bilateral heels at bedtime, starting 12/30/24; apply house barrier cream to peri-area and buttocks every shift, starting 12/30/24; encourage her to keep her feet elevated on a pillow while in bed and check every shift, starting 12/30/24; apply skin repair cream to chest/back/stomach every shift, starting 12/30/24; monitor for signs and symptoms of bruising and bleeding, and to notify medical provider with complications; and to elevate the head of her bed to her preference to alleviate/avoid shortness of breath while lying flat every shift, starting 1/22/25. The February 2025 TAR indicated the moisture barrier to bilateral buttocks at bedtime was not applied every night shift the entire month; the skin prep to bilateral heels was not applied at bedtime the entire month; the house barrier cream to peri-area and buttocks was not applied every night shift the entire month; she was not encouraged to keep her feet elevated on a pillow while in bed every night shift the entire month; the skin repair cream to her chest/back/stomach was not applied every night shift the entire month; she was not monitored for signs and symptoms of bruising and bleeding every night shift the entire month; and the head of her bed was not elevated to her preference every night shift the entire month. 45291 3. The clinical record for Resident 36 was reviewed on 2/26/2025 at 11:30 a.m. The medical diagnosis included Parkinson's disease. A Quarterly Minimum Data Set assessment, dated 11/27/2024, indicated Resident 36 was cognitively intact and did not have skin alterations. A care plan, revised 12/2/2024, indicated Resident 36 was at risk for developing skin alterations. A physician order, dated 12/31/2024, indicated to utilize barrier cream to peri-area and buttocks. Review of the February 2025 TAR for Resident 36 indicated the night shift administrations for barrier cream were not recorded as completed. 4. The clinical record for Resident C was reviewed on 2/25/2025 at 11:38 a.m. The medical diagnoses included chronic kidney disease, extended spectrum beta-lactamase (ESBL) resistance, and urinary tract infections. A Quarterly Minimum Data Set assessment, dated 12/23/2024, indicated Resident C was cognitively intact, utilized an indwelling urinary catheter, and received isolation due to infectious disease. A care plan, revised 10/23/2024, indicated Resident C utilized an indwelling urinary catheter for management of obstructive uropathy. Interventions included providing catheter care every shift. A physician order for Resident C, dated 12/30/2024, indicated to apply skin prep to heels at bedtime for prevention. A physician order, dated 12/31/2024, indicated Resident C to have barrier cream to peri-area and buttocks. A physician order, dated 12/31/2024, indicated to assess Resident C's indwelling urinary device every day and night shift. A physician order, dated 12/31/2024, indicated to complete catheter care every shift for Resident C. A physician order, dated 12/31/2024, indicated to ensure Resident C's head of bed was elevated as tolerated every day and night shift. A physician order for Resident C, dated 12/31/2024, indicated to record the amount of output every shift and report to medical doctor if output was less than 240 milliliters (ml). Review of the February 2025 TAR for Resident C indicated the night shift administrations for barrier cream, catheter care and associated orders as aforementioned, and skin prep were not documented as completed. 50436 5. The clinical record for Resident 24 was reviewed on 2/26/25 at 9:54 a.m. The diagnoses included, but were not limited to, Parkinson's disease, diabetes mellitus, and overactive bladder. Physician's orders, dated 12/29/24, indicated Resident 24 had orders for catheter care every shift, to monitor catheter output every shift, and verify catheter was anchored every shift. The TAR was provided by the Chief Nursing Officer (CNO) on 2/27/25 at 2:15 p.m. The TAR indicated no catheter care, catheter output, or verification of catheter being anchored was documented for night shift from 2/1/25 to 2/25/25. 6. The clinical record for Resident G was reviewed on 2/26/25 at 10:02 a.m. The diagnoses included, but were not limited to, dementia and peripheral vascular disease. Physician's orders, dated 12/30/24, indicated Resident G had orders to document keeping the head of the bed elevated to alleviate/avoid shortness of breath while lying flat every shift, to monitor oxygen saturations every shift, and to apply oxygen at or up to two liters per minute, to maintain saturation levels greater than 90%. The TAR was provided by the CNO on 2/26/25 at 12:45 p.m. The TAR indicated Resident G had no documentation on night shift, from 2/1/25 to 2/25/25, for keeping the head of the bed elevated or monitoring oxygen levels. Resident G had physician orders, dated 12/30/24, to apply house barrier cream to peri-area and buttocks every shift. During review of the TAR for February 2025, no documentation for application of barrier cream was documented for night shift from 2/1/25 to 2/25/25. A physician's order, dated 2/10/25, indicated Resident G had orders for bacitracin ointment (topical) to RLE (right lower extremity) two times daily and hydrocortisone external cream 1% to be applied to BLE (bilateral lower extremities) two times a day. The February 2025 TAR indicated there was no documentation of these treatments during night shift from 2/10/25 to 2/25/25. During an interview with the Director of Nursing (DON) on 2/26/25 at 12:05 p.m., they indicated the computer system should flag if nurses were not charting what they were supposed to be charting and checking off. They did not know why there was no documentation recorded for treatments on night shift. The treatments are not popping up on the nightly scheduled medication pass on the medication administration record (MAR). The DON indicated it was found the night shift nurses did not have access to the TAR when they transitioned from one electronic health record (EHR) computer system to a different EHR computer system on 1/1/25. During an interview with the CNO on 2/26/25 at 1:52 p.m., they indicated the night shift nurses did not have the availability to see the night shift TAR due to a security issue. He wasn't sure if they were doing it. The nurses can see the MAR, but not the TAR. It was on the label, and he would expect a competent nurse to look at the label and order to know to administer it. The CNO indicated they did not know it was an issue until today, 2/26/25, when it was discovered. During an interview with Qualified Medication Aide (QMA) 3 on 02/26/25 at 04:45 p.m., they indicated treatments were not scheduled at night and she had access to the TAR, but nothing triggered at night. QMA 3 indicated if any treatments were due, they trigger on the TAR to let the nurse know something needed to be done. During an interview with QMA 4 on 02/27/25 at 09:51 a.m., she indicated she did not have any treatments ordered right now at nighttime. QMA 4 indicated nothing had been triggering on the TAR for administration. During an interview with the CNO on 02/27/25 at 11:13 a.m., they indicated, It's our expectation that physician's orders are followed, it's a standard of care. A Prevention of Pressure Injuries policy was provided by the CNO on 2/26/25 at 3:40 p.m. It indicated, .7. Use a barrier product to protect skin from moisture .20. Select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice . A Catheter Care, Urinary policy was provided by the CNO on 2/27/25 at 2:17 p.m. It indicated the following, .Documentation: The following information should be recorded in the resident's medical record . 57. The date and time that catheter care was given., 58. The name and title of the individual(s) giving the catheter care . A Medication Therapy policy was provided by the CNO on 2/26/25 at 3:40 p.m. The policy indicated the following, .2. All decisions related to medications shall include appropriate elements of the care process, such as: a. adequately detailed assessment; b. review of causes of symptoms . A Pulse Oximetry (Assessing Oxygen Saturation) policy was provided by the DON on 2/27/25 at 10:00 a.m. The policy indicated the following, .8. Assess the resident for the following signs and symptoms of impaired oxygen saturation: a. altered respirations, c. cyanotic appearance, d. restlessness, irritability, e. confusion .Documentation: The SaO2 flow sheet should be placed in the medical record. In addition, the following information should be recorded in the resident's medical record: 30. the date and time that the procedure was performed, 32. the assessment data gathered prior to the procedure, 34. any unusual findings, 36. the signature and title of the person performing the procedure . An Administering Medications policy was provided by the DON on 2/26/25 at 1:15 p.m. The policy indicated the following, .4. Medications are administered in accordance with prescriber orders, including any required time frame .24. Topical medications used in treatments are recorded on the resident's treatment record (TAR) . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure proper eating utensils were provided to 1 of 1 resident reviewed for assistive devices. (Resident 29) Findings include: During an observation on 2/25/25 at 12:44 p.m., Resident 29 was laying back in bed eating lunch. He had a curved spoon, regular fork, and regular dinner plate on his lunch tray. A carton of milk with a straw in it and a plastic cup with no handle that contained lemonade with a straw were also on the tray. The clinical record for Resident 29 was reviewed on 2/25/25 at 11:33 a.m. The diagnoses included, but were not limited to, flaccid hemiplegia (paralysis and loss of muscle tone on one side of the body) affecting left non-dominant side and dysphagia (difficulty swallowing). A Quarterly Minimum Data Set (MDS) assessment, dated 11/22/24, indicated Resident 29 was mildly cognitively impaired. The MDS indicated he received a mechanically altered diet, requiring a change in texture of food or liquids (e.g., pureed food, thickened liquids). A physician's order, dated 12/30/24, indicated Resident 29 was to have a plate guard with all meals as necessary, independence cup with handle and fluid control lid with every meal, and right-hand adaptive spoon and fork with meals. A therapy special instruction order, dated 12/30/24, indicated Resident 29 was to have scoop bowls and curved utensils on tray at all times. During an observation of Resident 29 on 2/26/25 at 12:47 p.m., he was laying back in bed with his lunch tray in front of him. A regular dinner plate, an adaptive spoon, regular fork, carton of milk with a straw in it, and a cup with no handle of lemonade and straw in it were noted on the lunch tray. During an interview with Licensed Practical Nurse 2 on 2/26/25 at 12:49 p.m., they indicated Resident 29 was to have a plate guard and specialized cup with a handle on every tray. During an interview with the Dietary Manager (DM) on 2/26/25 at 3:19 p.m., they indicated the kitchen was missing a lot of specialized utensils, because they kept coming up missing, and she needed to order more. She indicated only specialized spoons were available in the kitchen. The DM indicated dietary receives the nursing order for any specialized utensils needed for a resident and that information was printed on the resident's tray card, so dietary staff know each resident's special needs. The DM indicated she did not know why Resident 29 was not receiving a plate guard on his meal trays. An activities of daily living care plan provided by the Director of Nursing (DON), on 2/27/25 at 10:00 a.m., indicated Resident 29 was to be provided with adaptive equipment, if necessary. An Assistance with Meals policy was provided by the DON on 2/27/25 at 10:33 a.m. It indicated, .Residents Who May Benefit from Assistive Devices: 1. Adaptive devices (special eating equipment and utensils) will be provided by residents who need or request them. These may include devices such as silverware with enlarged/padded handles, plate guards, and/or specialized cups. 2. Assistance will be provided to ensure that residents can use and benefit from special eating equipment and utensils . 3.1-21(h)

Based on interview and record review, the facility failed to utilize Enhanced Barrier Precautions (EBP) for a resident with an indwelling medical device for 1 of 2 residents reviewed for catheters (Resident C). Findings include: The clinical record for Resident C was reviewed on 2/25/2025 at 11:38 a.m. The medical diagnoses included chronic kidney disease, extended spectrum beta-lactamase (ESBL) resistance, and urinary tract infections. A Quarterly Minimum Data Set assessment, dated 12/23/2024, indicated Resident C was cognitively intact, utilized an indwelling urinary catheter, and received isolation due to infectious disease. A care plan, revised 10/23/2024, indicated Resident C utilized an indwelling urinary catheter for management of obstructive uropathy. Interventions included providing catheter care every shift. A physician order, dated 12/31/2024, indicated Resident C had an indwelling catheter. During an interview with Resident C on 2/25/2025 at 11:20 a.m., she indicated staff do not utilize gowns with her when they assist with her catheter care. During a confidential interview conducted during the survey, Confidential Interviewee 1 indicated they did not know who was on transmission-based precautions, including EBP. They stated they use standard precautions for all residents and only utilize gloves when providing care for Resident C, including providing care for Resident C's indwelling medical device. During a confidential interview conducted during the survey, Confidential Interviewee 2 indicated they were not aware Resident C was on EBP. They stated Resident C does not have an EBP bin in the room, so they did not utilize EBP with Resident C when providing care, which included bed baths and catheter care. During an observation with Confidential Interviewee 2, Resident C's room had an EBP container, containing only a box of gloves, in the entry way of the room. The bin was covered in clean linen and spare pillows and a confidential interviewee stated, Oh, I never even know that was there. I thought it was just storage for [Resident C]. A policy entitled, Enhanced Barrier Precautions, was provided by the Assistant Director of Nursing on 2/26/2025 at 2:05 p.m. The policy indicated that EBP should be utilized to prevent the spread of multi-drug-resistant organisms (MDROs). EBP was to be used during high-contact resident care activities, including dressing, bathing, and device care such as care for a urinary catheter. EBP should have been used for residents with indwelling medical devices, including urinary catheters, and that signage should have been posted .in the door or wall outside the resident room . This citation relates to Complaint IN00440035. 3.1-18(b)(2)

Based on interview and observations, the facility failed to promote a clean environment for Resident 6 by having a thick layer of dusk on her over bed tables, including her personal items and plants, as we well as a thin layer of dust on her window ledge for 1 of 3 resident reviewed for environmental concerns. Findings include: The clinical record for Resident 6 was reviewed on 12/7/2023 at 11:45 a.m. The medical diagnosis included chronic obstructive pulmonary disease. The Quarterly Minimum Data Set Assessment, dated for 11/15/2023, indicated that Resident 6 was cognitively intact. An observation of Resident 6's room on 12/7/2023 at 11:40 a.m. indicated a thick layer of dust on an over bed table by the back corner of the room with some personal potted plants that also had a layer of dusk on them. Another bedside table was located next to the resident's bed that contained personal items with a thick layer of dust and the window ledge in the room had a thin layer of dust. An interview with Resident 6 on 12/7/2023 at 11:43 a.m. indicated that the dust in her room bothers her and will make her cough. She stated she will usually get a wet washcloth every few weeks and wipe down her items. She stated that when housekeeping comes into her room, they only mop the floor, but they never dust. An observation of Resident 6's room on 12/8/2023 at 11:04 a.m. indicated a thick layer of dust on an over bed table by the back corner of the room with some personal potted plants that also had a layer of dusk on them. Another bedside table was located next to the resident's bed that contained personal items with a thick layer of dust. A policy entitled, Room Cleaning, was provided by the Administrator on 12/11/2023 at 2:30 p.m. The policy indicated that a deep clean should be completed monthly and include a dust mop and high duster. 3.1-19(f)

Based on interview and record review the facility failed to provide routine optometry services for a resident experiencing blurred vision for 1 of 1 resident reviewed for vision (Resident 30). Finding include: During an interview with Resident 30 on at 12/07/23 at 1:32 p.m., indicated her vision had been blurry for the last 3-4 months. The resident had reported this to the facility staff and had not seen an eye doctor yet. During an interview with the Social Service Director (S.S.D.) on 12/08/23 at 2:06 p.m., indicated she was unable to find where Resident 30 had seen an eye doctor or refused to see an eye doctor. The S.S.D. indicated she would go talk with the resident at this time and make an appointment for the resident to see the eye doctor. During an interview with Resident 30 on 12/11/23 at 1:33 p.m., indicated she had not wore glasses for years except reading glasses. The resident indicated she had not seen an eye doctor or was offered by the facility to see an eye doctor since her admission in September 2022. The resident indicated she did have an appointment now. Review of the record of Resident 30 on 12/11/23 at 2:08 p.m., indicated the resident's diagnoses included, but were not limited to, anemia, muscle weakness, diabetes, major depressive disorder, anxiety, osteoarthritis, mild protein calorie malnutrition, peripheral vascular disease and chronic pain syndrome. The consent for services for Resident 30, dated 9/26/22, indicated the resident signed consent to have optometry services. The Significant Change Minimum Data (MDS) assessment for Resident 30, dated 10/1/23, indicated the resident was cognitively intact with daily decision making. The physician Recapitulation (recap) for Resident 30, dated December 2023, (original date 12/12/22) indicated the resident was to be seen by optometrist. 3.1-39(a)(1)

Based on observation, interview and record review the facility failed to provide routine dental services for a resident with missing teeth and a chipped tooth for 1 of 2 residents reviewed for dental services (Resident 30). Finding include: During an observation and interview with Resident 30 on 12/07/23 at 1:31 p.m., the resident's front tooth was chipped off and she was missing several teeth. The resident indicated she had not seen a dentist and had report to the facility staff she needed to see a dentist. During an interview with the Social Service Director (S.S.D.) on 12/08/23 at 2:06 p.m., indicated she was unable to find where Resident 30 had been seen by a dentist or refused to see the dentist. The S.S.D. indicated she would go talk with the resident at this time and make an appointment for the resident to see a dentist. During an interview with Resident 30 on 12/11/23 at 1:33 p.m., indicated she had not seen a dentist or was offered by the facility to a dentist since her admission in September 2022. The resident indicated she did have an appointment now. Review of the record of Resident 30 on 12/11/23 at 2:08 p.m., indicated the resident's diagnoses included, but were not limited to, anemia, muscle weakness, diabetes, major depressive disorder, anxiety, osteoarthritis, mild protein calorie malnutrition, peripheral vascular disease and chronic pain syndrome. The consent for services for Resident 30, dated 9/26/22, indicated the resident signed up for dental services. The Significant Change Minimum Data (MDS) assessment for Resident 30, dated 10/1/23, indicated the resident was cognitively intact with daily decision making. The resident had obvious or likely cavity or broken teeth. The physician Recapitulation (recap) for Resident 30, dated December 2023, (original date 12/12/22) indicated the resident was to be seen by a dentist. 3.1-24(a)(1) 3.1-24(b)

Based on interview, observation, and record review, the facility failed to change Resident 1's oxygen tubing and pre-filled humidifier at least weekly, failed to label and store Resident 1's nebulizer within a plastic bag when not in use, failed to store Resident E's nasal cannula and [CONDITION(S)] (Continuous Positive Airway Pressure) mask within a clean plastic bag when not in use, failed to label and/or date the nasal cannula for 4 residents (Resident 34, Resident 19, Resident G, and Resident F), failed to ensure ear pads were in use with oxygen therapy (Resident 19) for 6 of 6 residents reviewed for oxygen therapy. Findings include: 1. The clinical record for Resident 1 was reviewed on 10/6/2022 at 11:47 a.m. The medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS) Assessment, dated 7/9/2022, indicated that Resident 1 utilized oxygen therapy and was cognitively intact. A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview and observation on 10/4/2022 at 12:06 p.m. indicated that the nasal cannula and humidifier for Resident 1 were dated for 9/25/2022. The nebulizer for Resident 1 was laying on the bedside table at this time without a date. Resident 1 indicated that staff changed his oxygen equipment every two or three weeks and that he utilized his nebulizer as needed a few times a week, but they kept it on the bedside table when not in use without a bag. An observation on 10/5/2022 at 1:34 p.m. indicated the nebulizer was being stored in a plastic bag at this time with oxygen tubing still dated for 9/25/2022. 2. The clinical record for Resident E was reviewed on 10/6/2022 at 11:09 a.m. The medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A Comprehensive MDS Assessment, dated 9/8/2022, indicated that Resident E was cognitively intact and utilized oxygen therapy. A MAR, dated October 2022, indicated that Resident E utilized oxygen therapy at 2 lpm as needed for shortness of breath and a [CONDITION(S)] at bedtime. An observation on 10/5/2022 at 10:48 a.m. indicated that Resident E's oxygen tubing at on the floor under her bed with her [CONDITION(S)] laying on her unmade bed. No date was present on either piece of respiratory equipment. An observation on 10/5/2022 at 1:36 p.m. indicated Resident E's oxygen tubing was in place at this time without a date and her [CONDITION(S)] was laying on the bedside table, not within a storage bag. 3. The clinical record for Resident 19 was reviewed on 10/5/2022 at 2:01 p.m. The medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS Assessment, dated 8/18/2022, indicated that Resident 19 had mild cognitive impairment and utilized oxygen therapy. A MAR, dated October 2022, indicated that Resident 19 utilized oxygen therapy at 3 lpm via nasal cannula and for staff to make sure that nasal cannula pads are in place. An observation and interview on 10/4/2022 at 12:34 p.m. indicated that Resident 19 was in his room at this time utilizing a large oxygen tank via nasal cannula without the use of ear pads. He indicated they change his tubing about once a month. An observation on 10/5/2022 at 1:40 p.m. indicated that Resident 19 was in his room at this time utilizing a large oxygen tank via nasal cannula without the use of ear pads. 4. The clinical record for Resident 34 was reviewed on 10/6/2022 at 11:55 a.m. The medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Annual MDS Assessment, dated 9/7/2022, indicated that Resident 34 was cognitively intact and utilized oxygen therapy. A MAR, dated October 2022, indicated that Resident 34 utilized oxygen therapy at 2 lpm via nasal cannula at bedtime and as needed for shortness of breath. An interview and observation on 10/4/2022 at 2:06 p.m. indicated that nasal cannula for Resident 34 was in a storage bag on the concentrator at the end of his bed but did not have a date listed. The bag only indicated the resident's last name. Resident 34 indicated the staff change his tubing every 2 or 3 weeks and that he only used it at bedtime. An observation on 10/5/2022 at 1:38 p.m. indicated that Resident 34's oxygen tubing was in the bag on the oxygen concentrator at the end of the bed without a date. 5. On 10/04/22, at 4:12 p.m., Resident G was observed wearing oxygen at 2 liters per minute and her oxygen tubing was not labeled with a date. Resident G's record was reviewed on 10/5/22 at 1:43 p.m. and indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set assessment, dated 8/10/22, indicated Resident G was moderately impaired in cognitive skills for daily decision making and she received oxygen therapy. A care plan, last reviewed on 8/10/22, indicated she required oxygen use, continuous and as needed, for obstructive sleep apnea. Goals were for the resident to be free of respiratory distress every day until the next review. Interventions included, but were not limited to, apply oxygen as the physician orders, monitor for breathing difficulties during care and observe how effective the oxygen therapy is, notify physician if resident looks like she is in distress. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/07/22 at 2:34 p.m., Resident G was observed seated on the side of her bed, her oxygen was in place with her nasal cannula at 2 liters, and neither the tubing, nor the bag the tubing is stored, in if the resident is not wearing the nasal cannula, was dated. 6.) During an observation on 10/04/22 at 1:41 p.m., Resident F's oxygen tubing and humidifier were not dated. Review of the record of Resident F on 10/7/22 at 1:09 p.m., indicated the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) for Resident F, dated 9/2/22, indicated the resident was severely cognitively impaired rarely/never made decisions. The resident received oxygen therapy. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The oxygen therapy policy provided by the Director Of Nursing (DON) on 10/5/22 at 2:00 p.m., indicated when oxygen delivery devices were changed, they would be labeled and stored in an equipment bag at the resident's bedside. 3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure 1 of 3 residents reviewed for transfer and discharge had the appropriate discharge and transfer documentation completed prior to transfer and discharge. (Resident 43) Findings include: The clinical record of Resident 43 was reviewed on 10-7-22 at 12:20 p.m. It indicated she was admitted to the facility on [DATE] and discharged on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note, dated 8-22-22 at 4:00 p.m., indicated, Res [resident] demanded to be discharged . NP [Nurse Practitioner] called & new order to discharge to home obtained. An accompanying document entitled, Discharge Against Medical Advice; Release of Responsibility form was located in the clinical record with notation by the Social Services Designee and RN 10 that resident refused to sign. The Assistant Director of Nursing (ADON) provided a copy of a document entitled, Discharge Check Off. This document indicated, Fill out the discharge summary, and it was not checked off as completed. At the bottom portion of the document was a hand-written notation which indicated, Resident refused to stay for Discharge instructions. Left AMA [against medical advice]. In an interview with the NP/APRN (Nurse Practitioner/Advanced Practice Registered Nurse) on 10-7-22 at 1:15 p.m., she indicated, The resident was here barely two full days. To be honest, I'm not really sure why she was even admitted because she was able to do most of own care and was walking around everywhere. She had been a resident here sometime in the past. When the nurse got ahold of me about [name of Resident 43] wanting to go home, we [the medical providers] had not even conducted our first official visit with her. I initially told the nurse that I could not sign off on her discharge and I think that is what prompted the AMA paper work. After talking with my partners, I called the nurse back and said that I could in fact sign her discharge order. By this time, the lady had already left the building. I was actually scheduled to see her either the day she left or the following day for her admission H&P [history and physical exam]. In an interview with the ADON on 10-7-22 at 2:45 p.m., she indicated, When [name of Resident 43] decided she wanted to go home, she did not take the time to sign any paperwork at all, pretty much wanted to leave immediately and did. She did not hang around long enough for us to go over her meds list, either. However, we did not fill out the transfer and discharge paperwork due to that. We did not complete the discharge summary or the official 'Notice of Transfer or Discharge' form. 3.1-12(a)(6)(A)(i) 3.1-12(a)(6)(A)(ii) 3.1-12(a)(6)(A)(iii) 3.1-12(a)(6)(A)(iv) 3.1-12(a)(6)(A)(v)

Based on interview and observation, the facility failed to ensure the call light was within reach for 2 of 2 residents that required extensive assistance from staff with activities of daily living reviewed for accommodation of needs. (Resident D and E) Findings include: 1. The clinical record for Resident D was reviewed on 10/6/2022 at 10:47 a.m. The medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission Minimum Data Set (MDS) Assessment, dated 7/20/2022, indicated that Resident D had mild cognitive impairment, utilized a wheelchair, and needed extensive assistance with locomotion and transferring. An interview and observation on 10/4/2022 at 1:33 p.m. indicated Resident D was sitting in wheelchair towards the foot of her bed. She had her over the bed table in front of her wither lunch tray still present. Her call light was on the floor next to the head of her bed. The resident indicated that she could not reach her call light but would like to be assisted to her recliner. Resident Assistant came in to pass ice and was notified of Resident D's request. An observation on 10/5/2022 at 1:51 p.m. indicated Resident D was sitting in her recliner with her call light clipped to the edge of the quilt on her bed. She indicated she could not reach the call light. 2. The clinical record for Resident E was reviewed on 10/6/2022 at 11:09 a.m. The medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A Comprehensive MDS Assessment, dated 9/8/2022, indicated that Resident E was cognitively intact, utilized a wheelchair, and needed extensive assistance for locomotion and transferring. An interview and observation on 10/5/2022 at 11:02 a.m. indicated that Resident E was sitting in her wheelchair between the two beds within her room. Her call light was on the floor under her bed. She indicated she could not reach it. A policy entitled, Call Lights, was provided by the Director of Nursing on 10/7/2022 at 10:00 a.m. The policy indicated, .Call lights must remain functional and within reach of each resident . 3.1-3(v)(1)

Based on interview and record review, the facility failed to complete a Significant Change in Status Assessment (SCSA) in a timely manner for a resident electing hospice benefits for 1 of 1 resident reviewed for Minimum Data Set (MDS) accuracy. (Resident 26) Findings include: The clinical record for Resident 26 was completed on 10/6/2022 at 1:45 p.m. The medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A SCSA for Resident 26, completed on 9/7/2022, indicated a prognosis of less than 6 month or less and hospice services. A hospice election, dated 8/3/2022, indicated that Resident 26 elected the hospice benefit with a start of care on 8/3/2022. An interview with MDS 14 on 10/6/2022 at 1:40 p.m., indicated that a SCSA should be completed with an assessment reference date (ARD) of 14 days of the hospice election and verified the assessment date for Resident 26 fell outside of the assessment timeframe set forth by the Center of Medicare and Medicaid Services Resident Assessment Instrument (RAI) Manual. She indicated they do not have a specific policy for assessment accuracy, but they would assess based on the RAI. The RAI Manual, last revised October 2019, indicated .An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than).

Based on interview, observation and record review the facility failed to safely transfer a resident resulting in a fall with 4 probable rib fractures and the resident experiencing ongoing rib pain, for 1 of 1 residents reviewed to falls.(Resident 27) Findings include: In a record review on 8/1/17 of Resident 27's record, her [DIAGNOSES REDACTED]. An interview on 7/27/17 at 11:53 a.m., with Resident 27 indicated I called one of the girls (CNA) colored, I think she got mad, she took me to the bathroom with my walker, she made me sit on it to push me back into my room, it's not made for people to ride on it. I don't know for sure but I think she tipped me over as we were going through the bathroom door. I hit my head on the bathroom door and she tried to make me get up, I told her I couldn't I was hurt bad and to get the nurse. A review of the Minimum Data Set (MDS) Assessment quarterly review dated 6/1/17 indicated Resident 27 was understood and had the ability to understand others. She required extensive assistance of 2 persons to transfer and toilet. Resident 27 required the extensive assistance of 1 person to walk in her room and in the corridor. On 7/27/17 at 1:59 p.m., an interview with the Corporate Nurse, related to a fall Resident 27 had on 7/9/17, she explained, a CNA was transferring the resident from the toilet to the rollator walker and the walker collapsed or folded and she sat on the floor. A review of the nurses notes dated 7/9/17 at 3:00 p.m., resident was in bathroom with a CNA when she fell to the floor. This nurse writing asked the resident what happened, and she stated she started to sit down on her walker seat and it folded up and she sat on the bathroom floor. Was checked and no injuries found. B/P 156/74, pulse 72, respirations 16, temperature 98.7, O2 sat 94% with O2 at 2 L/min. Resident stated she hit the back of her head. Was checked and no injuries noted. Neuro checks were implemented. Resident's blood sugar was 132 at the time of the fall. Family and physician was notified. A review of an Incident Report on 8/1/17 at 9:22 a.m., relayed time of incident 7/9/17 at 3:01 p.m .7/10/17 resident transferred from commode to rollator walker seat. After sitting, walker folded causing resident to fall to floor. One should note the resident normally transfers with a 1 person assist with minimal difficulty. Type of Injury .7/10/17 upon initial assessment, no injury was noted however resident did complain of left side pain by evening. Per x-ray results it was noted that resident had probable fracture of rib(s) on left side. Immediate Action Taken .7/10/17 administrator and DON was immediately notified as well as family. Resident was assessed by nurse with no acute findings. Resident was placed in recliner and monitored throughout the evening .7/10/17 Resident's walker was removed for inspection . Review of Radiology Report dated 7/10/17 at 8:58 a.m., indicated Examination: ribs uni-lat 2v, left . Results: Exam limited. Recent fractures lateral fourth through seventh ribs cannot be excluded . Conclusion: probable fractures as above. Study limited . A Fall Risk assessment dated [DATE], indicated the resident had a fall risk assessment score of 22, 10 or higher is at risk for a fall. Review of physician's orders [REDACTED]. Physician's recapitulation Orders dated 7/1/17 through 7/31/17 indicated give Norco 5/325 mg give 1 tab PO every 6 hours PRN moderate-severe pain. A review of Resident 27's PRN Medication Flowsheet, the resident received PRN pain medication two times on 7/11/17, for complaints of pain, rated a 6 both times, on a scale of 1 -10 with 10 being the highest for pain, 7/12/17, she received two doses of PRN pain medication for complaints of rib pain, rated pain as a 9 both times, 7/15/17, received one dose of PRN pain medication for complaints of rib pain, rated pain as a 5, 7/16/17, received one dose of PRN pain medication for complaints of pain, rated pain as a 7, 7/17/17, received one dose of PRN pain medication for complaints of rib pain, rated pain as an 8, 7/18/17, received one dose of PRN pain medication for complaints of rib pain, rated pain as a 7, 7/19/17, received one dose of PRN pain medication for complaints of rib pain, rated pain as a 7, 7/20/17, received one dose of PRN pain medication for complaints of rib pain, rated pain as an 8, 7/23/17, received one dose of PRN pain medication for complaints of rib pain, rated pain as a 7, 7/26/17, received one dose of PRN pain medication for complaints of rib pain, rated pain as a 7, 7/27/17, received one dose of PRN pain medication for complaints of rib pain, rated pain as a 7, 7/28/17, received one dose of PRN pain medication for complaints of rib pain, rated pain as a 7. An interview on 8/1/17 at 2:38 p.m., with CNA 3 indicated the resident was wet, I helped her to the bathroom in her wheelchair then from the wheelchair onto the toilet. I changed her clothes, the wheelchair was wet, so I used her walker, it collapsed on her when she sat down on it as I went to turn the walker. An observation on 8/1/17 at 3:00 p.m., of CNA 3 folding rollator walker, she indicated it had never been folded up that she knew of, but the seat has to be up and then the walker will fold with the legs coming together. Review of a document on 8/1/17 at 3:40 p.m., provided by the Administrator indicated .(Resident 27) pulled her light. I answered it. She asked me to take her to the bathroom. So I did and I got her changed into a new brief and gown. The wheelchair was wet and I didn't have extra washcloths so I grabbed the walker and made sure it was open and okay. She sat down in the walker and I went to turn and it collapsed under her. The handle was up against her sides. I had my foot under her because I tried to ease her down and I was trying to brace her. She said she's having trouble breathing so I tried to get her head up so she can breath and I got my call light on. 2 aides came and stayed with her while I got the nurse. After that the nurse asked to help her to her recliner so the two aides got her up and helped her there. Then the nurse got her vitals and everything. I got her an ice pack and said I was sorry. She said it was alright and that it's not your fault. After that I stayed out of her room for today and had another aide get her light. I also wrote a statement for the nurse. On 8/2/17 at 3:07 p.m., observation of CNA 4 assisting Resident 27 to transfer to the wheelchair from her recliner to go to the bathroom. She transferred from the wheelchair to the toilet with minimal assistance of one staff person. Resident 27 stood up and utilized the grab bar, held herself up while CNA 4 washed and dried peri area, then assisted her back into her wheelchair. The resident complained of left rib pain after toileting. Review of a care plan for falls, updated on 7/9/17 indicated, staff education on transfer, not to sit on rollator for transfer, 7/9/17- x-ray for left side pain, 7/9/17- rollator removed and inspected to ensure no issues. A review of a document obtained from the maintenance personal, provided by DON on 8/1/17 at 10:58 a.m., revealed Rollator walker examined for malfunction. Rollator found to be in working order. No repairs were required. Rollator walker returned to resident's room. On 8/1/17 at 9:50 a.m., review of a document provided by the DON specified Fall Prevention Program . Policy: It is the policy of this facility to identify any resident who is at increased risk for falls. Identified residents shall be monitored by the Interdisciplinary Team (IDT) in an effort to implement fall prevention interventions that minimize occurrence of falls thereby minimizing resident risk of injury. The IDT shall review those residents identified as being at risk for falls or those residents who have sustained falls and are at risk for recurrent falls . Review of manufactures guidelines provided by the Corporate Nurse on 8/1/17 at 10: 32 a.m., indicated . DO NOT use the rollator as a wheelchair or transport device. Rollators are not intended to be propelled while seated . Folding the Rollator 1. If necessary, remove the accessories and lift the seat. 2. Lift up on locking mechanism on the crossbar if needed . Safety precautions 1. Please make sure the rollator is fully opened, seat is down and the folding bar under seat is locked in the down position . 6. Do not have anyone push you while you are seated on the rollator. This is a walking aid only and is not to be used as a transportation device. 3.1-45(a)(1) 3.1-45(a)(2)

BASED ON INTERVIEW, OBSERVATION AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE CARE AND SERVICES FOR 2 OF 5 SAMPLED RESIDENTS IN THAT THE NURSING STAFF FAILED TO COMPLETE A THOROUGH ASSESSMENT FOLLOWING CHANGES IN CONDITION AND FAILED TO NOTIFY THE PHYSICIAN PROMPTLY SO THAT TREATMENT COULD BE INITIATED. THIS AFFECTED 1 OF 5 RESIDENTS (RESIDENT #A) WHO EXPERIENCED A CHANGE IN LEVEL OF CONSCIOUSNESS AND WAS SUBSEQUENTLY admitted TO THE HOSPITAL AND AFFECTED 1 OF 5 RESIDENTS (RESIDENT #B) WHO DEVELOPED A VAGINAL DISCHARGE AND HAD A CHANGE IN BEHAVIOR AND TREATMENT WAS NOT ORDERED FOR 7 DAYS. FINDINGS INCLUDE: RESIDENT #A'S RECORD WAS REVIEWED ON 12/3/10 AT 12:45 P.M. RESIDENT #A'S [DIAGNOSES REDACTED]. RESIDENT #A'S MINIMUM DATA SET ASSESSMENT, DATED 6/11/10, INDICATED RESIDENT #A'S COGNITIVE SKILLS FOR DAILY DECISION MAKING WERE MODERATELY IMPAIRED - DECISIONS POOR; CUES/SUPERVISION REQUIRED. A NURSES NOTE, DATED 5/30/10 AT 2:10 P.M., INDICATED THE FOLLOWING: THE RESIDENT IS ALERT BUT CONFUSED. ATTEMPTED TO GET UP SEVERAL TIMES BY HIMSELF. FED HIMSELF. A NURSES NOTE 5/31/10 AT 9:30 A.M., INDICATED THE FOLLOWING: THE RESIDENT IS ALERT AND CONFUSED. THE RESIDENT GOT UP NUMEROUS TIMES, SOUNDING HIS PAD ALARM. THE RESIDENT WAS BROUGHT TO THE NURSES STATION FOR SUPERVISION. A NURSES NOTE FOR RESIDENT #A, DATED 5/31/10 AT 9:30 P.M., INDICATED THE FOLLOWING: THE RESIDENT TRIED TO STAND OUT OF HIS WHEELCHAIR, AND CRAWLED OUT OF HIS LOW BED. HE WAS BROUGHT TO THE NURSES STATION FOR SUPERVISION. A NURSES NOTE FOR RESIDENT #A, DATED 6/1/10 AT 3:00 A.M., INDICATED THE FOLLOWING: THE RESIDENT CONTINUED TO TRY AND CLIMB OUT OF BED. THE RESIDENT WAS BROUGHT TO THE NURSES STATION FOR SUPERVISION. A NURSES NOTE FOR RESIDENT #A, DATED 6/1/10 AT 3:00 P.M., INDICATED THE FOLLOWING: THE RESIDENT HAS MADE SEVERAL ATTEMPTS TO GET UP UNASSISTED. THE RESIDENT IS ALERT BUT CONFUSED. A NURSES NOTE FOR RESIDENT #A, DATED 6/2/10 AT NO TIME, INDICATED THE FOLLOWING: THE RESIDENT IS ALERT BUT CONFUSED. A NURSES NOTE FOR RESIDENT #A, DATED 6/7/10 AT 2:30 P.M., INDICATED THE FOLLOWING: THE RESIDENT IS SLEEPY, DROOLING, AND WAS FED BY STAFF. ATE 50 % OF HIS MEAL AND DRANK 360 CC OF FLUID FOR BREAKFAST, AND ATE 25% OF HIS MEAL AND DRANK 200 CC OF FLUID FOR LUNCH. THE FACILITY WAS UNABLE TO PROVIDE ASSESSMENT DOCUMENTATION FOR RESIDENT #A REGARDING A CHANGE IN LEVEL OF CONSCIOUSNESS. NO PHYSICIAN NOTIFICATION DOCUMENTATION WAS AVAILABLE IN RESIDENT #A'S RECORD REGARDING A CHANGE IN LEVEL OF CONSCIOUSNESS A NURSES NOTE FOR RESIDENT #A, DATED 6/7/10 AT 5:00 P.M., INDICATED THE FOLLOWING: THE RESIDENT WAS UP IN A WHEELCHAIR FOR SUPPER. ATE 75% WITH ASSISTANCE FROM STAFF. THE RESIDENT IS LETHARGIC. NO ATTEMPTS TO GET UP WITHOUT ASSISTANCE. THE FACILITY WAS UNABLE TO PROVIDE ASSESSMENT DOCUMENTATION FOR RESIDENT #A REGARDING A CHANGE IN LEVEL OF CONSCIOUSNESS. NO PHYSICIAN NOTIFICATION DOCUMENTATION WAS AVAILABLE IN RESIDENT #A'S RECORD REGARDING A CHANGE IN LEVEL OF CONSCIOUSNESS AN INTERVIEW WITH A FAMILY MEMBER OF RESIDENT #A ON 12/3/10 AT 11:28 A.M., INDICATED RESIDENT #A WAS WEAK WHEN HE WAS admitted TO THE FACILITY FROM A LOCAL hospital on [DATE]. THE FAMILY MEMBER INDICATED RESIDENT #A NEEDED ASSISTANCE TO EAT AT TIMES, DUE TO HIS WEAKNESS. THE FAMILY MEMBER INDICATED WHEN RESIDENT #A WAS admitted TO THE FACILITY HE WAS WEAK, CONFUSED, AND ALERT. THE FAMILY MEMBER INDICATED RESIDENT #A BECAME INCREASINGLY LESS RESPONSIVE, AND LETHARGIC. THE FAMILY MEMBER INDICATED SHE SPOKE WITH NURSES FOR A COUPLE OF DAYS ABOUT HER CONCERNS, AND THEN WENT TO THE DIRECTOR OF NURSING WHEN SHE WAS AT HER "WITS END." A NURSES NOTE FOR RESIDENT #A, DATED 6/8/10 AT 9:30 A.M., INDICATED THE FOLLOWING: THE RESIDENT IS SLEEPY AGAIN TODAY. BLOOD PRESSURE 124/62, PULSE 55, RESPIRATIONS 16, TEMPERATURE 97.7, OXYGEN SATURATION 99%. A CALL WAS PLACED TO THE NURSE PRACTITIONER. RECEIVED A NEW ORDER FOR A COMPLETE BLOOD COUNT, BASIC METABOLIC PANEL, URINALYSIS, AND CULTURE AND SENSITIVITY. MAY CATHETERIZE RESIDENT. A NURSES NOTE FOR RESIDENT #A, DATED 6/8/10 AT 9:30 A.M., INDICATED THE FOLLOWING: THE RESIDENT WAS CATHETERIZED AND 1100 MILLILITERS OF DARK COLORED URINE WAS OBTAINED. HIS BLADDER WAS DISTENDED. HIS VITAL SIGNS WERE OBTAINED. A URINALYSIS WAS OBTAINED. CALLED THE NURSE PRACTITIONER TO UPDATE. A PHYSICIANS ORDER FOR RESIDENT #A, DATED 6/8/10 WITH NO TIME DOCUMENTED, INDICATED THE FOLLOWING: SEND TO THE emergency room DUE TO CRITICAL LABS AND BLOOD IN URINE. A LOCAL HOSPITAL NOTE FOR RESIDENT #A DICTATED 6/9/10 AT 10:50 A.M., INDICATED THE FOLLOWING: [AGE] year OLD MALE PRESENTS WITH GRADUAL PROGRESSIVE LETHARGY AND DECREASED MENTAL STATUS OVER THE PAST WEEK. HE WAS BROUGHT TO THE EMERGENCY DEPARTMENT WITH LETHARGY. HE WAS NOTED TO HAVE SEVERE ACUTE [MEDICAL CONDITION]. AN INTERVIEW WITH THE UNIT MANAGER ON 12/7/10 AT 3:45 P.M., INDICATED A FULL ASSESSMENT SHOULD BE COMPLETED ON ANY RESIDENT SHOWING SIGNS OF A CHANGE IN LEVEL OF CONSCIOUSNESS. SHE INDICATED THE PHYSICIAN WOULD THEN BE NOTIFIED OF THE FINDINGS. 2.) REVIEW OF THE RECORD OF RESIDENT #B ON 12-3-10 AT 11:00 A.M. INDICATED THE RESIDENT'S [DIAGNOSES REDACTED]. THE MINIMUM DATA SET (MDS) ASSESSMENT FOR RESIDENT #B, DATED 9-28-10, INDICATED THE RESIDENT HAD A URINARY TRACT INFECTION WITHIN THE LAST 30 DAYS. THE FACILITY FAX DOCUMENTATION TO THE PHYSICIAN FOR RESIDENT #B, DATED 11-25-10 (NO TIME) INDICATED THE RESIDENT HAD A LARGE AMOUNT OF GREEN VAGINAL DISCHARGE WITH FOUL ODOR WITH A REQUEST FOR AN ORDER. THE DOCUMENTATION INDICATED NO ASSESSMENT WAS COMPLETED. THE DOCUMENTATION INDICATED THE FACILITY DID NOT ATTEMPT TO CALL THE ON CALL PHYSICIAN. THE FACILITY FAX DOCUMENTATION TO THE PHYSICIAN FOR RESIDENT #B, DATED 11-27-10 (NO TIME), INDICATED THE RESIDENT HAD BEEN MORE RESTLESS, ATTEMPTING TO GET UP MORE AND POSSIBLY HAD A URINARY TRACT INFECTION. THE RESIDENT WAS REPORTED TO HAVE GREEN VAGINAL DRAINAGE. A REQUEST FOR A URINALYSIS AND CULTURE AND SENSITIVITY. THE RESIDENT'S BLOOD PRESSURE WAS 124/76, TEMPERATURE WAS 97.8, PULSE WAS 72 AND RESPIRATIONS WERE 20. THE DOCUMENTATION INDICATED THE FACILITY DID NOT ATTEMPT TO CALL THE ON CALL PHYSICIAN. THE NURSING NOTES FOR RESIDENT #B, DATED 11-27-10 AT 10:00 P.M., INDICATED THE RESIDENT HAD AN INCREASE IN BEHAVIORS, VERY RESTLESS AND ANXIOUS. THE RESIDENT'S BLOOD PRESSURE WAS 124/76, TEMPERATURE WAS 97.8, PULSE 72 AND RESPIRATIONS WERE 20. THE RESIDENT MADE NUMEROUS ATTEMPTS TO GET UP BY LUNGING OUT OF THE WHEELCHAIR. FAX THE PHYSICIAN IN REGARDS TO THE RESIDENT'S BEHAVIOR. THE NURSING NOTES FOR RESIDENT #B, DATED 11-30-10 AT 6:30 P.M., INDICATED THE RESIDENT WAS ORDERED A URINALYSIS, CULTURE AND SENSITIVITY AND VAGINAL CULTURE DUE TO INCREASE IN BEHAVIORS AND GREEN VAGINAL DISCHARGE. THE NURSING NOTES FOR RESIDENT #B, DATED 12-2-10 AT 7:00 P.M., INDICATED THE URINALYSIS RESULTS SHOWED HIGH LEVEL OF BLOOD (SHOULD BE NEGATIVE) AND PROTEIN 100 (SHOULD BE NEGATIVE). THE ON CALL NURSE PRACTITIONER WAS NOTIFIED AND [MEDICATION NAME] (ANTIBIOTIC TO TREAT URINARY TRACT INFECTION) 50 MILLIGRAMS FOUR TIMES A DAY WAS ORDERED. THE NURSING NOTES FOR RESIDENT #B INDICATED NO ASSESSMENT WAS COMPLETED FOR RESIDENT #B ON 11-25-10, 11-26-10, 11-28-10, 11-29-10,11-30-10, 12-1-10 OR 12-2-10. THE TREATMENT SHEET FOR NOVEMBER AND DECEMBER 2010 FOR RESIDENT #B INDICATED NO ASSESSMENT WAS COMPLETED FOR 11-25-10, 11-26-10, 11-27-10, 11-28-10, 11-29-10, 11-30-10, 12-1-10, 12-2-10 OR 12-3-10. INTERVIEW WITH MEDICAL RECORDS ON 12-3-10 AT 12:05 P.M., INDICATED SHE WAS UNABLE TO FIND AN ASSESSMENT OR VITAL SIGNS FOR RESIDENT #B FOR 11-25-10 OR 11-27-10. INTERVIEW WITH THE UNIT MANAGER ON 12-3-10 AT 12:20 P.M., INDICATED IF A RESIDENT HAD SIGNS AND SYMPTOMS OF INFECTION THE NURSE ON EACH SHIFT SHOULD DO AN ASSESSMENT. THE UNIT MANAGER INDICATED THE ASSESSMENT SHOULD BE DOCUMENTED IN THE NURSING NOTES OR THE TREATMENT SHEET. THE UNIT MANAGER INDICATED THERE WAS NO DOCUMENTATION OF AN ASSESSMENT FOR RESIDENT #B AND SHE WOULD ADD IT TO THE TREATMENT SHEET FOR THE NURSES TO START DOING IT. INTERVIEW WITH THE DIRECTOR OF NURSING (DON) ON 12-3-10 AT 1:00 P.M., INDICATED THE REASON A PHYSICIan order for [REDACTED]. THE PHYSICIAN OFFICE WAS CLOSED 11-25-10, 11-26-10, 11-27-10 AND 11-28-10. THE DON INDICATED THE PHYSICIAN OFFICE OPENED BACK UP ON 11-29-10 AND an order for [REDACTED]. DURING OBSERVATION ON 12-3-10 AT 1:55 P.M. RESIDENT #B WAS ASSISTED TO THE TOILET BY CNA #1. RESIDENT #B'S URINE WAS DARK YELLOW AND HAD A FOUL SMELL. CNA #1 INDICATED RESIDENT #B'S URINE HAD BEEN SMELLING A "TAD FOUL" LATELY. DURING OBSERVATION ON 12-3-10 AT 2:05 P.M., LPN #2 DID A COMPLETE HEAD TO TOE ASSESSMENT OF RESIDENT #B. LPN #2 INDICATED SHE WAS RESIDENT #B'S NURSE AND WAS NOT AWARE THE RESIDENT HAD BEEN EXPERIENCING SIGNS AND SYMPTOMS OF INFECTION IN REGARDS TO GREEN VAGINAL DISCHARGE. INTERVIEW WITH THE ASSISTANT DIRECTOR OF NURSING (ADON) ON 12-7-10 AT 10:15 A.M., INDICATED SHE WAS THE INFECTION CONTROL NURSE FOR THE FACILITY. THE ADON INDICATED THERE WAS NOT AN ASSESSMENT FORM OR POLICY FOR NURSES TO FOLLOW IN REGARDS TO A RESIDENT WITH SIGNS AND SYMPTOMS OF AN INFECTION. THE ADON INDICATED IF A RESIDENT WAS SHOWING SIGNS AND SYMPTOMS OF AN INFECTION THE NURSES WERE TO DO AN ASSESSMENT ON THE RESIDENT EVERY SHIFT UNTIL SIGNS AND SYMPTOMS WERE NO LONGER PRESENT. THE "PHYSICIAN AND FAMILY NOTIFICATION PROCEDURE" PROVIDED BY THE ADMINISTRATOR ON 12-3-10 AT 4:10 P.M., INDICATED THE FOLLOWING: THE PURPOSE WAS TO KEEP THE PHYSICIAN, RESIDENT AND FAMILY APPRAISED OF ALL CONDITION CHANGES. THE PROCEDURE WAS TELEPHONE NOTIFICATION IS REQUIRED FOR ALL EMERGENCIES OR ALL CONDITION CHANGES THAT REQUIRE AN IMMEDIATE RESPONSE. NOTIFY THE PHYSICIAN OF ANY CHANGE IN CONDITION THAT MAY OR MAY NOT WARRANT A CHANGE IN THE TREATMENT PLAN. NOTIFY THE PRIMARY PHYSICIAN DURING REGULAR OFFICE HOURS AND THE ON CALL OR ALTERNATE PHYSICIAN DURING CLOSED OFFICE HOURS OR WHEN THE PHYSICIAN IS NOT AVAILABLE. DOCUMENT THE INFORMATION REPORTED TO THE PHYSICIAN IN THE NURSES NOTES. THE PROCEDURE FOR FAXING WAS DOCUMENT INFORMATION TO BE FAXED LEGIBLY AND IN BLACK INK ON A FAX FORM. INCLUDE ALL ASSESSMENT INFORMATION THAT THE PHYSICIAN WILL NEED TO MAKE HIS DECISIONS. IF IMMEDIATE PHYSICIAN RESPONSE IS REQUIRED, DO NOT FAX, CALL THE PHYSICIAN. FAXING DOES NOT ELIMINATE NURSING RESPONSIBILITY OF FOLLOW UP ASSESSMENT AND FURTHER REPORTING TO THE PHYSICIAN, IF NECESSARY. THE "ACUTE CHANGE IN CONDITION/EMERGENCY PHYSICIAN SERVICES PROCEDURE" POLICY PROVIDED BY THE UNIT MANAGER ON 12-7-10 AT 2:42 P.M., INDICATED THE PURPOSE WAS TO ENSURE AN ACUTE CHANGE IN A RESIDENT'S CONDITION WOULD BE ADDRESSED IN A TIMELY MANNER AS IT PERTAINS TO NEEDED TRANSFER TO AN ACUTE CARE SETTING. THE PROCEDURE WAS CONTACT THE ATTENDING PHYSICIAN/ON CALL PHYSICIAN WHEN THE RESIDENT'S CONDITION REQUIRES IMMEDIATE ATTENTION OR ACUTE CARE FOLLOW UP. IF THE ATTENDING OR ON CALL PHYSICIAN IS NOT AVAILABLE OR DOES NOT RETURN THE PHONE CALL, CONTACT THE FACILITY'S MEDICAL DIRECTOR. IF NEITHER PHYSICIAN IS AVAILABLE OR DOES NOT RETURN THE PHONE CALL, NOTIFY THE DIRECTOR OF NURSING. THE DIRECTOR OF NURSING CAN INSTRUCT THE FACILITY TO SEND THE RESIDENT TO THE emergency room FOR EVALUATION, AS INDICATED. THIS FEDERAL TAG RELATES TO COMPLAINT NUMBER IN 509. 3.1-37(a)