Every finding on record at Envive of Sullivan

Based on observation, interview, and record review, the facility failed to ensure the dish machine temperatures were monitored to be at appropriate temperatures for 1 of 3 kitchen observations. This had the potential to affect 34 of 35 residents who were served meals out of the kitchen. Findings include:During the initial kitchen tour, on 5/17/26 at 9:09 a.m., the chemical dish machine was observed. A placard on the top of the dish machine indicated the minimal wash temperature was to be 140 degrees Fahrenheit (F) and 140 degrees F for the rinse temperature. Three run attempts were completed before the machine reached the minimal wash and rinse temperatures. Observation of the dish machine temperature log sheets, dated May 2026, lacked documentation of the temperatures being monitored after the breakfast meal on 5/12/26. At the same time, the log indicated temperature readings below the required 140 degrees F on the following dates: a. 5/5/26: The breakfast meal temperature indicated 125 degrees F. b. 5/6/26: The breakfast meal temperature indicated 125 degrees F. c. 5/7/26: The dinner meal temperature indicated 130 degrees F. d. 5/8/26: The dinner meal temperature indicated 135 degrees F. During an interview, on 5/17/26 at 9:20 a.m., [NAME] 3 indicated he was new to the facility. He had not completed the temperature log since he had started. During an interview, on 5/17/26 at 9:38 a.m., the Administrator indicated she was surprised that the dish machine log had not been completed daily as required. They had been working hard on keeping everything in the kitchen up to date. On 5/18/26 at 1:17 p.m., the Administrator provided a document, dated 1/2023, titled, Recording Dish Machine Temperature/Sanitizer, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure: .2. The Dietary Manager will train the staff to monitor the dish machine temperatures throughout the dishwashing process. 3. Staff will be trained to record dish machine temperatures for the wash and rinse cycles.Temperatures will be monitored and recorded before running dishes for each meal period. Temperatures should be observed routinely anytime dish machine is in operation to ensure temperature adequacy. 4. The Dietary Manager will spot check these logs. 410 IAC (Indiana Administrative Code) 16.2-3.1-21(i)(3)

Based on record review and interview, the facility failed to ensure a resident's representative was notified with new medication orders for 1 of 3 residents reviewed for notifications (Resident B). Findings include: Resident B's record was reviewed on 9/29/25 at 10:15 a.m. Diagnoses included, but were not limited to, Alzheimer's disease (a progressive and fatal brain disorder that causes memory loss, confusion, and other cognitive decline), cognitive communication deficit, and major depressive disorder recurrent and severe with psychotic symptoms (a severe form of depression characterized by persistent low mood, loss of interest, and other symptoms, accompanied by delusions and/or hallucinations). A quarterly Minimum Data Set (MDS) assessment, dated 8/27/25, indicated the resident had a severe cognitive impairment. A physician's order, dated 4/25/25 and discontinued on 6/23/25, indicated Risperdal (antipsychotic medication) 0.25 milligrams (mg) by mouth twice daily for major depressive disorder, recurrent and severe, with psychotic symptoms. A progress note, dated 6/23/25, indicated the resident continued to exit seek and wanted to go home. The resident stated her family was picking her up. When the resident was redirected, she stated if she was not able to go home, she would kill herself. The Social Services Director (SSD) called the psychiatric provider and received an order from the Nurse Practitioner (NP) to increase Risperdal to 0.5 mg twice daily. The progress note lacked documentation the resident's representative was notified of the new order. A physician's order, dated 6/24/25, indicated Risperdal 0.5 mg by mouth twice daily for major depressive disorder, recurrent and severe, with psychotic symptoms. A progress note, dated 7/4/25, indicated a new order was received for vitamin D3 25 micrograms (mcg), one tablet once daily. The next shift was to notify the resident's family. Progress notes lacked documentation the resident's representative was notified of the new Vitamin D3 order. A physician's order, dated 7/4/25, indicated vitamin D3 25 mcg by mouth daily. During an interview, on 9/29/25 at 9:50 a.m., Resident B's family member indicated there had been issues at times with the facility not communicating information with them regarding changes with the resident. During an interview, on 9/29/25 at 2:40 p.m., the Director of Nursing (DON) indicated she reviewed the 24-hour report documentation, and the resident's medical record, and she was unable to find documentation the resident's representative was notified of the Risperdal and Vitamin D3 orders. The facility should have notified the resident's representative of new medication orders, but she was not sure how long they had to complete the notifications. On 9/29/25 at 3:16 p.m., the DON provided a document titled, Health, Medical Condition and Treatment Options, Informing Residents of, last revised in August 2024, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Statement: Every resident is informed of his or her total health status, medical condition and options for treatment and/or care. Policy Interpretation and Implementation: 1. Each resident is informed of his/her total health status and medical condition, including.treatment recommendations.in advance of treatment and on an on-going basis. If a resident has an appointed representative, the representative is also informed. 2. The resident's attending physician, the facility's medical director, or the director of nursing services is responsible for informing the resident of his or her medical condition. Such information includes providing the resident/representative with information about the resident's.g. psychosocial status.i. type of care or treatment recommended.4. Information about the resident's health status is presented at times.when a change of treatment is proposed. This citation relates to Intake 1841129. 3.1-5(a)(2)3.1-5(a)(3)

Based on record review and interview, the facility failed to ensure documentation was completed in the resident's electronic health record related to falls that occurred at the facility, and they failed to ensure interventions were implemented for 2 of 3 residents reviewed for accidents (Residents C and B). Findings include: 1. Resident C's record was reviewed on 9/29/25 at 10:45 a.m. The profile indicated the resident diagnoses included, but were not limited to, unspecified dementia moderate with mood disturbance (a medical diagnosis with moderate level of dementia whose cause is unknown, accompanied by symptoms of mood disturbance like depression, apathy[lack of interest], of loss of pleasure), type 2 diabetes mellitus (a chronic condition where the body does not use insulin effectively or does not produce enough insulin), and paroxysmal atrial fibrillation (a type of heart rhythm disorder where the heart's upper chambers beat irregularly and rapidly for a short period). The facility census indicated Resident C admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) assessment, dated 6/24/25, indicated Resident C had severe cognitive impairment and required maximum assistance with toileting and bathing. A care plan, dated 6/17/25, indicated the resident was at risk for falls/injury due to impaired ADL (activities of daily living) function, incontinence of bowel/bladder, difficulty walking, and impaired condition related to dementia. Review of fall log, dated 6/10/25 through 9/22/25, indicated Resident C had a fall on 7/3/25 at 3:00 a.m. that was un-witnessed, the medical record lacked documentation of the fall occurring until 7/7/25 at 9:51 a.m. when an Interdisciplinary team (IDT) note was placed in the record. The record lacked documentation of a fall assessment, skin assessment, pain assessment, or progress note being completed on the resident related to the unwitnessed fall that occurred on 7/3/25 at 3:00 a.m. Review of progress note, dated 7/3/25 at 10:37 p.m., indicated Resident C had an unwitnessed fall at 9:30 p.m. The record lacked documentation of a fall assessment, skin assessment, pain assessment, or detailed progress notes of how or where the fall occurred. An IDT note was placed in the chart on 7/7/25 at 10:20 a.m. regarding the fall that occurred on 7/3/25 at 9:30 p.m. Review of fall log, indicated Resident C had a fall on 7/9/25 at 11:55 a.m., that was witnessed, the medical record lacked documentation of a fall until 7/10/25 at 12:28 a.m. The record lacked an IDT note related to the fall that occurred on 7/9/25 at 11:55 a.m. The record lacked documentation of any new interventions being added to the care plan due to the fall. Review of progress note, dated 7/11/25 at 7:15 p.m., indicated the resident had an unwitnessed fall, the medical record lacked documentation that the family was notified at the time of the fall. During an interview, on 9/29/25 at 11:26 a.m., Licensed Practical Nurse (LPN) 3 indicated that staff should complete a fall assessment, skin assessment, pain assessment, fall risk management assessment, and progress note whenever they had a fall that occurred in the facility. She indicated the IDT team would meet the next day or if over the weekend on Monday to discuss the falls and place new interventions in the care plans. During an interview, on 9/29/25 at 11:40 a.m., the Director of Nursing (DON) indicated staff should make sure to assess the resident, complete a fall risk management assessment, progress note, and fall assessment. Staff should also notify the DON, doctor, and family of all falls immediately. During an interview, on 9/29/25 at 1:56 p. the DON indicated she was not aware that the fall risk management assessment was not a part of the medical record. It was an internal document and not available for everyone to see. She was also not aware that if a resident fell more than once in a 24-hour period the computer system would not trigger staff to complete all of the fall assessments. She would need to investigate it and figure out how to fix it. 2. Resident B's record was reviewed on 9/29/25 at 10:15 a.m. Diagnoses included, but were not limited to, Alzheimer's disease (a progressive and fatal brain disorder that causes memory loss, confusion, and other cognitive decline) unspecified and cognitive communication deficit. A quarterly Minimum Data Set (MDS) assessment, dated 8/27/25, indicated the resident had a severe cognitive impairment and had one fall, with no injury, since the prior assessment. A care plan, last revised on 8/28/24, indicated the resident was at risk for falls and injury due to potential side effects from medications and diagnosis of Alzheimer's dementia. An incident log indicated the resident had an unwitnessed fall on 6/13/25. A change in condition evaluation included in the resident's assessments, dated 6/13/25, indicated the resident fell and included vital signs. The evaluation did not include a description of the circumstances of the fall or an intervention to prevent further falls. Progress notes, dated 6/13/25, lacked documentation of the resident's fall. A progress note, dated 6/14/25, indicated the facility attempted to contact the resident's son to notify him of the fall, but he did not answer. The note lacked documentation of information regarding the fall, an assessment, or an intervention put in place to prevent further falls. Progress notes, dated 6/15/25 and 6/16/25, lacked documentation of the resident's fall, an assessment, or an intervention put in place to prevent further falls. An interdisciplinary team (IDT) progress note, dated 6/17/25, indicated the IDT reviewed the resident for an unplanned change of plane that occurred on 6/13/25. The staff observed the resident on her knees in the hallway. The Certified Nurse Aide (CNA) alerted the nurse, and the nurse assessed the resident. The resident stated she stumbled when walking down the hallway. The resident's shoes were noted to be too big, and the resident was to be taken to get a pair of shoes that fit. During an interview, on 9/29/25 at 11:40 a.m., the Director of Nursing (DON) indicated when a resident fell the staff should have immediately assessed the resident and provided necessary assistance. If the intervention was an easy thing they might have implemented something at the time, however if it was more complicated, they would have waited until the IDT review. The IDT reviewed falls on the next business day. They documented fall information progress notes in the risk management portion of the chart. She was not aware that risk management was not visible in the resident's electronic health record. On 9/29/25 at 1:53 p.m., the DON provided an incident report from the risk management, dated 9/13/25. The bottom of the report indicated, Privileged and confidential-not part of the medical record. The report indicated the resident was found on the floor on her knees. There was an abrasion to the right knee. The report lacked documentation an intervention was put in place at the time of the fall. At the same time, the DON indicated they were not aware the risk management incident reports were not part of the resident's medical record. The DON indicated there was no further documentation of the resident's fall, on 6/13/25, in the resident's medical record. On 9/29/25 at 2:00 p.m., the DON provided a document titled, Falls-Clinical Protocol, last revised in August 2024. The policy indicated, .Assessment and Recognition.2. In addition, the nurse shall assess and document/report the following: a. Vital signs; b. Recent injury, especially forehead or head injury; c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc.; d. Change in cognition or level of consciousness; e. Neurological status; f. Pain; g. Freqeuncy and number of falls since last physician visit; h. Precipitating factors, details on how fall occurred; i. All current medications, especially those associated with dizziness or lethargy; and j. All active diagnoses.5. The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc.Cause Identification: 1. For an individual who has fallen the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall.Treatment/Management: 4. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. This citation relates to the Intake 1841129 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure an Infection Preventionist (IP) Nurse other than the Director of Nursing (DON) was designated to oversee the Infection Prevention and Antibiotic Stewardship programs within the facility. This deficiency had the potential to affect 38 of 38 residents residing at the facility. Findings include: A review of the Infection control program identified antibiotic tracking and infection surveillance was not completed between 5/1/24 to 11/30/24. On 5/30/25 at 2:34 p.m., during interview the DON indicated she started working at the facility in December 2024 and began tracking at that time according to infection control policy. She indicated she was the only IP nurse in the facility and acknowledged she was responsible for tracking infections including TB testing and surveillance and the antibiotic stewardship program. She indicated she did not know the DON could not be the IP nurse and must have an additional nurse who has had the infection preventionist training appointed as the IP nurse. On 5/30/25 review of the facility risk assessment, dated 4/30/25, indicated the facility had designated one full time DON and one full time IP nurse. On 5/28/2025 at 10:00 a.m., the Administrator provided a document titled, Surveillance for Infections, dated 8/2024, and indicated it was the policy currently being used by the facility. The policy indicated, .The infection preventionist will conduct ongoing surveillance for healthcare associated infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventive interventions .3. Infections that will be included in routine surveillance include those with a. evidence of transmissibility in a healthcare environment .Gathering surveillance data .1. The infection preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data .The surveillance should include a review of any or all of the following information to help identify possible indicators of infections .d. Laboratory records .k. Antibiotic review hh. Monthly collect information from individual resident infection reports and enter line listing of infections On 5/30/2025 at 11:00 a.m., the Administrator provided a document titled, Infection Preventionist, dated 8/2024, and indicated it was the policy currently being used by the facility. The policy indicated, .1. The infection Preventionist (or designee) coordinates the development and monitoring of the infection prevention program .4. The infection preventionist has the background and ability to fully carry out the requirements of the IP .Hours of Work .7. The infection preventionist is employed at least part time .p Additional hours are scheduled as indicated by the needs identified in the facility assessment

Based on record review and interview, the facility failed to ensure the facility tracked infections and antibiotic use within the facility and failed to ensure tuberculin testing was completed for 7 of 16 residents reviewed for immunizations and tuberculin testing administration (Residents 28, 4, 9, 14, 38, 192, and 5). Findings include: On 5/30/25 at 10:00 a.m., the medical record of Resident 28 was reviewed. The resident was admitted on [DATE]. A Tuberculin skin test (a Mantoux test involves injecting a small amount of fluid called tuberculin or purified protein derivative, PPD under the skin, and then checking for a reaction a few days later) was administered on 1/1/25. The record lacked evidence the results of the test were read. The record lacked documentation of a second TB test being administered after a minimum of seven days after administration of the initial test. A second TB test was required upon admission to the facility to determine exposure to tuberculosis. On 5/30/25 at 10:05 a.m., the medical record of Resident 4 was reviewed. The record indicated the last TB test had been administered to the resident on 5/16/24. The record lacked evidence of an annual TB test being completed. On 5/30/25 at 10:10 a.m., the medical record of Resident 9 was reviewed. The resident was admitted to the facility on [DATE]. The record lacked evidence of a second TB test being administered a minimum of seven days or a maximum of three weeks after initial TB test was administered. On 6/2/25 at 9:45 a.m., the medical record of Resident 14 was reviewed. The resident was admitted to the facility on [DATE]. The record lacked evidence of an initial TB test or a second TB test being administered. On 6/2/25 at 9:50 a.m., the medical record of Resident 38 was reviewed. The resident was admitted to the facility on [DATE]. The record lacked evidence of a second TB test being administered a minimum of seven days or a maximum of three weeks after the initial TB test was administered. On 6/2/25 at 10:05 a.m., the medical record of Resident 192 was reviewed. The resident was admitted to the facility on [DATE]. The initial TB test was administered on 5/20/25. The record lacked evidence of the second TB test being administered a minimum of seven days or a maximum of three weeks after the initial TB test was administered. On 6/2/25 the medical record of Resident 5 was reviewed. The resident was admitted to the facility on [DATE]. The initial TB test was administered on 4/22/25. The record lacked evidence of a second TB test being administered a minimum of seven days to a maximum of 3 weeks after the initial TB test was administered. On 6/2/25 at 10:30 a.m., during interview the Director of Nurses (DON) indicated she was the current Infection Preventionist (IP) Nurse, at the facility and acknowledged the IP nurse was responsible to oversee immunizations and TB testing of all residents within the facility. She acknowledged unless contraindicated, residents must have 2 initial TB tests upon admission. On 5/30/25 review of the facility risk assessment, dated 4/30/25, indicated the county was at moderate risk for communicable disease infections. Review of the Infection control program identified no antibiotic (ATB) tracking or infection surveillance was completed between May of 2024 to November 2024. The DON indicated she started working at the facility in December of 2024 and began tracking according to infection control policy. On 5/28/2025 at 10:00 a.m., the Administrator provided a document titled, Surveillance for Infections, dated 8/2024, and indicated it was the policy currently being used by the facility. The policy indicated, .The infection preventionist will conduct ongoing surveillance for healthcare associated infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventive interventions .3. Infections that will be included in routine surveillance include those with a. evidence of transmissibility in a healthcare environment .Gathering surveillance data .1. The infection preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data .The surveillance should include a review of any or all of the following information to help identify possible indicators of infections .d. Laboratory records .k. Antibiotic review hh. Monthly collect information from individual resident infection reports and enter line listing of infections On 5/30/2025 at 10:55 a.m., the provided a document titled, Tuberculosis Screening Residents, dated 8/2024, and indicated it was the policy currently being used by the facility. The policy indicated, .This facility shall screen all residents for tuberculosis infection and disease (TB) .If a potential resident has been exposed to active TB or is at increased risk of TB infection he or she will be screened for latent tuberculosis infection (LTBI) using tuberculin skin test (TST) .6. Screening of new admissions or readmissions for tuberculosis infection and disease is in compliance with state regulations .Serial testing of residents .The facility will conduct annual risk assessments to determine risk of exposure 3.1-18(b)

Based on record review and interview, the facility failed to ensure AIMS (abnormal involuntary movement scale) assessments were completed for 1 of 5 residents were reviewed for unnecessary medications (Resident 18). Findings include: Resident 18's record was reviewed on 1/23/25 at 11:06 a.m. The profile indicated the resident's diagnosis included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and major depressive disorder (mental health condition characterized by persistently low or depressed mood and loss of interest or please in activities). An annual Minimum Data Set (MDS) assessment, dated 3/5/25, indicated the resident had severe cognitive impairment and was on anti-psychotic and anti-depressant medications. A care plan, dated 5/24/22, indicated the resident had impaired cognitive function related to Alzheimer's, dementia. Interventions included, but were not limited to, administer medication as ordered, assist resident with making safe decisions, and monitor/document/report as needed any changes in cognitive function. A care plan, dated 5/25/22, indicated the resident used antipsychotic medications related with depression with psychotic features. Interventions included, but were not limited to, administer psychotropic medications as ordered by physician and monitor for side effects and effectiveness, consult with pharmacy, and discuss with medical doctor, and family about ongoing need for use of medication. A physician order, dated 4/5/25, with an original start date of 5/18/22, indicated to administer one tablet of Risperidone (a drug used to treat certain mental disorders) 0.25 mg (milligrams) by mouth two times a day. Review of Resident 18's record indicated an AIMS assessment had been completed on 7/13/24 but the record lacked documentation of an AIMS assessment being completed since July of 2024. During an interview, on 5/28/25 at 11:23 a.m., Licensed Practical Nurse (LPN) 3 indicated AIMS assessments should be completed on admission and every 3 months. During an interview, on 5/28/25 at 11:33 a.m., the Director of Nursing (DON) indicated she was not aware of how the previous staff completed the AIMS assessments and didn't know if they were on the computer or on paper. She was unable to find documentation for an AIMS assessment being completed on Resident 18 since July 2024. On 5/28/25 at 1:58 p.m., the Regional Nurse Consultant provided a document with a revised date of 8/24, titled, Psychotropic Medications Use, and indicated it was the policy currently being used by the facility. The policy indicated, .1. Purpose .60. Assessment: Lift, AIMS (Recommended Quarterly) 3.1-48(b)

3. Resident 14's record was reviewed on 5/28/25 at 10:26 a.m. The profile indicated the resident's diagnoses included, but were not limited to, unspecified dementia, mild, with psychotic disturbance (when a person has a type of cognitive decline where the specific cause or type of brain damage leading to the decline is not clearly identified and are experiencing psychotic symptoms [loss of touch with reality] as part of the dementia). A current care plan, dated 11/14/24, indicated the resident had venous access device in her midline right arm related to antibiotic (a medication used to treat bacterial infections) administration. A current care plan, dated 11/14/24, indicated the resident was receiving IV medications for a urinary tract infection (UTI-an infection of the urinary system) due to ESBL (Extended-Spectrum Beta-Lactamase: an enzyme produced by certain bacteria that makes them resistant to many commonly used antibiotics) in her urine. A physician's order, dated 11/14/24, with an end date of 11/19/24, indicated to administer 1 gram of Ertapenem Sodium Injection Solution Reconstituted (a way of administering the antibiotic Ertapenem via IV to treat moderate to severe bacterial infections) one time daily for ESBL in the urine for 5 days. A progress note, dated 11/13/24 at 1:14 p.m., indicated the resident had returned to the facility from a hospital stay. The resident had a midline IV access in her right arm. A progress note, dated 11/14/24 at 2:34 p.m., indicated the resident had an order to administer 1 gram of Ertapenem Sodium Injection Solution Reconstituted one time daily for ESBL in the urine for 5 days. A progress note, dated 11/26/25 at 1:00 p.m., indicated the resident's midline IV access had been removed. A quarterly Minimum Data Set (MDS) assessment, dated 2/20/25, indicated the resident had no cognitive deficit. The assessment lacked documentation that the resident had received an antibiotic or that the resident had IV (intravenous access-a safe and reliable access to a vein for the purpose of administering fluids, medications, or other substances directly into the bloodstream) during the assessment period. An annual MDS assessment (in progress), dated 5/23/25, indicated the resident had no cognitive deficit. The assessment lacked documentation that the resident had received an antibiotic or that the resident had IV access during the assessment period. During an interview, on 5/28/25 at 11:23 a.m., the resident indicated she no longer had the IV access line where she was getting her antibiotic through. She had the IV access right after she returned from the hospital in November. She had not had the line for quite some time. During an interview, on 5/28/25 at 12:03 p.m., the Director of Nursing (DON) indicated she was not surprised about the care plan not being updated. She and the Administrator had only been in the facility for a few months. Since that time, they had been finding all kinds of things that had not been done. On 5/28/25 at 1:56 p.m., the Regional Nurse Consultant provided a document, dated 8/2024, titled, Care Plans, Comprehensive Person-Centered, and indicated it was the policy currently being used by the facility. The policy indicated, .A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation .3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change 3.1-35(a) 3.1-35(d)(2)(B) Based on interview and record review, the facility failed to ensure care plan meetings were conducted quarterly for 1 of 16 residents reviewed for care plan meetings (Resident 9), and failed to ensure care plans were implemented and updated for 2 of 5 residents reviewed for care plans (Residents 32 and 14). Findings include: 1. During a phone interview, on 5/2725 at 2:01 p.m., Resident 9's daughter indicated she did not remember being invited to a care plan meeting ever. She indicated she would be happy to attend via phone call if someone would reach out to her. Resident 9's record was reviewed on 5/29/25 at 11:27 a.m. An annual Minimum Data Set (MDS) assessment, dated 3/3/25, indicated the resident had severe cognitive impairment. Census information indicated that the resident was admitted to the facility on [DATE]. A care conference review note, dated 2/13/25, indicated a care plan meeting was conducted on this day. The record lacked documentation of a care plan meeting being conducted before 2/13/25. During an interview, on 5/29/25 at 1:39 p.m., the Social Service Director (SSD) indicated she conducted the care plan meetings once a quarter with the residents and/or family representatives. She had not invited Resident 9's daughter because she did not have an address on file to send her an invitation. The SSD indicated she would conduct a care plan meeting over the phone with family if they did not live close to the facility. During an interview, on 5/30/25 at 9:07 a.m., the SSD indicated she was unable to find any documentation for a care plan meeting being conducted for Resident 9 prior to 2/13/25, she further indicated she had a care plan meeting with the resident yesterday on 5/29/25. The SSD was unaware of where or how the previous SSD documented the care plan meetings. During an interview, on 5/20/25 at 9:09 a.m., the Administrator indicated she was aware there was no documentation available to verify care plan meetings had been conducted quarterly as per policy. On 5/30/25 at 10:10 a.m., the Administrator provided a document with a revised date of 8/24, titled, Care Planning - Interdisciplinary Team, and indicated it was the policy currently being used by the facility. The policy indicated, .4. The resident, the resident's family and/or resident's legal representative/guardian or surrogate are encouraged to participate in the development of a revisions to the resident's care plan. 5. Care plan meetings are scheduled at the best time of the day for the resident and family when possible. 6. If it is determined that participation of the resident or representative is not practicable for development of the care plan, an explanation is documented in the medical record 2. During an interview, on 5/27/25 at 1:40 p.m., Resident 32 indicated she had frequent pain and was on pain medication as needed. Resident 32's record was reviewed on 5/28/25 at 2:56 p.m. The profile indicated the resident's diagnosis included, but were not limited to, acute and chronic respiratory failure with hypoxia (the lungs are unable to adequately supply oxygen to the blood, leading to low oxygen levels in the blood and potentially low oxygen levels in the tissues), chronic pain (defined as pain that persists longer than three months or beyond the typical healing period of an illness or injury), and chronic obstructive pulmonary disease (progressive lung disease that makes it difficult to breathe). Census information indicated that the resident was admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment, dated 3/13/25, indicated the resident had no cognitive impairment and was taking a opioid (a class of drug that were used primarily for pain relief) medication. The MDS assessment indicated the resident received as needed pain medication and had frequent complaints of pain and the pain frequently interfered with activities of daily living. A physician order, dated 1/21/25, indicated to administer one tablet of Hydrocodone- Acetaminophen (opioid pain medication) tablet 7.5-325mg (milligrams) by mouth every 8 hours as needed for pain. Review of the resident's Medication Administration Record (MAR) for the months of March, April, and May indicated Resident 32 received the Hydrocodone medication daily except for a few days when she was in the hospital in March 2025. Resident 32's record lacked documentation of a care plan being implemented for pain management or the use of opioid pain medication. During an interview, on 5/30/25 at 11:00 a.m., the Director of Nursing (DON) indicated Resident 32 had been on an as needed pain medication since admission and acknowledged the resident was taking the pain medication on a regular basis. The nurse practitioner was aware and would be looking into the matter. The DON indicated she was not aware that the resident didn't have a care plan for pain management or opioid medication use. During an interview, on 5/30/25 at 11:17 a.m., Licensed Practical Nurse (LPN) 3 indicated Resident 32 had been on pain medication since admission and that she complained of generalized all over pain. During an interview, on 5/30/25 at 2:00 p.m., the MDS coordinator indicated she was not aware that Resident 32 didn't have a care plan implemented for pain management or for use of pain medication. She was in the process of going through all the care plans to get them updated.

Based on observation, record review, and interview, the facility failed to ensure residents were provided assistance to shave for 2 of 16 residents reviewed for activities of daily living (ADL) care (Residents 33 and 21). Findings include: 1. During an observation, on 5/27/25 at 11:11 a.m. Resident 33 was up in his wheelchair, in the therapy gym. Resident 33 had untrimmed beard and mustache facial hair growth. During an observation, on 5/28/25 at 1:52 p.m., Resident 33 was up in his wheelchair, in the hallway. The resident had untrimmed beard and mustache facial hair growth. At the same time, the resident indicated he did not want to have facial hair and wanted to be shaved at least once a week. During an observation, on 5/29/25 at 10:33 a.m., Resident 33 was sitting up in his wheelchair, in the therapy gym. The resident had untrimmed beard and mustache facial hair growth. During an observation, on 5/29/25 at 1:20 p.m., the resident was observed up in his wheelchair, in his room. The resident had untrimmed beard and mustache growth. At the same time, the resident indicated he received a shower the day before, but the staff had not asked him if he wanted shaved. The resident indicated he would have let the staff assist him with shaving if they had asked. Resident 33's record was reviewed on 5/28/25 at 2:03 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 3/29/25, indicated the resident had a severe cognitive impairment and required substantial/maximal staff assistance with personal hygiene. The assessment lacked documentation the resident refused care. Diagnoses on the resident's profile included, but were not limited to, muscle wasting and atrophy (decrease in muscle mass and strength) and need for assistance with personal care. A care plan, last revised on 4/15/25, indicated the resident had an ADL self-care performance deficit. Interventions indicated the resident usually required substantial/maximal staff assistance with personal hygiene and bathing. Progress Notes, dated May 2025, lacked documentation the resident refused care. Shower Sheets, dated May 2025, indicated the resident received a shower on 5/3/25, 5/7/25, 5/10/25, 5/14/25, 5/17/25, 5/21/25, 5/24/25, and 5/28/25. The shower sheet, dated 5/3/25, indicated the resident was shaved. All other shower sheets lacked documentation the resident was shaved or was offered to be shaved and refused. During an interview, on 5/29/25 at 1:22 p.m., Licensed Practical Nurse (LPN) 3 indicated Resident 33 should have been shaved on shower days, however, sometimes he refused. LPN 3 indicated shaving or refusal should have been documented on the shower sheets. 2. On 5/27/25 at 11:25 a.m., during initial observation and interview, Resident 21observed in his room sitting in a wheelchair. Resident had a strong urine odor. His hair was oily and disheveled with extensive facial hair. On 5/28/25 11:35 a.m., observed resident in his room. During an interview the resident indicated he had his hair washed and was unshaven. The resident indicated he did not like having facial hair. On 5/28/25 at 11:37 a.m., during an interview, Certified Nurse Aide (CNA) 4 indicated the resident preferred to be shaved. On 5/28/25 at 12:06 p.m., during an interview, Licensed Practical Nurse (LPN) 3 indicated residents were shaved on shower days. On 5/28/25 at 2:34 p.m., The medical record of Resident 21 was reviewed. The resident was admitted to the facility on [DATE]. Admitting diagnoses included but not limited to Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high). A care plan, dated 8/26/24, indicated the resident had an ADL (activities of daily living) (bathing, dressing grooming) self-care performance deficit related to Parkinson's, impaired respiratory status. Interventions included but were not limited to personal hygiene. Usual performance fluctuated, usual performance was dependent on assistance of 2, bathing/showering usual performance may fluctuate with usual performance of dependent on assistance of 2. A Minimum Data Set (MDS) assessment, dated 5/3/25, indicated the resident had mild cognitive impairment and required extensive assistance with ADL care. On 5/29/2025 at 2:30 p.m., the Director of Nursing provided a document titled, Activities of daily living, dated 8/2024, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Interpretation and Implementation .2. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care) 3.1-38(a)(1)

Based on observation, record review, and interview, the facility failed to ensure oxygen equipment was changed and dated according to facility policy for 1 of 1 residents reviewed for respiratory care (Resident 28). Findings include: On 5/27/25 at 11:17 a.m., during an initial observation an oxygen concentrator was in the resident's room next to the bed. Oxygen tubing was in a clear storage bag dated 4/27/25. During an interview the resident indicated she was not receiving oxygen. On 5/28/25 at 11:50 a.m., observed oxygen tubing inside of a clear storage bag, dated 4/27/25, which was attached to the oxygen concentrator next to the resident's bed. During an interview the resident again indicated she had not been receiving oxygen at any time including at night. On 5/28/25 at 11:55 a.m., during an interview Licensed Practical Nurse (LPN) 3 indicated the oxygen tubing was changed weekly on Sunday nights. She indicated Resident 28 did not use her oxygen very often. On 5/29/25 at 9:39 a.m., the medical record of Resident 28 was reviewed. The resident was admitted on [DATE]. Admitting diagnoses included but was not limited to, Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high), shortness of breath and chronic obstructive pulmonary disease (COPD) (a group of diseases that cause airflow blockage and breathing-related problems). A Physician order, dated 2/22/25, indicated to administer oxygen at 2L (liters) per nasal cannula (a thin flexible tube device to provide supplemental oxygen therapy to people who have lower oxygen levels) at night for SOB (shortness of breath), check oxygen saturation (a measurement of the percentage of hemoglobin in your blood that is carrying oxygen) every shift at bedtime for shortness of breath and PRN (as needed), and may wean off (gradually reduce amount of oxygen). A Physician order, dated 5/9/25, indicated to change oxygen tubing every night shift every Sun and PRN for oxygen use. Review of the Medication administration record (MAR) from 3/1/25 through 5/27/25 indicated the resident was administered oxygen nightly. The medical record lacked documentation of a care plan related to oxygen use. A quarterly Minimum Data Set (MDS) assessment, dated 3/19/25, indicated the resident was cognitively intact and received oxygen during the assessment period. On 5/29/25 at 10:00 a.m., during an interview the Director of Nursing (DON) indicated she discontinued the oxygen order because the resident did not use oxygen, and the storage bag and tubing was not changed due to being overlooked. On 6/2/2025 at 11:00 a.m., the Administrator provided a document titled, Respiratory Therapy, dated 8/2024, and indicated it was the policy currently being used by the facility. The policy indicated, .Infection Control Considerations Related to Oxygen Administration .13. Change the oxygen cannula and tubing every seven (7) days, or as needed 3.1-47(a)(4) 3.1-47(a)(5) 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure a resident's antibiotic was not administered past the stop date for 1 of 2 residents reviewed for antibiotic use (Resident 33). Findings include: Resident 33's record was reviewed on 5/28/25 at 2:03 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 3/29/25, indicated the resident had a severe cognitive impairment and received an antibiotic during the assessment look-back period. A chest x-ray, dated 5/12/25, showed the resident had an infiltrate (pneumonia). A May 2025 Medication Administration Record (MAR) included a physician's order, dated 5/12/25. The physician's order indicated doxycycline (an antibiotic) 100 milligrams (mg) by mouth twice daily for seven days for infection. The medication was documented as administered, from the evening of 5/12/25 to the evening of 5/27/25, and was not stopped after seven days. A pharmacy delivery log indicated 14 doxycycline 100 mg tablets were delivered to the facility for Resident 33 on 5/12/25. An Emergency Drug Kit (EDK) log indicated doxycycline 100 mg was removed from the EDK twice on 5/21/25, twice on 5/22/25, once on 5/24/25, once on 5/26/25, and once on 5/27/25. During an interview, on 5/28/25 at 2:39 p.m., the Director of Nursing (DON) indicated she reviewed Resident 33's doxycycline order and administration. The resident received doxycycline until the evening of 5/27/25. The pharmacy filled the medication because the stop date was in the text of the order, but it was not put in the system correctly so the order was not stopped when it should have been. On 5/24/25 at 2:00 p.m., the DON provided a document titled, Antibiotic Stewardship, last revised in August 2024, and indicated it was the policy currently being used by the facility. The policy indicated, .4. If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following elements .d. Duration of treatment: (1) start and stop date; or (2) Number of days of therapy 3.1-48(a)(2)

Based on observation, interview, and record review, the facility failed to ensure medications were labeled properly and the facility failed to ensure expired medications were disposed of for 1 of 1 medication storage rooms reviewed and for 2 of 3 medication carts reviewed (Residents 193 and 24). Findings include: 1. On 5/29/25 at 3:10 p.m., the medication storage room contained an undated multi use vial of Aplisol (a clear, colorless solution for injection as an aid in the diagnosis of tuberculosis) solution. During an interview, on 5/29/25 at 3:10 p.m., Licensed Practical Nurse (LPN) 3 indicated she was not aware of how long Aplisol was good for once opened, but was aware the vial should be dated once opened. During an interview, on 5/29/25 at 3:15 p.m., the Regional Nurse Consultant indicated the vial of Aplisol was good for 30 days once opened. During an interview, on 5/29/25 at 3:16 p.m., the Director of Nursing indicated the vial of Aplisol should be dated once opened. On 5/29/25 at 4:04 p.m., the Regional Nurse Consultant provided an undated document, titled, Medications with Shortened Expiration Dates, and indicated it was the current policy used by the facility. The policy indicated, .Aplisol solution discard 30 days after initial use 2. On 5/29/25 at 3:11 p.m., the medication storage room contained 3 prefilled syringes of hepatitis B Vaccines (a preventive shot that protects against the hepatitis B virus, a common cause of liver disease and cancer) intended for facility stock. The vaccines contained a label that they were delivered to the facility on 1/29/25 from the pharmacy and had an expiration date of 5/19/25. During an interview, on 5/29/25 at 3:11 p.m., LPN 3 indicated the hepatitis B vaccines should have been discarded. On 5/29/24 at 4:00 p.m., the Regional Nurse Consultant provided an undated document, titled, Expired Medications and Medications with Shortened Expiration Dates, and indicated it was the current policy used by the facility. The policy indicated, .Ensure that all medications in the facility are rotated and/ or reviewed on a consistent basis to prevent having expired medications in the facility .2. The Director of Nursing or other authorized personnel will delegate to appropriate personnel the task of ensuring that all outdated or expired medications (with the exception of controlled substances, refer to controlled substances policy) are removed from the medication cart or other area that medication may be stored in 3. On 5/29/25 at 4:41 p.m., the 300-hall medication cart contained an insulin (medication used to lower blood sugar) pen injector that had no open date. The pen contained a label that indicated it was for Resident 193. During an interview, on 5/29/25 at 4:42 p.m., Licensed Practical Nurse (LPN) 3 indicated the insulin pens and vials should be dated once opened. She further indicated that the insulin pens and vials were good for 28 days once they were opened. Resident 193's record was reviewed on 5/30/25 at 8:43 a.m. The profile indicated the resident's diagnosis included, but were not limited to, Type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). A physician order, dated 5/15/25, indicated Glargine (insulin medication) solution 100 unit/ml (milliliter) inject 30 units subcutaneous (under the skin) at bedtime for diabetes. 4. On 5/29/25 at 4:44 p.m., the 200-hall medication cart contained 2 insulin pen injectors that had no open dates on them. The insulin pens contained a label that indicated they were for Resident 24. Resident 24's record was reviewed on 5/30/25 at 8:44 a.m. The profile indicated the resident's diagnosis included, but were not limited to, Type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). A physician order, dated 4/18/25, indicated Glargine (insulin medication) solution 100 unit/ml (milliliter) inject 45 units subcutaneous (under the skin) at bedtime. During an interview, on 5/29/25 at 4:44 p.m., LPN 3 indicated she was not aware of how long the insulin pens had been opened. On 5/29/24 at 4:00 p.m., the Regional Nurse Consultant provided an undated document, titled, Expired Medications and Medications with Shortened Expiration Dates, and indicated it was the current policy used by the facility. The policy indicated, .Ensure that all medications in the facility are rotated and/ or reviewed on a consistent basis to prevent having expired medications in the facility .3. All medications will be labeled per State Board of Pharmacy and Regulations that includes specific directions pertaining to expired or discard after language. 4. In the event that a medication has a shortened expiration date once opened the medication (open-dated) will be labeled with the date opened and the initials of the nurse 3.1-25(j) 3.1-25(o)

Based on interview and record review, the facility failed to ensure a licensed nurse was on duty 24 hours a day for 1 of 61 days reviewed on a shift when two residents fell (Residents W and T). This deficient practice had the potential to affect 42 of 42 residents who resided in the facility. Findings include: 1. During an anonymous interview Employee C indicated, on 12/25/24, there was no nurse in the facility on day shift, 6:00 a.m. to 6:00 p.m. The Director of Nursing (DON) came in at breakfast and lunch and administered insulin. Residents W and T fell on the shift, and there was no nurse at the facility at the time of the falls. A Facility Assessment, dated 10/24/24, indicated the facility's staffing pattern included two licensed nurses on day shift and one licensed nurse on night shift. A Daily Nursing Assignment Sheet, dated 12/25/24, indicated a Registered Nurse (RN) was scheduled as the charge nurse from 6:00 a.m. to 6:00 p.m., but the name was crossed out. Two Qualified Medication Aides (QMAs) were scheduled on day shift. The top of the document included the DON's name and phone number. A Facility Bed Board, dated 12/25/24, indicated 42 residents resided in the facility. A written statement, dated 1/31/25, indicated, On 12/25/24, I, [DON's name], was notified at on or around 7am [sic] that the agency nurse never showed up. I went down to the building to pass the insulins. I stayed through the morning, left for an hour around 10am [sic] and was back to check accu checks and insulins at 11am [sic]. During the time I was gone, I was always available by phone and less than 40 minutes away. The Qs [QMAs] did not practice outside their scope. I stayed and helped with what I could and tried to get coverage. I had to leave again on or around 5pm [sic] and night shift came in at 6pm [sic] Resident W's record was reviewed on 1/31/25 at 12:11 p.m. A 5-day Minimum Data Set (MDS) assessment, dated 12/25/24, indicated the resident had a moderate cognitive impairment and required substantial assistance with transfers. Diagnoses on the resident's Face Sheet included, but were not limited to, history of falling. A Progress Note was written by the DON and dated 12/25/24. The note was opened at 3:50 p.m. and indicated the effective time was 3:43 p.m. The note indicated the resident fell in his room when he attempted to self-transfer without using the call light. There was a skin tear to the resident's right elbow. Two staff members assisted the resident back to bed. The DON was notified, oxygen was started as a nursing measure, and the physician was notified. The resident's oxygen level was 79 percent (normal is between 95 and 100 percent), and the oxygen level continued to fall to 41 percent. The resident's blood pressure was 59/44 (normal is around 120/80), and the pulse was 48 beats per minute (bpm) (normal is 60 to 100 bpm). There was no response from the physician so 911 was called and the resident was sent to the hospital. This nurse called report to the hospital. 2. Resident T's record was reviewed on 1/31/25 at 11:59 a.m. Diagnoses on the resident's Face Sheet included, but were not limited to anoxic brain injury (occurs when the brain is deprived of oxygen) and dementia in other disease classified elsewhere severe with mood disturbance. A quarterly Minimum Data Set (MDS) assessment, dated 12/24/24, indicated the resident had two or more falls since the prior assessment, and the resident required substantial assistance with transfers. A Progress Note, dated 12/25/24, indicated it was created by the DON at 3:59 p.m. The effective time of the note was 1:57 p.m. The note indicated the resident fell while ambulating in his room. The resident had a scrape on his forehead and an abrasion on his left knee. The resident was assisted into his wheelchair by two staff members. The physician and family were called. During an interview, on 1/31/25 at 9:29 a.m., the DON indicated the agency nurse had not shown up as scheduled on 12/25/24. The DON was at the facility for most of the shift from 6:00 a.m. to 6:00 p.m., but she had to leave for part of the day. There was no way for her to show exactly what hours she worked because she was a salaried employee and did not clock in and out for shifts. During an interview, on 1/31/25 at 10:56 a.m., the DON indicated she was at the facility when one of the falls occurred on 12/25/24, but she could not remember which resident's fall it was. On 1/31/25 at 11:56 a.m., the DON provided a document titled, POLICIES AND PROCEDURES MANUAL, last revised in August 2024, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Statement: The nursing services department shall be under the direct supervision of a registered or licensed practical/vocational nurse at all times. Policy Interpretation and Implementation: 1. A licensed nurse .is on duty twenty-four hours per day, seven (7) days per week, to provide resident care services and supervise the nursing services activities provided by unlicensed staff. A licensed nurse is designated as a charge nurse on each shift This citation relates to Complaint IN00450270. 3.1-17(a)

Based on record review and interview, the facility failed to ensure medications were reordered in a timely manner so they were available for administration for 1 of 18 residents reviewed for pharmaceutical services (Resident D). Findings include: Resident D's record was reviewed on 1/31/25 at 11:04 a.m. An annual Minimum Data Set (MDS) assessment, dated 12/20/24, indicated the resident was cognitively intact. Diagnoses on the resident's face sheet included, but were not limited to, unspecified polyneuropathy (nerve damage throughout the body). A care plan, initiated on 8/30/22, indicated the resident had the potential for pain related to polyneuropathy. Interventions included, but were not limited to, administer medications as ordered. A Medication Administration Record (MAR), dated December 2024, indicated pregabalin (nerve pain medication) 75 milligrams (mg), 1 capsule 3 times daily for unspecified polyneuropathy. The MAR indicated the pregabalin was not available for administration on 12/27/24, 12/28/24, and 12/29/24. A Narcotic Count Sheet indicated 60 capsules of pregabalin 75 mg were delivered to the facility on [DATE]. The last capsule was signed for on 12/25/24. A Progress Note, dated 12/25/24, indicated a message was left with the physician to call or write a prescription for pregabalin. A Progress Note, dated 12/26/24, indicated the nurse called the physician and requested a prescription for the resident's pregabalin. The physician physically wrote prescriptions and did not use an electronic prescription service. The physician had not returned the call. Progress Notes, dated 12/26/24 and 12/27/24, indicated the pregabalin was on order and awaiting delivery. A Progress Note, dated 12/27/24, indicated the nurse called the pharmacy and attempted to get the pregabalin refilled. The pharmacy indicated a new prescription was needed. The Director of Nursing (DON) planned to call the physician for a prescription. A Progress Note, dated 12/28/24, indicated the pregabalin was not available for administration. A Progress Note, dated 12/29/24, indicated the pregabalin was not available for administration and awaiting arrival from pharmacy. A Progress Note, dated 12/30/24, indicated another call was placed to the physician to request the prescription for the resident's pregabalin. The physician had not returned the calls. The nurse called the hospital to check if another physician was available on call, but there was no one on call for the resident's physician. A Narcotic Count Sheet indicated 28 capsules of pregabalin 75 mg were delivered to the facility on [DATE]. The first capsule was signed for on 12/30/24. The Narcotic Count Sheets lacked documentation doses of pregabalin were available from 12/25/24 to 12/30/24. The last capsule was signed for on 1/8/25. A Progress Note, dated 1/9/25, indicated the pregabalin was on order. A Progress Note, dated 1/10/25, indicated the staff was awaiting the medication to be sent from the pharmacy. A MAR, dated January 2025, indicated pregabalin was not available for administration on 1/11/25. Census information indicated the resident was hospitalized from 1/11/25 to 1/12/25. An emergency room (ER) Physician Report, dated 1/11/25, indicated the resident reported not feeling well for several days with generalized pain. The nursing home reported the resident had high blood pressure. The resident's daughter reported the resident had not received the pregabalin for over a week. A Hospital History and Physical, dated 1/11/25, indicated, .he has been out of his Lyrica [pregabalin] for the past week due to miscommunication with nursing home staff, and he has been having increasing amounts of his chronic leg neuropathy A Narcotic Count Sheet indicated 8 capsules of pregabalin 75 mg were delivered to the facility on [DATE]. The first capsule was signed for on 1/13/25. The Narcotic Count Sheets lacked documentation doses of pregabalin were available from 1/8/25 to 1/13/25. During an interview, on 1/30/25 at 12:32 p.m., Qualified Medication Aide (QMA) 6 indicated there had been some issues obtaining narcotic medications when they switched Medical Directors. Their new Medical Director started around a week ago. There was an Emergency Drug Kit (EDK) available, but it required a prescription authorization to obtain narcotic medications from there. During an interview, on 1/30/25 at 3:25 p.m., the DON indicated there was an issue getting the resident's pregabalin when the prior Medical Director had not answered calls or sent a prescription. The physician needed to come into the facility and write a prescription. During an interview, on 1/31/25 at 10:50 a.m., the DON indicated the resident missed pregabalin doses from 12/25/24 to 12/30/24 according to the Narcotic Count Sheets. There was one dose of pregablin pulled from the EDK on 12/27/24. There was no documentation provided to support a dose of pregabalin was removed from the EDK on 12/27/24. During an interview, on 1/31/25 at 10:56 a.m., the DON indicated the resident missed pregabalin doses from 1/8/25 to 1/11/25 because the medication ran out. The resident went to the hospital on 1/11/25. On 1/31/25 at 9:30 a.m., the DON provided undated drug guidance for pregabalin and indicated it was the information currently being used by the facility. The document indicated, .Increased Risk of Adverse Reactions with Abrupt or Rapid Discontinuation .Following abrupt or rapid discontinuation of LYRICA [pregabalin], some patients reported symptoms including insomnia, nausea, headache, anxiety, hyperhydrosis [excessive sweating], and diarrhea. If LYRICA is discontinued, taper the drug gradually over a minimum of 1 week rather than discontinue the drug abruptly On 1/31/25 at 9:30 a.m., the DON provided a policy titled, Medication Orders, dated 2020, and indicated it was the policy currently being used by the facility. The policy indicated, Policy: Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe .D. Renewed or recapitulated orders .The prescriber renews the order either by repeating the entire order process or with a statement such as 'continue medication for ten days.' The prescriber writes a new order for continued therapies that require different direction, dosage form, or strength This citation relates to complaints IN00451119, IN00451735, and IN00452377. 3.1-25(a)

Based on interview, observation, and record review, the facility failed to ensure the temperature and palatability of food served for 1 of 1 test tray. Findings include: During a confidential interview, conducted during the survey, the interviewee indicated the resident's hall tray food was served cold for all meals, breakfast, lunch, and supper. During an interview, on 12/19/24 at 11:05 a.m., Resident C indicated she ate meals in her room and the food was served cold at times. Resident F, on 12/19/24 at 11:20 a.m., indicated he ate meals in his room and sometimes the food was not hot, but cold. During an interview, on 12/19/24 at 11:30 a.m., Resident E indicated she ate meals in her room and the food was often cold when she got it and did not taste very good. On 12/19/24 at 12:03 p.m., test tray food temperatures were measured by the Dietary Manager (DM). The fried potatoes temperature measured at 128 degrees Fahrenheit (F), the cooked broccoli temperature measured at 118 F, and the BBQ sandwich measured at 128 F. The DM indicated the food was too cool and the food temperatures should have been at least 135 F. On 12/19/24 at 12:55 p.m., the DM provided and identified a document as a current facility policy titled Kitchen Operations: Food Temperatures, dated 1/2023. The policy indicated, .Policy .The facility will maintain proper temperature control to prevent food borne illness .Procedure .1. Hot foods that are potentially hazardous will be held for service at or above 135 degrees Fahrenheit .2. All hot and cold food items will be served to the resident at a temperature that is considered palatable at the time the resident receives the food This citation relates to Complaint IN00448031. 3.1-21(a)(2)

Based on observation, record review, and interview, the facility failed to ensure refrigerator temperature logs were maintained for 5 of 15 days in April and freezer temperature logs were maintained for 2 of 15 days in April. Findings include: During the initial kitchen tour, on 4/15/24 at 10:10 a.m., with the housekeeping supervisor, the temperature logs for the walk-in refrigerator and walk-in freezer were observed to have not been completed. At the same time, the housekeeping supervisor indicated she was filling in as the cook for that day. The regular cook, had the day off. The walk-in refrigerator temperature log, was observed sitting on a shelf in the dry storage area. The log lacked documentation of the refrigerator's temperatures for 4/1/24, 4/11/24, 4/12/24, 4/13/24, and 4/14/24. At the same time, the housekeeping supervisor documented the temperature of the walk-in refrigerator for the date of the initial tour, on the log. The walk-in freezer temperature log, was observed posted on the door of the walk-in freezer. The temperature log lacked documentation of the freezer's temperatures for 4/13/24 and 4/14/24. At the same time, the housekeeping supervisor documented the temperature of the walk-in freezer for the date of the initial tour, on the log. During an interview, on 4/15/24 at 10:15 a.m., the housekeeping supervisor indicated she was not sure why the temperature logs had not been completed, or why the refrigerator log was not hanging on the door as it usually was. During an interview, on 4/15/24 at 10:17 a.m., dietary aide 17 indicated he was not aware that the logs had not being completed or why the refrigerator log was not hanging on the door. His understanding was that the temperatures should be checked and documented every day. On 4/16/24 at 11:00 a.m., the dietary manager provided a document, dated 1/2023, titled, Kitchen Operations: Food Storage, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure: .11. Refrigeration: .b. Thermometers should be checked utilizing an internal thermometer at least two times each day .12. Frozen Foods: a. Temperatures for the freezer should .be checked at least two times daily 3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to ensure proper administration of inhaled medication during the medication administration pass for 1 of 3 residents observed, resulting in a medication error rate of 6.67% (Resident 6). Finding includes: During a medication administration observation, on 4/17/24 at 9:01 a.m., Licensed Practical Nurse (LPN) 7 was administering an Advair (medication used to prevent asthma symptoms) inhaler (small handheld devices that allows you to breath medicine through your mouth, directly to your lungs) to Resident 6. Resident 6 then handed the inhaler back to the nurse and the nurse immediately gave the resident a Spiriva (medication used to prevent bronchospasms) inhaler to use. The resident did not rinse and spit after the use of the first inhaler nor did she wait in between administering the two inhaled medications. Resident 6's record was reviewed on 4/17/24 at 10:00 a.m. The profile indicated the resident's diagnoses included, but were not limited to, emphysema (a condition that causes shortness of breath), unspecified asthma (a chronic disease in which the bronchial airways in the lungs become narrowed and swollen, making it difficult to breathe). A physician order, dated 3/8/24, indicated Advair Diskus inhalation powder breath 100-50mcg (micrograms) one puff inhale orally two times related to emphysema. A physician order, dated 2/28/24, indicated Spiriva Handihaler inhalation capsule 18mcg inhale orally one time a day for emphysema. A care plan, dated 6/13/23, indicated the resident is at risk for impaired gas exchange related to asthma and emphysema. Interventions included, but were not limited to, administer medication as ordered and monitor for signs and symptoms of respiratory distress and repot to medical doctor. During an interview, on 4/18/24 at 9:04 a.m., LPN 10 indicated the resident should rinse and spit after use of inhaled medications and should wait several minutes in between administrating multiple inhalers to the same resident. During an interview, on 4/18/24 at 9:24 a.m., Registered Nurse (RN) 9 indicated she would wait several minutes in between administering inhaled medications to the same resident. The RN indicated the resident should rinse and spit after use of inhaled medications to prevent thrush (a fungal infection typically on the skin or mucous membranes). During an interview, on 4/18/24 at 11:51 a.m., the [NAME] President of Clinical Operations, indicated with a steroid inhaler the nurse should have had the resident swish and spit after use per manufacturer guidelines. On 4/18/24 at 11:20 a.m., the [NAME] President of Clinical Operations provided an undated document, titled, Oral and Nasal Inhalation Administration, and indicated it was the policy currently being used by the facility. The policy indicated, .7. If more than one inhalation is ordered, wait one minute then repeat steps one to six for each inhalation ordered On 4/18/24 at 11:40 a.m., the [NAME] President of Clinical Operations provided a document, dated April 2008, titled, Adviar Diskus and indicated it was the policy currently being used by the facility. The policy indicated, .After each dose, rinse your mouth with water and spit the water out. Do not Swallow 3.1-48(c)(1)

Based on observation, interview, and record review, the facility failed to ensure expired medications were disposed of properly for 1 of 1 medication storage room reviewed for medication storage. Finding includes: On 4/18/24 at 10:31 a.m., the medication storage room contained an opened multi-use vial of Aplisol (a clear, colorless solution for injection as an aid in the diagnosis of tuberculosis) solution and had an open date of 2/27/24. On 4/18/24 at 10:33 a.m , the medication storage room contained an opened multi-use vial of flu vaccine solution and had an open date of 11/2/23. During an interview, on 4/18/24 at 10:35 a.m., Registered Nurse (RN) 9 indicated she was not aware of the facility policy for how long the medication was good for once it was opened but did believe they needed to be discarded. During an interview, on 4/18/24 at 10:51 a.m., the Administrator indicated the medication vials were expired. During an interview, on 4/18/24 at 11:20 a.m., [NAME] President of Clinical Operations indicated both the medications should have been discarded and were expired. On 4/18/24 at 11:20 a.m., the [NAME] President of Clinical Operations provided as a current facility policy, titled, Medication with Shortened Expiration Dates, dated 2/11/21. The policy indicated, .Aplisol discard vials 30 days after initial use .Flu Vaccine discard 28 days after initial use 3.1-25(j)

Based on record review and interview, the facility failed to ensure the documentation of wound treatments being completed for 1 of 2 residents reviewed for pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) (Resident 25). Findings include: Resident 25's record was reviewed on 4/17/24 at 11:00 a.m. The profile indicated the resident's diagnoses included, but were not limited to, type 2 diabetes mellitus (a disease that occurs when your blood glucose is too high), heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), and end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). An admission Minimum Data Set (MDS) assessment (part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes), dated 3/21/24, indicated the resident had severe cognitive deficit and was at risk for development of pressure ulcers. A care plan, dated 3/30/24, indicated the resident was at risk for impaired skin integrity related to incontinence of bowel and bladder (the inability to control the flow of urine from the bladder or the escape of stool from the rectum), weakness, impaired mobility, and need for assistance with activities of daily living (ADLs-activities related to personal care). A physician's order, dated 3/13/24, indicated weekly skin assessment, every day shift, every Wednesday morning for monitoring. The March 2024 treatment administration record (TAR) lacked documentation of an assessment having been completed on 3/27/24. A physician's order, dated 3/13/24, indicated float heels while in bed. Every shift for monitoring. The March TAR lacked documentation of the order being completed as written on 3/27/24. The April 2024 TAR lacked documentation of the order being completed as written on 4/4/24. A physician's order, dated 3/13/24, indicated offer/assist to turn/reposition resident. Every 2 hours for skin breakdown prevention. The March TAR lacked documentation of the order being completed as written on 3/27/24, at 8:00 a.m., 10:00 a.m., 12:00 p.m., and 4:00 p.m. The April 2024 TAR lacked documentation of the order being completed as written on 4/4/24, at 8:00 a.m., 10:00 a.m., 12:00 p.m., and 4:00 p.m. A wound and skin progress note, dated 3/26/24 at 9:09 a.m., indicated the resident had a deep tissue injury (DTI-purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) noted to her left buttocks. Treatment orders were provided, at that time. A physician's order, dated 3/26/24, indicated wound assessment to the left buttocks. Every day and night shift for wound care. The March TAR lacked documentation of the order being completed as written on the day shift of 3/27/24. The April 2024 TAR lacked documentation of the order being completed as written on the day shift of 4/4/24. A physician's order, dated 3/26/24, indicated apply triad paste (treatment that allows natural moisture spreads evenly across the wound surface, maximizing contact and creating a moist environment) to bilateral (both sides) buttocks every day and night shift for wound care. The March TAR lacked documentation of the order being completed as written on the day shift of 3/27/24. A physician's order, dated 3/28/24, indicated may use low air loss mattress (designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown). Check functioning every day and night shift. The April 2024 TAR lacked documentation of the order being completed as written on the day shift of 4/4/24. A wound and skin progress note, dated 4/2/24 at 8:29 a.m., indicated the area to the resident's left buttocks had been restaged to a stage 3 pressure ulcer (full thickness tissue loss where subcutaneous [beneath, or under, all the layers of the skin] fat may be visible). New treatment order to cleanse with wound cleanser, apply hydrogen (dressings that provide a mechanical barrier and moist wound environment), and cover with border foam. During an interview, on 4/17/24 at 3:15 p.m., the Director of Nursing (DON) indicated the TAR should always be signed off when the treatment was completed. Without a signature, there was no way to ensure the treatment was completed as ordered. On 4/17/24 at 3:07 p.m., the DON provided a document, dated 2020, titled, Medication Administration and General Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure: .11. The resident's .administration record is initialed by the person administering the medication .Or if utilizing and Electronic Medical Record, the initials of the nurse are electronically stamped into the record 3.1-50(a)(1)

Based on observation, interview, and record review, the facility failed to ensure accurate staffing sheets were posted daily for 3 of 5 days during the recertification survey. Finding includes: During an observation, on 4/15/24 at 12:40 p.m., the staffing sheet posted on the wall across from the nurses' station, was dated correctly, but the posting lacked documentation of the total number and the actual hours worked by licensed and unlicensed nursing staff. During an observation, on 4/16/24 at 11:08 a.m., the staffing sheet posted on the wall across form the nurses' station, was dated correctly, but the posting lacked documentation of the total number and the actual hours worked by licensed and unlicensed nursing staff. During an interview, on 4/17/24 at 8:48 a.m., the Director of Nursing (DON) indicated she was not aware the staffing sheet posted was not completed accurately. She indicated the night shift nurse was responsible for making sure the sheet was posted and was completed accurately. The staffing sheet was to be posted at midnight every night shift. The total number of hours and the actual hours worked by staff should be on the sheet. The DON indicated she would have to address the issue at the next in-service meeting. During an observation, on 4/19/24 at 9:00 a.m., the staffing sheet posted on the wall across from the nurses' station, was dated correctly, but the posting lacked documentation of the total number and the actual hours worked by licensed and unlicensed nursing staff. On 4/17/24 at 10:50 a.m., the DON provided a document, with a revised date of August 2022, titled, Posting Direct Care Daily Staffing Numbers, and indicated it was the policy currently being used by the facility. The policy indicated, .1. At the beginning of each shift, the number of licensed nurses . and the number of unlicensed nursing personnel . directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in a clear and readable format .g. The actual time worked during that shift for each category and type of nursing staff; and h. Total number of licensed [NAME] non licensed nursing staff working for the posted shift

Based on record review and interview, the facility failed to ensure sufficient on-duty staff were certified in cardio-pulmonary resuscitation (CPR-an emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped) for 2 of 3 residents reviewed for emergent situations (Residents B and D). Findings include: An anonymous interviewee indicated some residents have had CPR performed on them in the past few months, but no staff in the facility had CPR certification. The previous director had commented to a staff that no one had CPR certification and if something happened the director would be the one to administer CPR. 1. Resident B's closed record was reviewed on [DATE] at 10:58 a.m. The profile indicated the resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing-related problems), pulmonary fibrosis (a lung disease that occurs when lung tissue becomes damaged and scarred), and coronary arteriosclerosis (plaque buildup in the wall of the arteries that supply blood to the heart). A physician's order, dated [DATE], indicated the resident was a full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). A care plan, dated [DATE] and revised on [DATE], indicated the resident wished to be a full code. Interventions included, but were not limited to, CPR to be performed in event of cardiac/respiratory arrest (the state or condition of heartbeat or breathing being stopped). A progress note, completed by Registered Nurse (RN) 2, dated [DATE] at 12:45 a.m., indicated upon entering room to complete routine check the resident was found to have no visual or audible respirations and no palpable (felt) or audible heartbeat. The resident's code status was a full code. CPR was initiated at 12:50 a.m., and 911 (any situation that requires immediate assistance from the police, fire department or ambulance) was called. Emergency Medical Technicians (EMTs) arrived at 1:10 a.m. and took over CPR. 2. Resident D's closed record was reviewed on [DATE] at 11:25 a.m. The profile indicated the resident's diagnoses included, but were not limited to, autistic disorder (a neurological and developmental disorder that affects how people interact with others, communicate, learn, and behave), dementia (he loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), and stage 3 chronic kidney disease (mild to moderate damage of the kidneys). A physician's order, dated [DATE], indicated the resident was a full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). A care plan, dated [DATE] and revised on [DATE], indicated the resident wished to be a full code. Interventions included, but were not limited to, CPR to be performed in event of cardiac/respiratory arrest (the state or condition of heartbeat or breathing being stopped). A progress note, completed by Registered Nurse (RN) 2, dated [DATE] at 5:00 a.m., indicated staff entered the resident's room to complete routine check and get resident up for the day. Staff this nurse to room. Upon entering the room found resident to have no respirations and no audible heartbeat. The resident's code status was a full code. CPR was immediately initiated and 911 (any situation that requires immediate assistance from the police, fire department or ambulance) was called. A progress note, dated [DATE] at 5:08 a.m., indicated the ambulance arrived with 3 Emergency Medical Technician's (EMT's). CPR continued while they assessed the resident. During an interview, on [DATE] at 2:31 p.m., the Administrator (ADM) indicated after contact with RN 2, she was able to confirm that the RN did not have current CPR certification and did not have the certification when she performed CPR on Residents B and D. The facility did not track the staff's CPR certifications, nor did they offer CPR certification classes to the staff. At the same time, the ADM indicated she was not able to find a policy related to CPR certification. On [DATE] at 2:31 p.m., the ADM provided an undated document, titled, Position Description: Director of Nursing, and indicated it was the current job description being used by the facility. The job description indicated, Essential Position Functions .Certificates. Licenses, Registrations .Current CPR Certification On [DATE] at 2:31 p.m., the ADM provided an undated document, titled, Position Description: Assistant Director of Nursing, and indicated it was the current job description being used by the facility. The job description indicated, Essential Position Functions .Certificates. Licenses, Registrations .Current CPR Certification On [DATE] at 2:31 p.m., the ADM provided an undated document, titled, Position Description: Unit Manager/Licensed Practical Nurse (LPN), and indicated it was the current job description being used by the facility. The job description indicated, Essential Position Functions .Certificates. Licenses, Registrations .Current CPR Certification On [DATE] at 2:31 p.m., the ADM provided an undated document, titled, Position Description: Qualified Medication Aide (QMA), and indicated it was the current job description being used by the facility. The job description indicated, Essential Position Functions .Certificates. Licenses, Registrations .Current CPR Certification This citation relates to complaint IN00422015. 3XXX,d+[DATE](s)

Based on observation, record review, and interview, the facility failed to provide supervision to prevent a cognitively impaired resident assessed to be at risk for elopement from being removed from the facility by two unknown individuals unrelated to the resident, placed in a car, and driven away without staff's knowledge for 1 of 3 residents reviewed for supervision to prevent an accident (Resident B). The Immediate Jeopardy began on November 24, 2022, when a severely cognitively impaired resident with diagnoses of dementia and Parkinson's disease and assessed at risk of elopement with an order for a Wander Guard was taken from the facility by two strangers not related to the resident without the staff's knowledge. The resident required extensive assistance from nursing staff to meet all activities of daily living needs and decision making needs. Using the reasonable person concept, it is likely a dependent vulnerable resident would be afraid and at risk for harm if taken by strangers away from their home. Staff were only made aware of the missing resident when the individuals' car was pulled over by a county Sheriff Deputy approximately 4.8 miles away from the nursing home in a different city and the Sheriff Deputy notified the facility at that the resident was missing from the building. The Regional [NAME] President, Executive Director, and Director of Nursing were notified of the Immediate Jeopardy on December 6, 2022 at 12:10 p.m. The Immediate Jeopardy was removed, and the deficient practice corrected on November 25, 2022 prior to the start of the survey and was therefore Past Noncompliance Findings include: Resident B's clinical records were reviewed on December 05, 2022 at 10:15 a.m. Diagnoses included but were not limited to Parkinson's disease (disorder of the central nervous system that affects movement), dementia, and dystonia (involuntary muscle contractions that cause repetitive movements). The most current quarterly Minimum Data Set (MDS) assessment, dated October 05, 2022. indicated Resident B had exhibited moderate cognitive impairment (decision making was poor, he required cues and supervision when making decisions). He had not exhibited any behaviors; no wandering had occurred during the look back assessment period of seven days. He required extensive assistance from one staff to transfer between surfaces. He required limited assistance from one staff to walk in his room. Having walked outside of his room had not occurred. His balance had been unsteady when going from a sitting to standing position, when walking, when turning, and when transferring from surface to surface and had only been able to stabilize with human assistance. His source of mobility had been utilizing a wheelchair or walker. The most current Elopement Evaluation, dated April 14, 2022, indicated Resident B had been assessed as an elopement risk due to having been independently mobile, a diagnosis of dementia, having tried to find family, and having perceived he needed to go home. A clinical suggestion was to apply a Wander Guard (a device to help protect memory care residents against elopement). Resident B's clinical records lacked subsequent Elopement Evaluations. Physician orders indicated an opened ended order, dated April 14, 2022, for a Wander Guard alarm to be placed on the resident at all times due to elopement risk. Resident B's clinical record lacked documentation of a Care Plan that identified an assessed risk for elopement with interventions for staff to implement to prevent an occurrence of elopement. A Social Service note, dated November 24, 2022 at 7:49 p.m., indicated a cognitive assessment of Resident B had been implemented. The assessment indicated severe cognitive impairment. Dependent on nursing staff for daily decision making. Resident B's most current Elopement Evaluation had been completed on April 14, 2022. Evaluations were to be completed quarterly. Resident B did not have an elopement risk care plan. During an observation and interview on December 05, 2022 at 9:30 a.m., Resident B was in his room seated in a wheelchair. A Wander Guard was positioned on his right wrist. At the time of the observation, Resident B pointed to the Wander Guard and indicated he had honestly earned the guard due to having taken a car trip outside that resulted in the State Troopers putting him in their car. He did not recall additional details regarding the event. During an interview on December 05, 2022 at 11:00 a.m., the Social Service Director indicated she had come to the facility on [DATE] because Resident B had been found by the Sheriff Deputy in a car with two strangers. Resident B's mobility monitor had been positioned on his wheelchair due to swelling and discomfort of the appliance on his ankle. During an interview on December 05, 2022 at 3:15 p.m., an office worker at the local Sheriff department indicated on November 24, 2022 a Sheriff Deputy had a pull over. During the pull over two minors were observed in their car with a resident from the nursing home. No additional information could be provided other than the case had been sent to the prosecutor's office due to the individuals involved being minors. During an interview on December 05, 2022 at 3:30 p.m., an office worker at the prosecutor's office indicated on November 24, 2022 two minors were discovered to have a resident from the nursing home in their car. No additional information could be provided. The office had not currently charged the minors with a crime. During an interview on December 06, 2022 at 9:50 a.m., Employee 1 verified she had worked on November 24, 2022 and provided care to Resident B. Resident B had last been seen sitting at the entrance lobby area in his wheelchair. He had been wearing a sweatshirt, shorts, and house slippers. The resident easily presented as a nursing home resident, there was no way to confuse that. She received a telephone call from the Sheriff's department at approximately 4:50 to 5:00 p.m The Sheriff Deputy asked, if our facility had a loose resident. It was at that time Employee 1 implemented a head count and determined Resident B was missing. His empty wheelchair had been observed in the front entrance lobby area. The Sheriff Deputy reported two teenage boys, unrelated to the resident, had been pulled over in a town approximately five miles north of the nursing home. Resident B had been taken to a local hospital, found to have no injury, and returned to the nursing home. An observation of the facility, on December 05 and 06, 2022, indicated upon entrance in the nursing facility one only had to push a button to the left of the door. Once pushed the entrance door was unlocked and you could easily enter. Staff were not observed to be present in the front lobby entrance area. On December 06, 2022 at 11:45 a.m., the Administrator and Corporate Consultant were interviewed. During the interview, the staff verified on November 24, 2022 two male teenagers, unrelated to Resident B, had removed Resident B from the nursing facility without staff knowledge. Knowledge of the event became evident when the Sheriff Deputy notified nursing facility staff. During an interview on December 07, 2022 at 10:20 a.m., Resident B's family member indicated they came in to talk with their dad in regard to the incident on November 24, 2022. Resident B had indicated to the family member someone had come to him and asked, would you like a ride. Resident B had gone willingly because he thought the person(s) who offered the ride would take him home. Resident B had asked if they could take him home and they reportedly said yes, so Resident B went with them. On December 05, 2022 at 1:45 p.m. the Administrator provided a copy of the facility's current Wandering and Elopement Policy and Procedure dated August 2022. A review of the procedure indicated, It is the policy of the facility that staff who have residents under their care and responsible to prevent elopement [sic]. Elopement is defined at a resident that is away from the facility property and unsupervised [sic]. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain resident's safety. The policy lacked a specific procedure for supervision from staff to prevent elopement. The past noncompliance Immediate Jeopardy began on November 24, 2022. The Immediate Jeopardy was removed, and the deficient practice corrected by November 25, 2022 after the facility implemented a systemic plan that included the following actions: -All facility staff had been provided education on the facility's Elopement Policy. -All facility staff completed an elopement drill. -Following the in-service education and drill all staff completed a posttest to ensure clear comprehension of safety from elopement expectations. -All residents who resided in the nursing facility were assessed for their elopement risk. For each resident assessed to be at risk. Care plans were updated with interventions to prevent elopement. -Monitoring for correct implementation of elopement precaution interventions has been established every shift and documented on each residents' Treatment Administration Record. -Maintenance checked all doors for proper alarm function and proper Wander Guard System function. -Daily monitoring has been established through the QAPI committee to ensure correct implementation of elopement preventative actions. This Federal tag relates to Complaint IN00395721. 3.1-45(a)(2)