Every finding on record at Greenwood Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure a physician's order for nephrostomy tube (a tube inserted through the skin of the lower back and advanced into the kidney to drain urine) site care was clarified for 1 of 3 residents reviewed for tube site care. (Resident C) Findings include: During an interview on 7/23/26 at 1:18 p.m., Registered Nurse (RN) 2 indicated Resident C has a nephrostomy tube on each side of the lower back. The facility provided nephrostomy site care when they were soiled or no longer secured. Each drainage bag had been emptied and measured each shift. Resident C had refused to allow staff to change the nephrostomy tube site dressings in the past and the physician had been notified. During an interview on 7/23/26 at 1:29 p.m., Resident C indicated the staff check in on him so often that he had to tell them to stop. The staff cared for his nephrostomy tube site dressings the way the doctor told him to care for them. Resident C's doctor told him that the nephrostomy dressings were to have been changed when soiled or when the dressings were no longer secured in place. Resident C had explained this to staff several times. The nurses had changed the nephrostomy tube site dressings in the past because they were loose. The clinical record for Resident C was reviewed on 7/23/26 at 3:54 p.m. The diagnoses included, but were not limited to, artificial opening of the urinary tract, quadriplegia, and respiratory failure. A Quarterly Minimum Data Set (MDS) assessment, dated 4/30/26, indicated Resident C was not cognitively impaired and had rejected care.A care plan, dated 10/29/25, indicated Resident C had nephrostomy tubes. Interventions included, but were not limited to, change nephrostomy site dressing per physician's order. A Physician's Order, started on 10/23/25, indicated cleanse nephrostomy tube site with soap and water and cover with sterile dressing. The order was not routinely scheduled. There was no discontinue date noted. During an interview on 7/23/26 at 4:58 p.m., RN 3 indicated the physician's order, dated 10/23/25, for Resident C's nephrostomy site care should have been clarified.On 7/24/26 at 9:00 a.m., RN 1 assisted Resident C to his right. A nephrostomy tube was observed on the lower right and left sides of Resident C's back. Each dressing was clean, secured in place, and dated 7/23/26. On 7/24/26 at 10:08 a.m., the Director of Nursing (DON) provided a copy of an undated facility policy, titled Plan of Care Overview, and indicated this was the current policy used by the facility. A review of the policy indicated the facility will review and update the plan of care quarterly or with a change. This citation relates to Intake 3073585.410 IAC (Indiana Administrative Code) 16.2-3.1 -35(g)(1)

Based on interview and record review, the facility failed to ensure a resident's oxycodone (narcotic pain medication) was accounted for after the medication had been delivered for 1 of 3 residents reviewed for misappropriation of property. (Resident B) The deficient practice was corrected on June 12, 2026, prior to the start of the survey, and was therefore past noncompliance. Findings include:During an interview on 7/23/26 at 9:48 a.m., the Director of Nursing (DON) indicated, on 6/9/26 at approximately 6:00 a.m., she had been notified that two packets of 30 oxycodone (narcotic pain medication) 10 milligrams (mg) tablets (60 tablets in total) had been delivered the day before, but there was only one packet of 30 tablets left in the locked narcotic box. The oxycodone 10 mg tablets were delivered on 6/8/26. Resident B's oxycodone 10 mg tablets were accepted and signed for by Licensed Practical Nurse (LPN) 1. Two packets of Resident B's oxycodone 10 mg and two folded narcotic count sheets were wrapped together with a rubber band and were taken to RN 1 who had been caring for Resident B that day. When the night shift Qualified Medication Aide (QMA) came to work for third shift the narcotic count was reconciled as usual and Resident B had only one narcotic count sheet and only one packet of oxycodone. At some time during the early morning hours, on 6/9/26, the QMA noticed the number at the top of the narcotic count sheet indicated 60 tablets had been delivered but had been marked over with black ink with the number 30. When the DON interviewed RN 1, first she admitted that she had used a black sharpy to change the number of tablets but then said she felt like she had been pressured when she said that and never admitted to diverting any medications. RN 1 quit over the phone. During an interview on 7/23/26 at 1:46 p.m., LPN 1 indicated on 6/8/26, she had signed for two packets of 30 tablets of oxycodone 10 mg for Resident B. LPN 1 took Resident B's oxycodone 10 mg tablets to RN 1 and RN 1 walked down the hall to her cart. LPN 1 did not witness RN 1 put the oxycodone in the locked narcotic box on the medication cart. LPN 1 received a message on her phone that the night shift QMA noticed the number of tablets delivered had been written over and changed the number from 60 tablets to 30 tablets and there was only one narcotic count sheet instead of two. That morning on 6/9/26, LPN 1 came into work and asked RN 1 why the numbers were drawn over, she didn't really respond and grabbed her things and left work.The clinical record for Resident B was reviewed on 7/23/26 at 10:02 a.m. The diagnoses included, but were not limited to, multiple sclerosis, pressure ulcer, and diabetes.A Physician's Order, started on 3/27/25, indicated oxycodone 10 mg, administer two tablets by gastric tube every four hours as needed for pain. There was no discontinue date noted.A Controlled Substance Administration Record, dated 6/8/26, indicated, prescription number ********, two packets of 30 tablets of oxycodone 10 mg for Resident B were received by RN 1 as indicated by the signature at the top of the document. Under RN 1's signature box was another box that indicated amount received and indicated 30 in thick black ink. The label on the document indicated quantity 30 of 60 tablets with a line drawn through 60 and 30 written on the label. A pharmacy packing slip, dated 6/8/26, indicated Resident B, prescription number ********, two packets of 30 tablets (60 tablets total) oxycodone 10 mg were delivered on 6/8/26, and signed for by LPN 1.On 7/24/26 at 10:38 a.m., the Administrator provided a copy of a transcribed phone interview with RN 1, the Regional Director of Nursing (RDCO), and the Administrator, dated 6/8/26, and indicated it was the transcribed interview with RN 1 regarding Resident B's missing oxycodone. A review of the interview indicated RN 1 admitted to using a black sharpy to change the number of cards delivered from two to one because she had only received one card of 30 tablets. RN 1 denied taking any medications.On 7/23/26 at 9:27 a.m., the DON provided a copy of an undated facility policy, titled Abuse and Neglect and Misappropriation of Property, and indicated this was the current policy used by the facility. A review of the policy indicated it was the intent of the facility to prevent misappropriation of property.This deficient practice was corrected on June 12, 2026, after the facility implemented a systemic plan that included the following actions: staff education on narcotic pain medication reconciliation and ongoing monitoring.This citation relates to Intake 3039358.410 IAC (Indiana Administrative Code) 16.2-3.1- 28(a)

Based on observation, interview, and record review, the facility failed to ensure food was not stored beneath a water line on which water had condensed for 2 of 2 observations of the kitchen freezer. Findings include: During a tour of the facility's walk-in freezer, on 6/24/25 at 2:15 p.m. and 7/1/25 at 10:30 a.m., food was observed to be stored beneath the freezer condenser water line, upon which water had condensed and ice had formed. Beneath the freezer condenser were three boxes of cookie dough, two boxes of pizza dough, and two boxes of dinner rolls. Ice had fallen from the frozen condenser line onto the boxes. During an interview on 6/24/25 at 10:35 a.m., the Dietary Manager indicated there was ice formed on the leaking condenser and food was stored beneath the condenser. During an interview on 6/24/25 at 10:45 a.m., the facility Administrator indicated the facility used the Indiana State Department of Health Retail Food Establishment Sanitation Requirements, effective date, November 13, 2004, as the facility policy and procedure regarding food storage. A review of the policy indicated, .410 IAC 7-24-178 Food storage; prohibited areas Sec. 178. (a) Food may not be stored as follows: .(2) Under the following: .under lines on which water has condensed . 3.1-21(i)(2) 3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for 2 of 32 residents reviewed for accuracy of the MDS assessments. (Resident 12, Resident 152) Findings include: 1. On 6/26/25 at 11:52 a.m., Resident 12's clinical record was reviewed. The diagnoses included, but were not limited to, Chronic Obstructive Pulmonary Disease (a progressive lung disease that makes it hard to breathe due to airflow blockage), dysphagia (difficulty swallowing), and dementia (a decline in mental ability severe enough to interfere with daily life). A review of the Discharge MDS assessment, dated 6/18/25, did not indicate the resident had a significant weight loss (5% or more in the last 30 days or 10% or more in the last 180 days), in section K0300: Weight Loss. A review of a dietary progress note, dated 6/14/25, indicated Resident 12 had a significant weight loss in the last 180 days. The resident had a 16.8% weight loss in 90 days and a 10% weight loss in 180 days. During an interview with the MDS Coordinator on 7/1/25 at 10:55 a.m., she confirmed the MDS assessment, dated 6/18/25, indicated no to weight loss for Resident 12, and it should have been marked yes. During an interview with the Administrator on 7/1/25 at 12:07 p.m., the Administrator indicated the facility did not have an MDS policy, they followed the RAI (Resident Assessment Instrument) manual for coding the MDS assessment. A review of the RAI manual on 7/1/25 at 12:30 p.m., indicated for section K0300, .Code 2, yes, not on physician-prescribed weight-loss regimen: if the resident has experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight loss was not planned and prescribed by a physician 2. On 6/30/25 at 10:23 a.m., Resident 152's clinical record was reviewed. The diagnoses included, but were not limited to, vascular dementia (a condition where damage to the brain's blood vessels impairs cognitive functions, leading to memory, thinking, and behavioral changes) and atherosclerotic heart disease (buildup of fats, cholesterol and other substances in and on the artery walls). A review of Quarterly MDS Assessment, dated 4/11/25, did not indicate depression as a diagnosis in section I5800, depression. A review of Resident 152's medication orders indicated, the resident was taking Sertraline (a medication used to treat mental health conditions) 100 milligrams daily. The medication was prescribed on 1/10/25 for a diagnosis of depression, and the resident had continued to take this medication. A review of Resident 152's care plan indicated, the resident used an anti-depressant medication for depression. The care plan was initiated on 1/14/25. During an interview with the MDS Coordinator on 7/1/25 at 10:55 a.m., she confirmed the MDS assessment, dated 4/11/25, indicated no active diagnosis of depression for Resident 152 and it should have been marked yes. During an interview with the Administrator on 7/1/25 at 12:07 p.m., the Administrator indicated the facility did not have an MDS policy, they followed the RAI manual for coding the MDS assessment. A review of the RAI manual on 7/1/25 at 12:30 p.m., indicated for section I5800: .In the absence of specific documentation that a disease is active, the following indicators may be used to confirm active disease .Ongoing therapy with medications or other interventions to manage a condition that requires monitoring for therapeutic efficacy or to monitor potentially severe side effects in the last 7 days. A medication indicates active disease if that medication is prescribed to manage an ongoing condition that requires monitoring . 3.1-31(d)

Based on observation, interview, and record review, the facility failed to ensure staff provided the services for a resident to maintain good personal hygiene (Resident 109) for 1 of 1 resident reviewed for Activities of Daily Living (ADLs). Finding includes: During an interview on 6/24/25 at 3:16 p.m., Resident 109's toenails were observed to be very long in length and thick in texture. He indicated they were bothering him and he needed them clipped by someone because he could not reach his feet. On 6/27/25 at 11:06 a.m., Resident 109's toenails were observed to be very long in length and thick in texture. On 6/25/25 at 10:02 a.m., Resident 109's clinical record was reviewed. The diagnoses included, but were not limited to, diabetes mellitus, morbid (severe) obesity, and osteoarthritis. The quarterly Minimum Data Set (MDS) assessment, dated 4/13/25, indicated the resident was cognitively intact. A 10/15/23 physician's order, indicated the resident was ordered podiatry consults as needed. The resident's clinical record lack documentation the resident had received podiatry services. During an interview on 7/1/25 at 9:45 a.m., LPN 1 indicated residents all get standard orders (for dental, podiatry, etc) when they are admitted . During an interview on 7/1/25 at 10:18 a.m., the 100 hall Unit Manager and the Social Services Director (SSD) indicated the resident was not on the list to be seen by podiatry. On 7/1/25 at 12:39 p.m., the Executive Director provided the facility policy, Resident Rights, ICF Policy, dated 5/1/22, and indicated it was the policy currently being used. A review of the policy indicated, .It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents . 3.1-38(a)(3)(E)

Based on observation, interview, and record review, the facility failed to ensure the care plan was revised for 1 of 4 residents reviewed for accidents. (Resident 92) Finding include: During an observation on 6/26/25 at 12:20 p.m., Resident 92 was observed to be ambulating with her walker. The walker was observed not to have bright colored tape on it. During an observation on 6/26/25 at 2:03 p.m., Resident 92 was observed to be ambulating with her walker. The walker was observed not to have bright colored tape on it. During an observation on 6/27/25 at 12:04 p.m., Resident 92 was observed to be resting in bed with the walker at bedside. The walker was observed not to have bright colored tape on it. During an observation on 6/30/25 at 10:13 a.m., Resident 92 was observed to be ambulating with her walker. The walker was observed not to have bright colored tape on it. During an observation on 6/30/25 at 12:38 p.m., Resident 92 was observed to be in the dining room with her walker. The walker was observed not to have the bright colored tape on it. On 6/26/25 at 2:28 p.m., the clinical record was reviewed. The diagnoses included, but were not limited to, left knee fracture, dementia, osteoporosis, and dementia. The care plan, dated 12/17/24, indicated Resident 92 was at risk for falls due to dementia and fracture. The intervention was to mark the walker with bright colored tape to help remind her to use it. During an interview on 7/1/25 at 10:30 a.m., the Director of Nursing (DON) indicated bright color tape would be on the front of the walker. Resident 92's walker did not have bright colored tape on the walker because therapy replaced it with a new walker. During an interview on 7/1/25 at 10:42 a.m., the DON indicated a new fall intervention was for a therapy evaluation. While she was in therapy, they gave her a new walker. The bright colored tape should of been discontinued from the care plan. On 7/1/25 at 12:05 p.m., the Administrator provided the facility policy, Plan of Care Review, undated and indicated it was the policy currently being used by the facility policy. A review of the the policy indicated, .iii. Review care plans quarterly and/or with significant changes in care . 3.1-35(d)(2)(B)

Based on observation, interview, and record review, the facility failed to ensure the resident's representative and physician were notified of significant weight loss for 2 of 7 residents reviewed for nutrition. (Resident 5, Resident 85) Findings include: 1. During an observation on 6/26/25 at 10:09 a.m., Resident 5 was observed to be eating a snack. During an observation on 6/26/25 at 12:37 p.m., Resident 5 was observed to be feeding herself a pureed diet. During an observation on 6/30/25 at 1:02 p.m., Resident 5 was observed to be feeding herself. On 6/26/25 at 11:05 a.m., Resident 5's clinical record was reviewed. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, and anemia. The Weights and Vitals Summary indicated the following: - On 5/6/25 at 4:05 p.m., Resident 5's weight was 111 pounds. - On 6/6/25 at 3:42 p.m., Resident 5's weight was 102 pounds. This was 8.11% weight loss in one month. The care plan, dated 1/29/25, indicated Resident 5 had altered nutritional status due to Alzheimer's disease and dementia. The intervention was to notify medical provider and resident's representative of unplanned weight changes. The progress notes indicated the following: - On 6/14/25 at 4:14 p.m., Registered Dietician indicated Resident 5 had a significant weight loss. Resident 5 had a weight change of 8.1% in 30 days and 10.5% in 180 days. Resident 5 triggered for a significant weight loss in 30 days and 180 days this month. (The progress note lacked documentation of the resident's representative notification.) -On 6/17/25 at 2:50 p.m., Resident 5's daughter was in for a visit and assisted Resident 5 with her breakfast. (The progress note lacked documentation of resident's representative notification.) During an interview on 6/30/25 at 11:14 a.m., the Director of Nursing (DON) indicated the resident's representative notification for weight loss would be in the dietary progress notes. During an interview on 6/30/25 at 12:55 p.m., the DON indicated the clinical record lacked documentation of resident's representative notification of Resident 5's significant weight loss. 2. On 6/26/25 at 12:34 p.m., Resident 85 was observed to be feeding herself a frozen nutritional supplement. On 6/30/25 at 12:37 p.m., Resident 85 was observed to be sitting in the dining room eating lunch. On 6/26/25 at 11:16 a.m., Resident 85's clinical record was reviewed. The diagnoses included, but were not limited to, were Alzheimer's disease, moderate protein-calorie malnutrition, and anemia. The Weights and Vitals Summary indicated the following: - On 1/8/25 at 11:43 a.m., Resident 85's weight was 174.6 pounds. - On 1/13/25 at 4:57 p.m., Resident 85's weight was 174.2 pounds. - On 1/28/25 at 4:19 p.m., Resident 85's weight was 174.6 pounds. - On 2/13/25 at 3:55 p.m., Resident 85's weight was 160.5 pounds. This was a 7.86% weight loss in one month. - On 3/3/25 at 1:09 p.m., Resident 85's weight was 164.6 pounds. The care plan, dated 12/9/24, indicated Resident 85 was at risk for altered nutritional status due to diagnoses of Alzheimer's disease, malnutrition, and anemia. The intervention was to notify medical provider and resident's representative of unplanned weight changes. The progress notes indicated the following: - On 2/16/25 at 9:10 p.m., Resident 85's weights were 161.2 pounds on 2/14/25, 174.2 pounds on 1/13/25, 182 pounds on 11/12/24, and 186 pounds on 8/14/24. Her weight change was 13.3% in 6 months and 7.5% in a month. (The progress notes lacked documentation of resident's representative or physician notification.) - On 3/6/25 at 1:00 p.m., Nurse Practitioner monthly note indicated Resident 85 was examined for monthly chronic disease and medication management. The note indicated Resident 85 had no significant weight change. Resident weight was 164.6 pounds. The clinical record lacked documentation of resident's representative or physician notification of the resident's significant weight loss. During an interview on 6/30/25 at 10:46 a.m., Registered Nurse (RN) 1 indicated Resident 85 had weight loss. During an interview on 6/30/25 at 11:14 a.m., the Director of Nursing (DON) indicated the resident's representative and physician notification for weight loss would be in the dietary progress notes. During an interview on 6/30/25 at 11:35 a.m., the DON indicated Resident 85 weight loss started in February 2025. The clinical record lacked documentation of resident's representative and physician notification of Resident 85's weight loss. On 7/1/25 at 12:05 p.m., the Administrator provided the facility policy, Notification of Change in Condition, undated and indicated it was the policy currently being used by the facility policy. A review of the the policy indicated, .When a change in condition is noted, the nursing staff will contact the resident representative .The medical practitioner is promptly notified of a significant changes in condition, and the medical record must reflect the notification, response, and interventions implemented to address the resident's condition . 3.1-5(a)(2)

Based on observation, interview, and record review, the facility failed to provide supervision to prevent a resident that resided on a secured memory care unit and was to be receiving one to one staff supervision for exit seeking behavior, from exiting the secured memory care unit through a window in another resident's room. The resident was found by staff approximately 2 miles from the facility. (Resident B) The Immediate Jeopardy began on April 27, 2025, when Resident B exited the secured memory care unit through another residents window. The Administrator, Regional Nurse, and Assistant Director of Nursing were notified of the Immediate Jeopardy on May 6, 2025 at 2:00 p.m. The Immediate Jeopardy was removed, and the deficient practice corrected, on 4/28/25, prior to the start of the survey and was therefore Past Noncompliance. Finding includes: On 5/6/25 at 8:32 a.m., observed Resident B's room. Just past the door and to the left was the restroom. CNA 1 was sitting in a chair just past the restroom. The privacy curtain was pulled around bed A (closest to the door). Resident B was lying in his bed sleeping. His bed was observed to be next to the window (bed B). At that time, CNA 1 indicated Resident B was on one-to-one staff supervision. Resident B was not in her line of site because she was trying to give him privacy due to behaviors. On 5/6/25 at 8:39 a.m., observed the Secured Memory Care Unit 1 secured courtyard area just outside the memory care dining room. The door to enter the secured courtyard was located in the dining room and was unlocked by typing in a code. The courtyard was surrounded by an approximately 6-foot privacy fence with a door that was also secured with a code to unlock. There was a wooden swing and a heavy wrought iron table in the middle of the courtyard. At that time, Activity Director 1 indicated it was her understanding that Resident B took the screws out of the window in a room next to the courtyard, then opened the window and climbed out to the courtyard. Once Resident B was in the courtyard, he used a chair to climb over the fence, so Activity Director 1 removed the furniture from the courtyard. During an interview on 5/6/25 at 9:30 a.m., the Assistant Director of Nursing (ADON) indicated Resident B was to be receiving one-to-one staff supervision at the time he climbed out the window and left the facility without staff knowledge. Resident B was to be receiving one-to-one staff supervision because he had requested to sign out for a leave of absence some time ago. Resident B was found by staff approximately 2 miles from the facility. The clinical record for Resident B was reviewed on 5/6/25 at 9:39 a.m. The diagnoses included, but were not limited to, dementia, alcohol abuse, and frontotemporal neurocognitive disorder. An Admission Evaluation, dated 12/6/24, indicated Resident B did not have a history of elopements. A Progress Note, dated 12/6/24 at 3:40 p.m., indicated Resident B was admitted to the secured memory care unit 1. Resident B was unhappy about being at the facility and wanted family to come get him. A care plan, dated 12/6/24, indicated Resident B was at risk for elopement related to frontotemporal lobe dementia. The interventions included, but were not limited to, complete a wandering evaluation upon admission, re-admission, quarterly, and as needed (dated 12/6/24) and provide diversionary activities as needed (dated 12/6/24). A care plan, dated 12/12/24, indicated Resident B required a secured unit related to elopement risk and poor cognition. The interventions included, but were not limited to, evaluate for the need of a secured unit (dated 12/12/24) and notify the medical provider and Resident B's representative of behavior changes (dated 12/12/24). A Quarterly Minimum Data Set (MDS) assessment, dated 2/20/25, indicated Resident B had no cognitive impairment. A progress note, dated 2/1/25 at 1:42 p.m., indicated Resident B got out of the building after he was told the door code by one of the other residents. Resident B wanted to leave with his parents after visiting, but his parents refused so he got out on his own. Resident B was accompanied by two staff members while outside the building. Staff tried to encourage him to come in the building. Resident B was finally persuaded to come back in the building after his parents had left, but he would not stop talking about how he intended to leave the building. A progress note, dated 2/8/25 at 10:30 a.m., indicated the writer received a phone call from a CNA who was with Resident B at a grocery store. The CNA reported that Resident B refused to sign the leave of absence book before going to the store. The CNA reported Resident B was unwilling to get back into the car with the CNA to return to the facility. The writer met the CNA and Resident B at the grocery store and Resident B stated he wanted a 2 liter of soda which was purchased. Resident B willingly got into writer's car and returned to facility without incident. Resident B remained his own responsible party and was educated on signing out for a leave of absence. Resident B was not receptive to education on the leave of absence process and was placed on one-to-one staff supervision to ensure that he was safe if attempting to leave the facility for a leave of absence. A Wander Observation Tool, dated 3/7/25 at 2:22 p.m., indicated Resident B was not accepting of the current living environment. Resident B's family/responsible party voiced concern that he might try to leave and had a history of elopement. Resident B was at risk for elopement. A Letter of Guardianship, dated 3/12/25, indicated Resident B was an incapacitated adults and granted guardianship to family members. A progress note, dated 4/27/25 at 3:00 p.m., indicated evening one-to-one staff reported to Secured Memory Care Unit 1 and Resident B was unable to be found. A window in another residents room was found to be open with the screen out and a screws securing the window were unscrewed and lying on the window seal. The window lead out to a secured courtyard. A chair was pushed up against the fence and appeared that Resident B had climbed over the fence. Facility initiated head count and found Resident B to be the only resident not to be in his room or in the facility. The police and staff returned to facility with Resident B. During an interview on 5/6/25 at 10:01 a.m., the Regional Nurse indicated the staff that was to be providing the one-to-one supervision had been told to perform other work duties for other residents due to call offs. On 5/6/25 at 10:10 a.m., the ADON provided a copy of a timeline of events when Resident B exited the facility through the window, on 4/27/25. A review of the timeline indicated: - At approximately 1:40 p.m., Resident B was seen at nurse's station. - At 2:20 p.m., the CNA arrived on the Secured Memory Care Unit 1 and could not locate Resident B. - A window in another resident's room was found to be open with the screen pushed out to the courtyard. - At 2:50 p.m., a staff member found Resident B approximately 2 miles from the facility at a fire station on a busy main road. Resident B refused to return to facility with staff. - At approximately 2:56 p.m., the ADON arrived at Resident B's location and Resident B refused to return with the ADON. - At approximately 3:00 p.m., a staff member contacted the police. - At approximately 3:08 p.m., police arrived at Resident B's location. - At approximately 3:10 p.m., the Director of Nursing (DON) arrived at Resident B's location. - At approximately 3:30 p.m., Resident B was returned to the facility by the police. During an interview on 5/6/25 at 1:03 p.m., CNA 2 indicated, on 4/27/25, she was scheduled to do one-to-one staff supervision with Resident B for day shift, but when she arrived to work she was asked to perform her normal work duties with other residents on the Secured Memory Care Unit 1. Resident B was not on one-to-one supervision, on 4/27/25 during day shift. CNA 2 left the facility before Resident B exited the facility through the window on evening shift. During an interview on 5/6/25 at 1:10 p.m., Qualified Medication Aide (QMA) 1 indicated Resident B normally displayed exit seeking behaviors. Resident B would case other resident's rooms and try to watch visitors type in the codes to unlock the doors. On 4/27/25 from 6:00 a.m. until 2:00 p.m., Resident B was to be receiving one-to-one staff supervision with CNA 2, but CNA 2 was asked to perform her normal work duties with other residents on the secured memory care unit. Resident B did not receive one-to-one staff supervision during the day shift. Resident B was upset because a lighter had been removed from his room. QMA 1 last saw Resident B standing at the nurse's station, on 4/27/25 at approximately 1:40 p.m. QMA 1 was unaware that Resident B exited the facility until approximately 2:20 p.m., when CNA 3 reported to QMA 1 that she could not locate Resident B. Resident B was located by staff and returned to the facility with the ADON. Resident B told staff he left the facility because it was too easy. Resident B exited the facility approximately 3 months ago, on a weekend, through the window in his own room. QMA 1 could not remember the details of that incident. On 5/6/25 at 1:43 p.m., observed Resident B's door to be shut and CNA 4 standing in the hallway. Resident B was sitting on his bed in his room with no staff present in the room. At that time, CNA 4 indicated Resident B should have been receiving one-to-one supervision. On 5/6/25 from 2:10 p.m. until 2:30 p.m., observed the likely path Resident B walked when he exited the facility and was found approximately 2 miles away. Resident B climbed out a window of another resident's room. The window lead to a secured courtyard with a privacy fence approximately 6 feet tall. Resident B placed a chair against the fence near the fence's door and climbed over the fence. Once over the fence there was a small sidewalk that lead around the facility and large grassy field surrounded by trees with a residential neighborhood just past the trees. Approximately 200 yards from the courtyard was a residential street with well-kept sidewalk on each side. Once in the residential neighborhood the roads were windy, and [NAME] like with speed limit of 25 miles per hour. After approximately 1.8 miles the road through the residential neighborhood met a busy main road with no sidewalk on the south side of the road and on the north side just past the road the land slopes down approximately 10 feet to an asphalt sidewalk. The sidewalk led to a driveway and then the fire station where Resident B was located. During an interview on 5/7/25 at 8:14 a.m., Resident B indicated he exited the facility through a window across the hall, climbed over the privacy fence in the courtyard, walked toward the woods at the back of the facility, and through the neighborhood to where the staff located him. Resident B did not remember removing any screws from the window. Resident B also remembered walking alone to a grocery store a few months ago. Resident B was able to open the memory care door by entering the code into the secured unit exit door and then he pushed on the service door and walked out. The service door was (Resident B accurately pointed in the direction of the service door) that way. Then he walked through the parking lot and down the street to the grocery store. During an interview on 5/7/25 at 9:40 a.m., CNA 4 indicated when she came to work, on 4/27/25 at approximately 2:00 p.m., she was not made aware that the staff for the day shift one-to-one supervision was asked to do general work duties with the other residents. CNA 4 was not aware there was no staff with Resident B. When CNA 3 came to the unit, she said she couldn't locate Resident B, and staff started looking for him. Resident B had been on one-to-one supervision for a couple months after he exited the facility through the window in his room and walked to the grocery store approximately 1.0 miles from the facility. CNA 4 was not at work when Resident B exited through the window in his room, but she received the information in report when she came in to work the day that happened. On 5/6/25 at 9:30 a.m., the Administrator provided a copy of an undated facility policy, titled Elopement Prevention and Management Overview, and indicated this was the current policy used by the facility. A review of the policy indicated an elopement is when a resident leaves the premises or a safe area without authorization or necessary supervision. The past noncompliance Immediate Jeopardy began on 4/27/25. The Immediate Jeopardy was removed and the deficient practice corrected by 4/28/25 after the facility implemented a systemic plan that included the following actions: audits of elopement evaluations and care plans, inservicing staff on elopement procedures and one-to-one staff supervision, and ongoing monitoring. This citation relates to Complaint IN00458484. 3.1-45(a)(2)

Based on interview and record review, the facility failed to protect the resident's rights to be free from physical abuse by a staff member for 1 of 3 residents reviewed for abuse. A staff member held down the residents arms to provide care. (Resident B, CNA 1) Finding includes: During an interview on 2/7/25 at 10:30 a.m., the Administrator (ADM) indicated CNA 1 was recently terminated for physically holding down Resident B's wrists/arms during resident care. She indicated Resident B had become combative during care and the CNA held down Resident B's limbs to prevent an injury to herself. On 2/7/25 at 10:45 a.m., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, and anxiety disorder. The Quarterly Minimum Data Set assessment, dated 12/26/24, indicated Resident B had severe cognitive impairment. A progress note, dated 1/23/25 at 12:00 p.m., indicated the resident was receiving care and the hospice aid became concerned with the CNA's technique. During an interview on 2/7/25 at 12:00 p.m., CNA 1 indicated the hospice aide called her into the Resident B's room to help with care because the resident was combative. When CNA 1 arrived to the room, the resident was swinging her arms around and biting at her and the hospice aide. CNA 1 indicated she grabbed the resident by the arm/wrist area, and held her arms down to the her chest. She further indicated she probably used poor judgement by holding down the resident's upper limbs. During an interview on 2/7/25 at 2:02 p.m., Hospice Aide 1 indicated she was dressing the resident after a bath and she began to kick and hit her. Hospice Aide 1 asked CNA 1 for help because the resident was not fully clothed. When CNA 1 entered the room, CNA 1 grabbed the resident by the arms/wrists and forcibly held down the resident's limbs. She further indicated the CNA told the resident, this is why we get bruises, as the she used her weight to hold down the resident's arms. On 2/7/25 at 2:26 p.m., the ADM provided a copy of the facility's policy, INDIANA Abuse & Neglect & Misappropriation of Property, undated, and indicated it was the policy currently being used. A review of the policy indicated, . Definitions . Physical Abuse . Examples . improper use of restraints. Policy: It is the policy of this facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents . This deficient practice was corrected on 1/25/25 after the facility implemented a systemic plan of correction that included the following actions: all staff was educated on the abuse, neglect, handling difficult behaviors, and restraint policies, with ongoing monitoring and audits. This citation relates to Complaint IN00451897. 3.1-27(a)(1)

Based on record review and interview, the facility failed to ensure the written notification required for a transfer and discharge was provided to the resident and/or the resident representative for 4 of 4 residents reviewed for hospitalization and discharge. (Resident 96, Resident 148, Resident 145, and Resident 160) Findings include: 1. On 8/9/24 at 1:00 p.m., Resident 96's clinical record was reviewed. The diagnoses included, but were not limited to, opioid dependence and acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). Residents 96's transfer forms indicated the resident was sent to the hospital on 5/12/24 and 6/23/24. The clinical record lacked documentation of written Notice of Transfer and Discharge forms having been provided to the resident and/or the resident representative. 2. On 8/12/24 at 2:27 p.m., Resident 148's clinical record was reviewed. The diagnoses included, but were not limited to, asthma, tracheostomy (procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck), dependence on respirator/ventilator (a machine that helps you breathe or breathes for you), acute and chronic respiratory failure with hypoxia, and gastrostomy (creation of an artificial external opening into the stomach for nutritional support) status. Residents 148's transfer form indicated the resident was sent to the hospital on 5/30/24. The clinical record lacked documentation of written Notice of Transfer and Discharge forms having been provided to the resident and/or the resident representative. 38312 3. On 8/12/24 at 11:17 a.m., Resident 145's clinical record was reviewed. The diagnoses included, but were not limited to, pressure ulcer and osteomyelitis (bone infection). A Progress Note, dated 7/30/24 at 4:33 p.m., indicated Resident 145 was transferred to the hospital for worsening of a wound. The clinical record lacked documentation of written Notice of Transfer and Discharge forms having been provided to the resident. During an interview on 8/12/24 at 3:55 p.m., the Director of Nursing (DON) indicated they did not have a written notification of the Transfer and Discharge forms provided to the resident. 35318 4. Resident 160's clinical record was reviewed on 8/12/24 at 3:02 p.m. The diagnosis included, but was not limited to, encephalopathy. Resident 160's progress notes indicated the resident was sent to the hospital on 6/5/24 and 7/17/24. The clinical record lacked documentation of written Notice of Transfer and Discharge forms having been provided to the resident and the resident's representative. During an interview on 8/12/24 at 11:50 a.m., the DON indicated there had been no documentation of the Notice of Transfer or Discharge forms having been provided to the resident and/or the resident representative for Resident 96, Resident 148, Resident 145, and Resident 160. On 8/12/24 at 4:00 p.m., the Director of Nursing provided the facility's policy,Transfer and Discharge Policy undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . 4. A letter containing admission/discharge/transfer and appeal rights will be discussed with the resident or responsible party and will be mailed to them as soon as practical . 3.1-12(a)(6)(A)(i) 3.1-12(a)(6)(A)(iii)

Based on interview and record review, the facility failed to ensure the notification of the bed-hold policy required for a resident who transferred to the hospital was provided in writing to the resident or the resident representative for 4 of 4 residents reviewed for hospitalization and discharge. (Resident 96, Resident 148, Resident 145, and Resident 160) Findings include: 1. On 8/9/24 at 1:00 p.m., Resident 96's clinical record was reviewed. The diagnoses included, but were not limited to, opioid dependence and acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). Residents 96's transfer forms, indicated the resident was sent to the hospital on 5/12/24 and 6/23/24. The clinical record lacked documentation of written notification of the bed-hold policy having been provided to the resident or the resident representative. 2. On 8/12/24 at 2:27 p.m., Resident 148's clinical record was reviewed. The diagnoses included, but were not limited to, asthma, tracheostomy (procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck), dependence on respirator/ventilator (a machine that helps you breathe or breathes for you), acute and chronic respiratory failure with hypoxia, and gastrostomy (creation of an artificial external opening into the stomach for nutritional support). Residents 148's transfer form, indicated the resident was sent to the hospital on 5/30/24. The clinical record lacked documentation of written notification of the bed-hold policy having been provided to the resident or the resident representative. 38312 3. On 8/12/24 at 11:17 a.m., Resident 145's clinical record was reviewed. The diagnoses included, but were not limited to, pressure ulcer and osteomyelitis (bone infection). A Progress Note dated, 7/30/24 at 4:33 p.m., indicated Resident 145 was transferred to the hospital for worsening of wound. The clinical record lacked documentation of written notification of the bed-hold policy having been provided to the resident. During an interview on 8/12/24 at 3:55 p.m., the Director of Nursing (DON) indicated they did not send the bed hold policy with the resident when they went to the hospital. 35318 4. Resident 160's clinical record was reviewed on 8/12/24 at 3:02 p.m. The diagnosis included, but was not limited to, encephalopathy. Resident 160's progress notes indicated the resident was sent to the hospital on 6/5/24 and 7/17/24. The clinical record lacked documentation of written notification which specified the facility's bed-hold policy having been provided to the resident or the resident's representative. During an interview on 8/12/24 11:50 a.m., the DON indicated there was no documentation of the bed-hold policy having been provided to the resident or the resident representative for Resident 96, Resident 148, Resident 145, and Resident 160. On 8/12/24 at 4:14 p.m., the Director of Nursing provided the facility's policy,Bed Hold Policy undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . b. If applicable according to state law if the bed hold authorization form cannot be signed prior to the resident leaving and needs to be mailed, it must be mailed certified return receipt . e. The business office manager or designee will follow all state specific guidelines upon resident return regarding notifying resident or responsible part of amount of bed hold days used and left . 3.1-12(a)(25) 3.1-12(a)(26)

Based on observation, interview, and record review, the facility failed to ensure residents were provided an adequately lit, homelike environment for 1 of 7 units reviewed for environmental concerns. (Unit G) On the following dates and times the main hallway of the secured Unit G was observed to have dim, flickering overhead fluorescent lights, and dark colored walls void of homelike decor or adornment: - On 8/6/24 at 12:35 p.m. - On 8/6/24 at 2:40 p.m. - On 8/7/24 at 10:40 a.m. - On 8/7/24 at 12:50 p.m. - On 8/7/24 at 3:05 p.m. - On 8/8/24 at 9:28 a.m. - On 8/8/24 at 2:26 p.m. - On 8/9/24 at 12:27 p.m. - On 8/9/24 at 3:10 p.m. - On 8/12/24 at 9:45 a.m. - On 8/12/24 at 12:05 p.m. Confidential interviews were conducted during the course of the survey from 8/6/24 through 8/12/24. These interviews indicated the secured Unit G was consistently dimly lit with flickering overhead fluorescent lights. The hallway walls were dark and lacked decor indicative of a homelike environment. During an interview on 8/12/24 at 12:15 p.m., the Administrator indicated the main hallway of the secured Unit G was dimly lit, with flickering overhead fluorescent lights, and the walls were dark and lacking homelike decor or adornment. On 8/12/24 at 10:20 a.m., the Assistant Director of Nursing provided the Residents Rights and Facility Responsibilities, undated, and indicated these were the resident rights currently used by the facility. A review of the Resident Rights and Facility Responsibilities indicated, .the resident has a right to a safe, clean, comfortable and homelike environment .adequate and comfortable lighting levels in all areas . 3.1-19(f)

Based on observation, interview, and record review, the facility failed to ensure a resident could self-administer medication for 1 of 1 randomly observed resident (Resident 38). Finding include: On 8/7/24 at 2:41 p.m., Resident 38 was observed to be resting in her bed. A bottle of Tums (antacid) was observed to be on her bedside table. On 8/8/24 at 11:15 a.m., Resident 38 was observed to be resting in her bed. A bottle of Tums was observed to be on her bedside table. On 8/12/24 at 10:58 a.m., Resident 38 was observed to be resting in bed with a bottle of Tums lying in bed beside her. On 8/12/24 at 11:37 a.m., Resident 38's clinical record was reviewed. The diagnoses included, but were not limited to, end stage renal disease (ESRD) and gastro-esophageal reflux disease (GERD). The Self Administration of Medication Assessment, dated 10/14/22 at 12:20 p.m., indicated Resident 38 could administer Halls throat lozenges. The Order Summary Report, dated 8/12/24, lacked a physician order for Tums or to self-administer medication. The care plan lacked a care plan to self-administer medication. During an interview on 8/12/24 at 11:46 a.m., LPN 1 indicated if a resident wanted to self-administer medication at bedside, a self-administer medication assessment would need to be completed. During an interview on 8/12/24 at 4:00 p.m., the Director of Nursing (DON) indicated Resident 38's clinical record lacked a recent self-administer medication assessment. She would need one to administer medication at bedside. On 8/12/24 at 4:15 p.m., the DON provided the facility's policy, Resident Self-Administration of Medications, undated, and indicated it was the policy being used by the facility. A review of the policy indicated, .a. Resident may not self-administer medications until the assessment is completed by the IDT [interdisciplinary team] team and determined to be safe to do so . 3.1-11(a)

Based on interview and record review, the facility failed to ensure accurate reconciliation and accounting for narcotics (controlled medications) were performed for 2 of 3 shifts reviewed. (LPN 2, LPN 3, RN 4) Findings include: On 3/26/24 at 9:00 a.m., Resident D's clinical record was reviewed. Resident D's physician orders included, but were not limited to, oxycodone (narcotic/controlled pain medication) 5 mg (milligrams) every 8 hours as needed for pain, started on 2/22/24 and discontinued on 2/23/24. The February Medication Administration Record (MAR) indicated Resident D had not received any oxycodone pain medication during the month of February. During an interview on 3/26/24 at 10:05 a.m., the Assistant Director of Nursing Services (ADNS) indicated the facility Controlled Drug Administration Record reflected no oxycodone were administered to Resident D. Additionally, the 30 oxycodone tablets were missing from the narcotic box. The number of tablets in the lock box and paper document should have matched. During an interview on 3/26/24 at 10:20 a.m., the ADNS indicated the following: - On 2/25/24 Licensed Practical Nurse (LPN) 2 worked the 6:00 a.m. to 2:00 p.m. shift on the 200 hall. At the end of the shift, LPN 2 and Registered Nurse (RN) 4 were notified that the next shift staff member, LPN 3 would be late reporting to work. - RN 4 advised LPN 2 to complete a fast narcotic count [not a detailed count] and then give the medication cart keys to RN 4. RN 4 would then give the medication cart keys to LPN 3 upon her arrival. LPN 2 conducted the narcotic count and indicated all 30 oxycodone tablets were in the narcotic lock box which was located inside the medication cart. - On 2/25/24 at 3:45 p.m., LPN 3 arrived at the facility and began her work duties on the 200 hall. LPN 3 failed to conduct a narcotic count upon her arrival at the facility. LPN 3 worked until 6:00 a.m. on 2/26/24. LPN 3 had not given any oxycodone tablets to Resident D during LPN 3's shift. - On 2/26/24 at 6:00 a.m., LPN 3 and LPN 5 conducted the narcotic count. At that time, it was discovered 30 oxycodone tablets were missing from the narcotic lock box. LPN 3 notified management of the missing narcotics. - The facility conducted an investigation of the missing 30 oxycodone tablets. The facility was unable to determine what happened to the missing narcotic tablets. LPN 2 and LPN 3 failed to follow the narcotic count procedures. Two nurses were to reconcile all narcotics in the lock boxes with the paper record document at the start and end of each shift as indicated by facility policy. During an interview on 3/26/24 at 11:20 a.m., LPN 2 indicated the following: - On 2/25/24, she was assigned the 200 hall and had worked the 6:00 a.m. to 2:00 p.m. shift. - At the beginning of the shift, she completed the narcotic count by herself as no other staff were available to witness the narcotic count. - LPN 2 indicated Resident D had not complained of pain and no pain medication was given during the shift. - At the end of the shift, RN 4 notified LPN 2 that her relief staff person LPN 3 would be late. - RN 4 directed LPN 2 to complete a fast narcotic count [not a detailed count] and to give the medication cart keys to RN 4. - LPN 2 indicated RN 4 was sitting at the nurses station and was about 6 feet away from the medication cart while LPN 2 conducted the narcotic count. RN 4 did not have a direct line of vision of the narcotic box while LPN 2 conducted the narcotic count. - LPN 2 indicated there were 30 oxycodone tablets observed in the narcotic box. On 3/26/24 at 1:22 p.m., the Administrator provided a copy of the Pharmacy Delivery Manifest. A review of the document indicated on 2/24/24 at 5:53 a.m., the pharmacy delivered 30 tablets of oxycodone 5 mg for Resident D. The document was signed by Qualified Medication Aide (QMA) 7 as receiving the medication. During an interview on 3/26/24 at 2:25 p.m., RN 6 indicated two staff members were to conduct and reconcile the narcotic counts at the start and end of each shift. On 3/27/24 at 11:10 a.m., the ADNS provided the February 2024 Controlled Drug Administration Record (document used to track and monitor controlled medications including, but not limited to, oxycodone). A review of the document indicated, on 2/24/24 the pharmacy delivered 30 tablets of oxycodone 5 mg for Resident D. QMA 7 signed the document indicating the receipt of the 30 tablets. The document indicated no oxycodone tablets were administered to Resident D during the month of February. On 3/27/24 at 8:50 a.m. the Administrator provided an undated copy of the Controlled Substance Storage policy and indicated it was the current policy in use by the facility. A review of the policy indicated, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal ands recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations .medications subject to abuse or diversion are stored in a permanently affixed, double locked compartment .controlled substance accountability record is prepared by the pharmacy/facility .at each shift change, or when keys are transferred, a physical inventory of all controlled substances .is conducted by two licensed personnel and is documented . This Federal tag relates to Compliant IN00429421. 3.1-25(e)(3)

Based on interview and record review, the facility failed to ensure a care plan was in place for a resident who was diagnosed with a urinary tract infection for 2 of 2 residents reviewed for urinary tract infections. (Resident 34, Resident 151) Findings include: 1. Resident 34's clinical record was reviewed on 6/30/23 at 11:00 a.m. The diagnosis included, but was not limited to, adult failure to thrive. Current physician orders, dated June 2023, indicated Resident 34 was taking amoxicillin-pot clavulanate (an antibiotic) tablet 875-125 milligrams 1 tablet by mouth every 12 hours for Extended Spectrum Beta-Lactamase (ESBL) in the urine. The start date was 6/23/23. The Infection Surveillance Criteria Report, dated 6/29/23, indicated Resident 34 was diagnosed with a urinary tract infection (UTI). A lab report, dated 6/22/23, indicated Resident 34 had greater than 100,000 escherichia coli ESBL which indicated the resident had a UTI. A review of the care plans on 6/30/23 at 12:00 p.m., for Resident 34 lacked documentation of a current care plan for a urinary tract infection. 38312 2. During an observation on 6/28/23 at 2:32 p.m., Resident 151 was observed to be resting in his bed with a urinary catheter drainage bag hanging from the bed frame. During an observation on 6/30/23 at 10:13 a.m., Resident 151 was observed to be resting in his bed with a urinary catheter drainage bag hanging from the bed frame. On 6/29/23 at 10:09 a.m., Resident 151's clinical record was reviewed. The diagnoses included, but were not limited to, cerebral infarction (stroke), respiratory failure, and neuromuscular dysfunction (lacks bladder control) of the bladder. The Physician orders, dated June 6/30/23, indicated Resident 151 was ordered Bactrim DS (antibiotic) 800-160 milligrams (mg) twice a day for 7 days for urinary tract infection (UTI) (start date 6/26/23). The Infection Surveillance Criteria, dated 6/27/23, indicated Resident 151 had a UTI with an indwelling catheter. Resident 151's care plan lacked a care plan for UTI. During an interview on 6/29/23 at 11:27 a.m., Licensed Practical Nurse (LPN) indicated Resident 151 had an UTI. During an interview on 6/30/23 at 2:25 p.m., the Director of Nursing (DON) indicated when a resident had a UTI, there should be a UTI care plan. The care plans lacked a UTI care plan. On 6/30/23 at 3:30 p.m., the Executive Director provided the facility policy, Plan of Care Overview, undated and indicated this was the policy currently being used by the facility. A review of the policy indicated It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents . 3.1-35(a)

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected resident status for 3 of 3 residents reviewed for accuracy of assessments. Level 2 PASRR (Preadmission Screening and Resident Review) and discharge status were coded incorrectly. (Resident 25, Resident 38, Resident 166) Findings include: 1. On 6/30/23 at 11:40 a.m., Resident 25's clinical record was reviewed. The diagnoses included, but were not limited to, bipolar disorder and major depressive disorder. The Level 2 PASRR, dated 7/19/21 indicated, You meet PASRR criteria based on your diagnoses, current symptoms, and treatment needs including recent medication management. The Annual MDS assessment, dated 9/23/22, indicated, Has the resident been evaluated by level 2 PASRR and determined to have a serious mental illness and/or mental retardation or related condition .no. 2. On 6/30/23 at 11:50 a.m., Resident 38's clinical record was reviewed. The diagnoses included, but were not limited to, schizoaffective disorders and dementia. The Level 2 PASRR, dated 10/26/21 indicated, You meet PASRR criteria based on your diagnosis of Schizoaffective, psychotic/delusional disorder current and past symptoms and need for mental health treatment to manage symptoms. The Annual MDS assessment, dated 10/22/22, indicated, Has the resident been evaluated by level 2 PASSR and determined to have a serious mental illness and/or mental retardation or related condition .no. During an interview on 6/30/23 at 3:50 p.m., the MDS Coordinator indicated the MDS assessments for Resident 38 and Resident 25 were coded incorrectly. 34848 3. On 6/30/23 at 2:40 p.m., Resident 166's clinical record was reviewed. The diagnoses included but were not limited to, anemia, cardiomyopathy, and rhabdomyolysis. A Discharge MDS assessment, dated 5/3/23, indicated the resident was discharged to an acute hospital. A review of the resident's progress notes indicated the following: - On 4/27/23 at 2:55 p.m., she would be discharged from the facility to a motel. - On 5/3/23 at 3:34 p.m., she was discharged from the facility with all of her belongings. During an interview on 6/30/23 at 3:50 p.m., the MDS Coordinator indicated the resident's MDS assessment was coded inaccurately as she was discharged to the motel. 3.1-31(d)

Based on observation, interview, and record review, the facility failed to ensure medications were not left at bedside without a self medication administration assessment for 1 of 1 random observations.(Resident 79) Finding includes: During an interview on 6/27/23 at 11:30 a.m., with Resident 79, a medicine cup full of pills was observed to be sitting on the bedside table. The resident indicated the nurse dropped them off that morning and had not left any water nor had she split the potassium in half as required by the resident to swallow the pill. During an interview on 6/27/23 at 11:45 a.m., Licensed Practical Nurse (LPN) 1 indicated she should have stayed with Resident 79 to watch her take the morning medications. LPN 1 indicated Resident 79 was not assessed to self administer medications. Resident 79's clinical record was reviewed on 6/27/23 at 11:50 a.m. The diagnoses included, but were not limited to, Multiple Sclerosis (MS) and peripheral vascular disease. Current physician orders, dated June, 2023, indicated Resident 79's medications included, but were not limited to: - Abilify (for depression) 5 milligrams (mg) 1 tablet in the morning. - Ascorbic acid (for wound healing) 500 mg 1 tablet in the morning. - Bupropion (for depression) 150 mg 1 tablet in the morning. - Cymbalta (for depression) 30 mg 1 capsule in the morning. - Cymbalta 60 mg 1 capsule in the morning. - Lasix (for swelling) 40 mg 1 tablet in the morning. - Linzess (for constipation) 72 micrograms (mcg) 1 capsule in the morning. - Multivitamin give 1 table in the morning. - Oxybutynin chloride (for bladder spasms) 5 mg 1 tablet in the morning. - Potassium chloride (for swelling) 20 milliequivalent (meq) 1 tablet in the morning. - Vitamin D3 give 2000 units in the morning. - Zinc sulfate oral capsule give 1 capsule in the morning. - Zyrtec (for allergies) 10 mg 1 tablet in the morning. - Cephalexin (for urinary tract infection) 250 mg 1 capsule in the morning. - Ferrex (iron) 150 capsule two times a day. - Senna-time (for constipation) 8.6-50 mg give 2 tablets by mouth two times a day. - Baclofen (for MS) 10 mg give 1 tablet three times a day. - Lyrica (for pain) 75 mg give 1 capsule three times a day. A review of the Medication Administration Record on 6/28/23 at 11:00 a.m., for Resident 79 indicated the above medications were administered as ordered on 6/27/23. During an interview on 6/27/23 at 12:18 a.m., the Infection Control Nurse indicated LPN 1 should have stayed to observe Resident 79 take her medications. On 6/30/23 at 3:35 p.m., the Executive Director provided the facility's policy, Medication Administration undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . bb. Remain with resident until the medication is swallowed . cc. Do not leave medication at bedside . 3.1-11(a)

Based on interview and record review, the facility failed to ensure resident grievances were acted upon and promptly resolved for residents who had food complaints for 8 of 8 residents reviewed for food. (Resident 8, Resident 67, Resident 31, Resident 139, Resident 76, Resident 108, Resident 166, and Resident 98). Findings include: The following interviews were conducted during the survey. -On 5/17/22 at 3:03 p.m., Resident 8 indicated the food was terrible. -On 5/19/22 at 10:42 a.m., Resident 67 indicated the food was terrible. The food was tough and overcooked. -On 5/17/22 at 2:00 p.m., Resident 31 indicated the food sucks and just does not taste good. -On 5/18/22 at 3:33 p.m., Resident 139 indicated the food was terrible. They served too much of the same things like broccoli and spinach. -On 5/18/22 11:26 a.m., Resident 76 indicated the food was not the best. -On 5/17/22 at 11:19 a.m., Resident 108 indicated the food does not taste good. -On 5/17/22 at 2:39 p.m., Resident 166 indicated the food was terrible. -On 5/17/22 at 12:10 p.m., Resident 98 indicated the food was terrible. On 5/23/22 at 3:00 p.m., the Dietary Manager provided copies of the Food Council Notes. The forms indicated the following: -On 3/18/22, the Food Council indicated the grilled cheese was soggy and was not toasted; a resident was given the wrong soup when ordered or was not given soup at all; chicken tenders were not given when ordered; the food was too salty; and too much pasta was on the menu. -On 4/15/22, the Food Council indicated the pancakes were hard; biscuits were hard; and breakfast was soupy. The Food Council Notes lacked documentation of the Dietary Manager's corrective action to the food council's concerns. During an interview on 5/24/22 at 11:36 a.m., the Dietary Manager indicated the food council meeting note's lacked documentation of corrective actions or follow-ups. On 5/24/22 at 1:10 p.m., the Director of Nurses provided the facility's policy, Resident Grievance Indiana, dated of 6/19/18, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .If corrective action was or will be taken, a summary of the corrective action. If corrective action will not be taken, then an explanation of why such action is not necessary . 3.1-7(a)(2)

Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment for 10 of 25 rooms and 2 of 5 units reviewed for environment. Ceiling vents were dirty, ceiling tiles were stained, light covers were missing, outlet covers were missing, walls were in disrepair, equipment was dirty and broken, urine odors were present. (Reflections Unit 1 Hallway, Resident 39, Reflections Unit 2, Room 217, Room 125, Room 131, Room 232, Room 326, Room 136, Room 113, Room 107, Room 216) Findings include: 1. On 5/16/22 at 11:20 A.M., the first 2 ceiling vents in the Reflections 1 Unit hallway were observed to have a black powder-like substance on the grills. On 5/18/22 at 2:30 P.M., the same was observed. On 5/24/22 at 2:00 P.M., the same was observed. 2. On 5/16/22 at 11:20 A.M., the ceiling tile around the second ceiling vent in the Reflections 1 Unit hallway was observed to be stained with a brown and black substance, indicative of water damage. On 5/18/22 at 2:30 P.M., the same was observed. On 5/24/22 at 2:00 P.M., the same was observed. 3. On 5/16/22 at 11:20 A.M., a fluorescent ceiling light in Reflections 1 unit hallway was observed to be missing a light covering. On 5/18/22 at 2:30 P.M., the same was observed. On 5/24/22 at 2:00 P.M., the same was observed. 4. On 5/17/22 at 10:45 A.M., the wall to the left of the entryway to the room of Room 125 was observed to have multiple dime size holes. 5. On 5/18/22 at 11:25 A.M., the electrical outlet next to the bed in Room 131 was observed to have a missing outlet cover. The walls next to and behind the bed were observed to be stained with light brown stains in a pattern indicative of dripping water. On 5/20/22 at 2:00 P.M., the walls next to and behind the bed were observed to be stained with light brown stains in a pattern indicative of dripping water. On 5/23/22 at 3:05 P.M., the walls next to and behind the bed were observed to be stained with light brown stains in a pattern indicative of dripping water. 6. On 5/18/22 at 11:30 A.M., the walls next to and behind the bed in Room 217 were observed to be stained with light brown stains in a pattern indicative of dripping. The feeding tube pole next to the bed was observed to be stained with a dry, brown substance. On 5/20/22 at 2:01 P.M., the same was observed. On 5/23/22 at 3:06 P.M., the same was observed. 7. On 5/17/22 at 2:02 P.M., Resident 39's broda chair and wedge pillow were observed to be dirty with a dried brown substance. On 5/19/22 at 11:11 A.M., the same was observed. On 5/24/22 at 2:30 P.M., the same was observed. 8. On 5/18/22 at 11:19 A.M., Room 232 was observed with scuff marks and stains on the walls, the closet door and drawers would not close, and the light in the bathroom was not working. 9. On 5/18/22 at 11:41 A.M., Room 326 privacy curtains were observed to be dirty with a dried dark red substance, the closet door was off the track, and the walls had scuff marks. 10. On 5/19/22 at 11:03 A.M., Room 136 was observed to have paint scuffs on the walls, the racks were broken in the closet, and the closet door was off the track. 11. On 5/19/22 at 11:07 A.M., Room 113 was observed with scuff marks on the walls and closet door and the trim was off the bottom of the wall. 12. On 5/19/22 at 11:15 A.M., the feeding pump in Room 107 was observed to be dirty with dried formula on the machine and pole, the walls had scuff marks, and there was a hole in the wall above the outlet next to the air conditioning unit. On 5/20/22 at 3:06 P.M., the feeding pump in Room 107 was observed to dirty with dried formula on the machine and pole. On 5/23/22 at 11:28 A.M., the feeding pump in Room 107 was observed to dirty with dried formula on the machine and pole. On 5/24/22 at 1:32 P.M., the feeding pump in Room 107 was observed to dirty with dried formula on the machine and pole. 13. On 5/19/22 at 11:26 A.M., Room 216 was observed to have scuff marks on the walls. 14. On 5/18/22 at 2:45 P.M., the following was observed on the Reflections 2 hall: a. A strong urine odor was noted immediately upon entrance to the unit. b. Blinds were Broken in the dining room. c. The paint was scuffed off of the floor board heating unit. d. The handrails on both sides of the hall were scuffed and discolored. e. Multiple bedroom thresholds were missing the lower doorjamb trim on both sides, approximately 5 inches above the floor. f. A broken ceiling fluorescent light cover in the dining room. g. Intake vents were covered in brown substance and lint, with one having a wash cloth shoved up between the vent and the ceiling in the dining room. During an interview on 5/24/22 at 3:00 P.M., the Maintenance Director indicated the damage, disrepair, uncleanliness, and foul odors were present and in need of repair and remedying. On 5/24/22 at 1:30 P.M., the Admissions Director provided the Resident Rights and Facility Responsibilities, dated 7/19/21, and indicated these were the Resident Rights and Facility Responsibilities currently used by the facility. A review of the policy indicated, .the resident has the right to a safe, clean, comfortable and homelike environment . 3.1-19(f)

Based on observation, interview, and record review, the facility failed to ensure resident room walls were free from damage, protruding nails and screws, and bathroom baseboard damage. (Resident B, Resident G, Resident H, Resident I, Resident E, and Resident F) Findings include: On 1/5/22 at 11:30 A.M., the wall next to Resident B's bed was observed to have cracks and exposed drywall mud beneath the window. On 1/5/22 at 11:35 A.M., the wall next to Resident G's bed was observed to have 5 holes in the wall where a bulletin board had been removed. On 1/5/22 at 11:40 A.M., the wall to the left of the entrance door of Resident H and Resident I's room was observed to have 3 nails and 2 screws in it with 1/2 inch of each of the nails and screws protruding from the wall. On 1/5/22 at 11:45 A.M., the wall to the left of the entrance door of Resident E and Resident F's room was observed to have 3 screws in it with 1/2 inch of each screw protruding from the wall. At the bottom corner of the wall, nearest the door, was 8 inches of exposed metal corner bead where drywall had broken off. The baseboard behind the toilet was observed to be falling away from the wall. During an interview, on 1/6/22 at 11:15 A.M., the facility Administrator indicated repairs were needed for each of the identified concerns in the rooms of Resident B, Resident G, Resident H, Resident I, Resident E, and Resident F. On 1/5/22 at 12:50 P.M., the facility Administrator provided the Resident Rights and Facility Responsibilities, undated, and indicated these were the Resident Rights and Facility Responsibilities currently used by the facility. A review of the Resident Rights and Facility Responsibilities indicated, .the resident has a right to a safe, clean, comfortable and homelike environment . This Federal tag relates to Complaint IN 359. 3.1-19(f)

Based on record review and interview, the facility failed to ensure medication was administered to the right resident which resulted in a four day acute care hospitalization to monitor a change in mental status for 1 of 3 residents reviewed for correct medication administration. (Resident B) Findings include: On 2/19/2020 at 9:27 a.m. Resident B's closed clinical record was reviewed. [DIAGNOSES REDACTED]. Resident B's cognitive assessment, dated 1/14/2020, indicated Resident B was mildly cognitively impaired. Nurses notes, dated 12/8/2019 at 8:58 p.m., indicated Resident B was accidentally given the wrong medication by QMA (Qualified Medication Aide) 1. QMA 1 advised LPN 1 and vital signs were monitored every hour for 24 hours, after medication administration. Vital signs being taken did not indicate any change, nor any change in Resident B's mental status (alert and oriented). The medications administered was [MEDICATION NAME] 60mg (opioid [MEDICATION NAME] medication) and [MEDICATION NAME] 25mg (neuropathic pain medication). Nursing 2014 drug handbook indicated [MEDICATION NAME] was an opioid [MEDICATION NAME] with potential central nervous system of hallucinations and agitation. [MEDICATION NAME] was an neuropathic pain medication with potential central nervous system reaction of dizziness and abnormal thinking. Nurses notes, dated 12/9/2019 at 1:48 p.m., indicated Resident B went out to an appointment with his daughter at the VA (Veteran's). The Resident's vital signs were within normal limits and the resident was easily aroused. Nurses notes, dated 12/13/2019 at 11:10 a.m. (returned the morning of the 5th day), indicated Resident B returned to the facility. VA records, dated 12/9/2019 to 12/13/2019, indicated resident was admitted to a medical floor for observation, due to change in cognitive status. VA discharge diagnosis, dated 12/13/2019 at 8:09 a.m., included, but was not limited to: acute [MEDICAL CONDITION], likely due to accidental ingestion of [MEDICATION NAME]. QMA 1, who administered the medication to Resident B, no longer worked at the facility, so an interview was not obtained. On 2/20/2020 at 2:50 p.m., interview with LPN 1 (charge nurse on the floor where the medication error occurred) indicated QMA 1 went to her and indicated he had given another resident's evening medications to Resident B. QMA 1 indicated he had set up Resident B's medication and proceeded to go into Resident B's room, however Resident B was in the bathroom. So QMA 1 brought the medication back to the cart. At that time, the other resident came up and asked for their medications and returned to their room. QMA 1 then set up the other resident's medications. The QMA then heard Resident B come out of his bathroom. QMA 1 picked up the other resident's medications, went into Resident B's room, and due to Resident B's tremors related to [MEDICAL CONDITION] assisted him with taking the medication. Right after Resident B swallowed the medications QMA 1 realized what had happened, he went directly to LPN 1, and reported he had given another resident's medications to Resident B. On 2/19/2020 at 10:30 a.m., the ADON (Assisted director of Nursing) provided Medication Administration, dated 05/29/2019, and indicated the policy was the one currently being used by the facility. A review of the policy indicated .observe the 'five rights' in giving each medication, . the 'right' resident, This Federal tag relates to Complaint IN 643. 3.1-48(c)(2)

Based on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status resulting in severe weight loss and abnormal labs over a six month time frame (Resident 116) and severe weight loss and abnormal labs over a 31 day period (Resident 84) for 2 of 3 residents reviewed for nutritional status. Findings include: 1.) On 4/3/18 at 10:36 a.m., Resident 116's clinical record was reviewed. [DIAGNOSES REDACTED]. Resident 116's current care plan, initiated on 7/31/17, indicated, (Resident Name) requires J (jejunostomy) tube feeding due to vent (ventilator) dependence, inability to consume food/fluid orally. Interventions included, but were not limited to, Administer formula by pump as ordered due to J-tube. Evaluate weight/weight changes . Monitor labs per physician's orders [REDACTED]. Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed . Resident 116's Medical Nutritional Therapy Review, dated 3/11/18, by the Registered Dietician (RD), did not indicate an assessment of the resident's protein or caloric needs. This information was blank on the assessment. A review of Resident 116's March, (YEAR) current physician's orders [REDACTED]. A review of Resident 116's Progress Notes indicated the following: On 8/18/17, a Health Status Note indicated, Patient remains on continuous feed [MEDICATION NAME] 1.5 @ (at) 65 mL/hour. On 11/20/17, a Dietary Progress Note indicated, Res (resident) . on ([MEDICATION NAME])1.5 kcal formula. Instructed to switch to [MEDICATION NAME] 1.2 at rate of 76 mL/hour . On 4/3/18 at 9:30 a.m., Resident 116 was observed lying in bed with a feeding pump infusing. A review of Resident 116's weights included but were not limited to the following: On 9/20/17 the resident weighed 217.2 pounds. On 10/9/17 the resident weighed 215 pounds. On 11/1/17 the resident weighed 213 pounds. On 12/1/17 the resident weighed 205.7 pounds. On 1/13/18 the resident weighed 195.5 pounds. On 2/22/18 the resident weighed 185 pounds. On 3/20/18 the resident weighed 178 pounds. This is an assessed 18.05%, weight loss in 6 months. A review of resident 116's labs included, but were not limited to the following: On 10/16/17: RBC (red blood cell) 2.76 (normal range 4.00-6.600), HGB (hemoglobin) 7.6 (normal range 14.0-18.0) *critical low, and HCT (hematocrit) 22.9 (normal range 42.0-54.0%). The 3 labs were low and the HGB was a critical low. On 10/25/17: [MEDICATION NAME] 2.6 (normal range 3.5-5.7) low. On 11/6/17: RBC 2.94 (normal range 4.00-6.60), HGB 8.1 (normal range 14.0-18.0), and HCT 25.1 (normal range 42.0-54.0%). The 3 labs were low. On 11/27/17: RBC 2.89 (normal range 4.00-6.60) low, HGB 7.8 (normal range 14.0-18.0) *critical low, HCT 24.4 (normal range 42.0-54.0%). The 3 labs were low and the HGB was a critical low. On 12/4/17: RBC 2.92 (normal range 4.00-6.60), HGB 7.9 (normal range 14.0-18.0) *critical low, HCT 24.7 (42.0-54.0). The 3 labs were low and HGB was a critical low. On 12/11/17: HGB 7.9 (normal range 14.0-18.0) critical low. On 12/26/17: [MEDICATION NAME] 2.9 (normal range 3.5-5.7) low. On 1/10/18: RBC 2.64 (normal range 4.00-6.60), HBG 7.4 (normal range 14.0-18.0) *critical low, HCT 22.4 (normal range 42.0-54.0%). The 3 labs were low and HBG was a critical low. On 1/24/18: RBC 2.65 (normal range 4.00-6.60), HGB 7.7 (normal range 14.0-18.0) *critical low, HCT 22.4 (normal range 42.0-54.0%). The 3 labs were low and HGB was a critical low. On 1/25/18: HGB 7.1 (normal range 14.0-18.0) critical low. On 2/28/18: RBC 2.65 (normal range 4.00-6.60), HGB 7.3 (normal range 14.0-18.0) *critical low, HCT 23.1 (normal range 42.0-54.0%). The 3 labs were low and HGB was a critical low. On 3/12/18: RBC 2.72 (normal range 4.00-6.60), HGB 7.5 (normal range 14.0-18.0) *critical low, HCT 22.9 (normal range 42.0-54.0%). The 3 labs were low and HGB was a critical low. A review of Resident 116's nursing notes indicated the resident was sent to the hospital on [DATE] and 12/26/17, and these were the times an [MEDICATION NAME] level was drawn. The notes lacked documentation staff followed up on the low [MEDICATION NAME] levels. Review of Resident 116's progress notes indicated the following: On 12/19/17, IDT (interdisciplinary team) met to review in NAR (nutritionally at risk) . Current weight is 209 which is stable. He is a daily weight . 1/31/18, WEIGHT WARNING: Value: 197 . MDS (Minimum Date Set): -5.7% change over 30 days . Resident triggered for wt (weight) loss from previous admission. Res (resident) receiving EN (enteral nutrition) to meet nutrition and hydration needs. Will cont (continue) to monitor for stable wts, tolerance of EN. 2/15/18, IDT (interdisciplinary team) met to review in NAR (nutritionally at risk) . Current weight 190 which is stable . No changes to nutritional P[NAME] (plan of care) at this time . 3/29/18, IDT (interdisciplinary team) met to review in NAR (nutritionally at risk) . Current weight is 178.4 and remains stable with previous weights . No further recommendations for changes in P[NAME] at this time. Will cont (continue) to monitor. The facility documented a weight change from 209 to 178, a 31 pound weight loss, a 14.83% weight loss in 3 and 1/2 months. This was documented as stable with no further recommendations or changes in the resident's nutritional plan of care. During an interview, on 4/6/18 at 11:59 a.m., the Registered Dietician indicated she did not see an [MEDICATION NAME] (gives your body the proteins it needs to keep growing and repairing tissue) lab drawn for Resident 116. The resident's formula was recently changed to the [MEDICATION NAME] due to the tube clogging. No changes were made to the resident's formula in regard to weigh loss or protein deficiency, because she was unaware of this information. On 4/6/18 at 1:30 p.m., the Director of Nursing provided the facility policy, Resident Weight, revised on 5/19/16, and indicated it was the policy currently being used. The policy indicated, (8) Reporting Weights a) Weight loss concerns will be discussed at the weekly clinical meetings. 2.) On 4/4/18 at 1:15 P.M., Resident 84 was observed in his room sitting in a chair with a bedside table beside him, upon which were empty food wrappers. The resident indicated he had his own snacks in his room, because he did not receive enough food throughout the day and evening for his needs. On 4/4/18 at 2:30 P.M., the clinical record of Resident 84 was reviewed. [DIAGNOSES REDACTED]. The 2/22/18, Minimum Data Set (MDS) assessment indicated the resident had a weight loss of 5% or more in the last month, a weight loss of 10% or more in the last 6 months, and was not on a physician prescribed weight loss regimen. physician's orders [REDACTED]. Physician orders [REDACTED]. The Dietary/Nutritional Assessment, dated 3/1/18, indicated a goal to maintain stable weights. The weight summary documentation indicated on 2/16/18 the resident weighed 307.5 pounds and on 4/2/18, weighed 245 pounds, which indicated a weight loss of 20.33% in 54 days. On 3/1/18, the resident weighed 254 pounds and on 4/1/18, the resident weighed 237 pounds, which indicated a severe weight loss of 6.69% in 31 days. A review of the resident's laboratory results indicated the following: On 2/16/18, [MEDICATION NAME] 3.2 grams per deciliter (normal 3.5 to 5.5), hemoglobin 7.7 grams per deciliter (normal range 35-180), and hematocrit 23.3% (normal range 42.0 to 54.0%). On 2/21/18, hemoglobin 7.3 grams per deciliter (normal range 14.0 to 18.0), hematocrit 21.8% (normal range 42.0 to 54.0%), and iron 28 micrograms per deciliter (normal range 35 to 180). On 3/23/18, hemoglobin 8.6 grams per deciliter (normal range 14.0 to 18.0), and hematocrit 26.4% (normal range 42.0 to 54.0%). Nursing progress note, dated 3/20/18, indicated no difficulty swallowing, consuming fluids, and a appetite good. There was no documentation of change in diet or change in the plan of care, in regard to the resident's identified weight loss and abnormal lab results During an interview, on 4/6/18 at 11:15 A.M., the Registered Dietician indicated the residents' weights were reviewed on a monthly basis, and the nutritional plan of care was revised as necessary. No documentation was provided to indicate the facility had acted upon the identified weight loss or low protein levels. 3.1-46(a)(1)

Based on observation, interview, and record review, the facility failed to ensure a cognitively impaired and independently mobile resident did not exit the facility which resulted in the resident having tipped over his wheelchair, hitting the ground, and sustaining a neck fracture for 1 of 3 residents reviewed for accidents. (Resident B) Findings include: Resident B's closed clinical record was reviewed on [DATE] at 1:00 p.m. [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment, dated [DATE], indicated Resident B's ambulation (walking) status was extensive assistance. The resident's BIMS (brief interview for mental status) was 3 out of 15 (severely cognitively impaired). Fall Risk Observation Tool, dated [DATE], indicated Resident B had fallen in the last 30 days due to impaired walking, difficulty rising from his chair, poor recall, and poor judgement. Interview, [DATE] at 3:00 p.m., the Director of Nursing indicated Resident B independently wandered, throughout the day, in his wheelchair. IDT (Interdisciplinary Team) notes, dated [DATE] at 11:20 a.m., indicated Resident B was found in the courtyard face down in the grass with his wheel chair turned over. Resident B noted to be taking shallow breaths, non-verbal, vital signs were within normal limits, and 911 was called immediately. Observation of the courtyard door, on [DATE] at 11:13 a.m., indicated the exit door into the courtyard was not visible from the nurses station. The door was locked when pushed. A sign on door the indicated supervised times for residents to be in courtyard. Interview with the E.D. (Executive director) and Social Service staff indicated there was a handicap press button to the left of the door. When the button was pressed the door to the courtyard opened. No audible sounds were heard when the door was opened. The courtyard consisted of wide concrete sidewalk paths leading to a patio area. The sidewalk paths had no railings on either side. Interview with the staff indicated Resident B wandered throughout the facility in his wheelchair. Interview, on [DATE] at 10:20 a.m., RN 1 indicated on [DATE] at approximately 3:30 p.m., a young man came up to the nurses desk and said they saw a resident on the ground. Observation by RN 1, of Resident B, indicated Resident B was noted to be on the ground with his wheelchair turned over. Vitals signs were within normal limits and Resident B made no verbal responses. Another resident indicated to RN 1, he had let Resident B outside into the courtyard and didn't know Resident B could not go outside. Review, on [DATE] at 10:40 a.m., of emergency room notes indicated a cat scan (CT) of the brain and spine had been done on [DATE] at 5:27 p.m. The test results indicated Resident B had a C1 (cervical/neck) fracture. There was a note of a previous ([DATE]) questionable fracture, involving C1 at that time, however appeared worse on the current study ([DATE]). Review of incident, dated [DATE], indicated Resident B was placed on hospital hospice care [DATE] and died 2 days later on [DATE]. This Federal tag relates to Complaint IN 690. 3XXX,[DATE](a)(1) 3XXX,[DATE](a)(2)

Based on record review and interview, the facility failed complete daily dressing changes following a surgical repair of an ankle, resulting in the need for antibiotics and cancellation of a surgery to further repair and restore the function of the ankle for 1 of 3 residents reviewed for wound care in a sample of 3. (Resident #A) Findings include: The record of Resident A was reviewed on 11/1/12 at 11:00 a.m. [DIAGNOSES REDACTED]. Resident A was admitted to the facility on [DATE]. An undated hospital "Discharge/Transfer Form," indicated Resident A had an Open Reduction Internal Fixation (ORIF) surgical procedure done to his left ankle on 9/18/12. It indicated "...Care Instructions...Daily Dressing changes cover incision with [MEDICATION NAME] soaked curity or [MEDICATION NAME] through window in cast (illegible) cover (with) gauze." This order had a line drawn through part of it and was written in 2 different appearing handwritings. A Hospital Discharge Summary, dated 9/21/12, indicated "...ORIF September 18, 2012, stage 1 surgery, still needing another surgery stage 2 in 2 weeks from now...Care Instruction: Daily dressing changes to left ankle/heel. Cover incision with [MEDICATION NAME] soaked Curity or [MEDICATION NAME] gauze that width...This patient will still need a second stage surgery for [REDACTED]. There was no documentation to indicate any dressing changes had been done on Resident A's left ankle surgical wound while he was at the facility. He was discharged from the facility on 10/2/12. During an interview with Unit Manager #1 on 11/1/12 at 1:40 p.m., she indicated wound care was not done at the facility for Resident A. During an interview with the Director of Nursing Services (DNS) on 11/1/12 at 1:45 p.m., she indicated the nurses assumed the part of the order about doing daily dressing changes, which had a single, slanted line going through it, was no longer applicable and the wound was just supposed to be kept covered with gauze. On 11/1/12 at 2:15 p.m., the DNS was observed talking on the telephone with the Physician's Assistant to the surgeon who performed the ORIF on Resident A's left ankle. She indicated, when the conversation was over, "They wanted daily dressing changes." During an interview on 11/1/12 at 4:00 p.m., with the Physician's Assistant to the surgeon who performed the ORIF on Resident A's left ankle on 9/18/12, he indicated the resident was seen by the physician shortly after his discharge from this nursing facility. He indicated at that office visit the left ankle wound was noted to be "macerated," "wet and wrinkly" and "draining" which "happens when dressings don't get changed." He indicated the resident was started on oral antibiotics at that time for 10 days. He indicated Resident A was seen again by the surgeon on 10/23/12. The antibiotics were not continued at that time. He indicated Resident A needed a second surgery 2-3 weeks after the first surgery because after the first wound has healed they can go back and better fixate the fracture from the opposite side. He indicated after a certain point it becomes impossible to easily manipulate the bones to get them into better position because they are too healed together. He indicated Resident A was not able to have this second surgery, as planned, because of having to wait so long for the original surgical wound to heal due to lack of dressing changes. During an interview with Resident A on 11/1/12 at 3:22 p.m., he indicated "They don't know what the next plan will be...They're not giving me a game plan...We missed the window where they could do it." (i.e. the second surgery) During an interview with the DNS on 11/1/12 at 2:15 p.m., she indicated "We should have clarified the dressing order." This federal tag relates to Complaint IN 744 3.1-37(a)

A. Based on observation, interview and record review, the facility failed to ensure the supervision and application of assistive devices for a resident who was identified as a fall risk. The resident had recently returned to the facility from an appointment and was left without the personal alarm which could have alerted the staff of the resident's unassisted transfer which resulted in a fractured hip. This deficient practice affected 1 of 4 residents reviewed for falls from a sample of 7. (Resident "G") B. Based on observation, interview and record review, the facility failed to perform ongoing assessment of cognitively impaired residents and the use of assistive devices, in that when residents had [DIAGNOSES REDACTED]. (Residents "B," "H" and "I"). Findings include: A. The record for Resident "G" was reviewed on 02-28-12 at 1:00 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The Resident Minimum Data Set Assessment, dated 01-20-12 indicated the resident required extensive assistance with transfer. Review of the local area hospital pre-admission information dated 01-13-12, provided to the facility indicated the resident was a "fall risk." A review of the Bed safety evaluation dated 01-13-12 and again on 01-16-12, indicated the resident had weakness, a low bed, soft mat and a tab/pull alarm. The resident's Social Service Careplan, dated 01-20-12 indicated the resident had STM (short term memory) impairments. The Physical Therapy Evaluation, dated 01-5-12 indicated the resident's posture - "forward head, kyphosis, rounded shoulder, balance (sitting) - fair, safety awareness - fair." The Occupational Therapist Evaluation, dated 01-16-12 determined the resident was a "fall risk," had weakness and required frequent assistance with "safety awareness." Review of the Resident Progress Notes indicated the following:"01-17-12 Resident up in W/C (wheelchair) as requested. PSA (personal alarm) on for safety." "01-22-12 PA (personal alarm) in place at all times. Staff responding to alarm several times to find resident transferring "I" (circled) (independently). Resident instructed to use call light to ask for assistance. Voices understanding." "01-27-12 12:30 p.m., Overall weakness decreased LOC (level of consciousness), noted jerking occ. (occasional) alert. answers questions, denies pain. 3:00 p.m. Resident returned from appt. (appointment). Went to room in WC. Resident attempted to get up from chair, lost balance and fell on right side hip hit head on chair, left a 2 cm (centimeter) abrasion on scalp. (Name of physician) called, right hip x-ray ordered. 4:00 p.m. Resident c/o (complaints of) pain in right hip. hydrocodone (a narcotic pain medication) order obtained from Dr. (Doctor) PRN (as needed) Tylenol (an analgesic) given. 7:40 p.m. Received x-ray results showing right hip fracture. N.O. (new order) to send to (name of local area hospital)." Review of the "Post Fall Evaluation," dated 01-27-12 at 3:00 p.m. indicated the resident performed "unassisted ambulation - lost balance. Condition that may Contribute" included - unsteady gait, history of fall(s), Non-compliance." The evaluation lacked documentation of any "intervention" in place at the time of the fall. During an interview on 03-02-12 at 12:30 p.m., the Director of Nurses confirmed the resident did not have the PSA in place at the time of the fall, "because (resident) didn't have a physician order [REDACTED]. B1. The record for Resident "B" was reviewed on 02-29-12 at 1:15 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The record indicated the resident was admitted to the facility after an evaluation by a local area hospital physician for rehabilitation. The hospital notations, dated 12-08-11 indicated "(resident) is falling almost every day and at times when (resident) fall in bathroom and lay there all night as did not has <sic> strength to get up from the floor. (Resident) reports depression as (spouse) is in nursing home and (resident) has no human contact for weeks. (Resident) feels lonely. Reports OA (osteoarthritis) of left knee and locks up that leads to fall. (Resident's) spouse is in (Kindred Transitional Care - Greenwood) and patient favors going there and being close to (spouse)." The admission "Patient Nursing Evaluation," dated 12-12-11 indicated the resident had "severe depression with functional decline," identified as a "high risk" for falls, but not an elopement risk. In addition, the evaluation indicated the resident arrived at the facility via "taxi." Review of the physician progress notes [REDACTED]. Hx. (history) of falls - feels as if left leg gives out." Review of the signed January 2012 physician re-write/orders indicated the resident was "capable of making own health decisions," however required supervision to "go out on pass." Review of the Resident Progress Notes indicated the following:"12-17-11 - 9:00 a.m. Res. (Resident) ambulated with walker to other unit and asked them to call a cab, (resident) was going home. Nurse went to talk with res. (resident). (Resident) got ahold of (family member) before nurse arrived. States (family member) is coming to pick (resident) up in a few (minutes) 'needs stuff from home and will be back.' Assisted into lobby to wait for (family member). Reminded (family member) or self needs to sign chart when (family member) picks (resident) up. Res. states ok." 9:15 a.m. Resident witnessed leaving facility - didn't sign chart or inform staff (resident) (family member) was here to get (resident)." "12-17-11 (no time noted) Condition Change Form - new order for Wanderguard received and noted after speaking with DON (Director of Nurses) regarding res. leaving without signing out." A subsequent physician order, dated 12-19-11, instructed the nursing staff to discontinue the use of the Wanderguard device due to the resident's non-compliance and right to sign out." "12-19-11 Pt. own POA (power of attorney) and requested to go LOA for a few hours and return. Pt. signed out." "12-22-11 - 1:00 p.m. Called <sic> made to Dr. office concerning resident's trips to (resident's) car where there is known to be wine, the concern being possible mixtures with (resident's) meds. (medications) was advised that Doctor would be notified. No new orders at this time." "12-23-11 12:15 p.m. SS (social service) 14 day assess (assessment) (12-20-11 through 12-26-11). Res. wanting to leave today and take (spouse) who is also a res. here with (resident). Explained to res. and (spouse) if left would be AMA (against medical advise). Resident stated wasn't going to leave but wanted to go out to car and look through some papers. Writer and DON walked res. to car. Res. had to take several breaks to catch breath also carried out empty cup to car. Once at car, res. sat in car and shuffled papers. Writer and UM (Unit Manager) escorted back. Res. stating wanting to leave by Christmas. DON explained to res. doesn't have order from MD to D/C (discharge), not safe at this time that if chose to leave could be would be AMA." "12-25-11 - Res. c/o that doesn't feel well. When asked what is wrong res. states is 'just sad.'" "12-31-11 Res. came to nurses station wanting to sign self out. Nurse asked res. who was picking (resident) up - (resident) did not answer. Nurse asked if (family member) was picking (resident) up - stated 'yes.' Nurse explained that (family member) needed to come sign out. Res. then states (family member) wasn't picking (resident) up - (resident) car is in parking lot. (Resident) was driving self home for an hour then will be back. Explained to res. after speaking with ADON (Assistant Director of Nurses) (resident) can't drive self off facility grounds." "01-07-12 Social Service note - Resident alert and oriented to self, room, facility. Has impaired decision making abilities. Has had 2 recent falls, has PA (personal alarm). Has temp (temporary) guardian for finances." "01-08-12 Attempted to leave facility this AM, but states car wouldn't start. CNA (certified nurses aide) followed resident out of building an <sic> observed while resident looked for items in car." "01-14-12 Res. had coat on and walker toward door. Nurse asked resident if (resident) was leaving with someone. Hatefully states 'I'm not leaving ! Just going to make sure my car starts !' Staff observed res. to make sure didn't drive car off grounds. Res. sat in car approx. (approximately) 5 mins. (minutes) to 10 mins. Never started car, then returned to facility." "01-24-11 12:00 p.m. Pt. (patient) returned from going LOA (leave of absence) at approx. 11:30 (went to parking lot/car area) signed out. Pt. reported fell , knees gave out and buckled. Reports hitting head; posterior intact not open. stl. (slightly) red." "01-27-12 Social Service note - Res. wants to go home." "01-27-12 4:00 p.m. LE (late entry) for 01-25-12 at 11:45 a.m. Res. returned from LOA accompanied by Police was taken to Administrators office then returned to this unit. Res. told writer he had been in a car accident et (and) totaled (resident) car." The record indicated the resident was assessed and found to have a right hip bruise 15 cm (centimeters) by 4 cm, right flank bruise 18 cm by 5 cm, left thumb bruise with swelling, left index finger cut." Review of the local area hospital treatment record, dated 01-25-12, indicated the air bag deployed during the motor vehicle accident, which involved two other vehicles. The hospital record also included the resident had a right flank hematoma and left knee pain. The emergency room physician ordered an MRI (magnetic resonance imaging) of the resident's head due to "confusion" and x-ray left forearm due to "pain/trauma." "Provisional [DIAGNOSES REDACTED]." "Clinical impression: abrasion left hand, right hand, contusion - abdomen." In addition, the record indicated the resident had falls on 01-03-12 at 7:15 a.m., 01-05-12 at 9:30 p.m., and 02-15-12 at 6:45 p.m. The record lacked the "Post Fall Evaluation," which included information (interventions in place at time of fall, location of resident prior to fall, activity at the time of the fall, predisposing diseases, conditions that may contribute (to the fall) footwear/assistive devices at time of fall, vital signs, medications that may contribute or pain/fall history, summary of Interdisciplinary Team, or intervention recommendations), related to the fall on 01-24-12, in which the resident sustained [REDACTED]. B2. The record for resident "H" was reviewed on 03-01-12 at 2:05 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. Review of the hospital discharge summary, dated as "corrected on 02-26-12," indicated the resident had "decompensated cirrhosis with anasarca as well as worsening alcoholic metabolic [DIAGNOSES REDACTED], in addition to impaired judgement and decreased safety awareness. "Precautions" included the resident was a fall risk and was highly impulsive. A review of the Patient Nursing Evaluation, indicated the resident was not at risk for wandering/elopement. Instructions to this component of the evaluation indicated "complete on all new/readmission patients. If yes to one or two (questions) complete FRM wander/elopement risk evaluation. Complete quarterly and annually if identified as potential risk for wandering/elopement or if significant change occurs changing patient's risk for wandering/elopement." During an interview on 03-01-12 at 9:20 a.m. Certified Nurses Aide employee #10 indicated when Resident "H" was admitted the nurse wanted to place (name of resident) in a room down here by the exit door. I told the nurse 'no, I didn't think that was a good idea because (resident) kept wandering around. They finally placed (resident) on the middle hall - that was safer." When requested on 03-01-12 at 9:35 a.m., the Director of Nurses provided a list of residents who currently wore an assistive device to alert the nursing staff of possible resident elopement. The resident's name did not appear on the listing. Review of the nurses notes, dated 02-29-12 at 8:50 a.m. indicated "Res. asking where (resident) is at and if relatives/friends are here to <sic>. Sensor alarms D/C (discontinued) r/t (related to) res. unplugging them and knows how to disable them. Wanderguard in place now r/t res. ambulating in halls by self and risk for wandering." During an observation on 03-01-12 at 11:00 a.m., the resident was observed with the Wanderguard bracelet attached to left wrist. The record lacked an assessment which provided early identification of the resident's risk for wandering and/or elopement. B3. The record for Resident "I" was reviewed on 03-0112 at 2:45 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The admission evaluation indicated the resident was not at risk for elopement. However a review of the resident progress notes, indicated the following: "02-10-12 Res. stating, "I'm going home today. If my (spouse) doesn't take me I will find another way. I'll walk home if I have to." "02-11-12 (spouse) on unit and res. getting angry. Demanding the (spouse) take (resident) home. States 'I'll just leave on my own.'" The nursing staff received a physician order [REDACTED]." "02-12-12 Res. angry and exit seeking from 7:00 p.m. to 8:00 p.m. states 'I gotta go home I can't be away from my (spouse).' Res. watched constantly during this time." The nursing staff failed to complete an elopement risk assessment/evaluation until 02-13-12. 3. Review of the policy on 03-01-12 at 1:15 p.m., titled "Wander/Elopement Risk Evaluation," dated 10-01-10 indicated the following:"Who completes (bold type) licensed nurses." "Purpose of the Form (bold type): to provide early identification of residents at risk for wandering and/or elopement: a. Complete on Admission/Readmission for all patients. b. Annually if wanderer or eloper. c. Quarterly if wanderer or eloper. d. New episode of wandering and/or elopement, and or (BLANK)." This Federal tag relates to complaint IN 219. 3.1-45(a)(2)