Every finding on record at Grey Stone Health and Rehabilitation Center

Based on interview and record review the facility failed to ensure residents were free from abuse for 1 of 3 residents reviewed (Resident B). Findings include:An incident report, dated 7/20/26, was provided by the Administrator on 7/29/26 at 12 PM. The report indicated someone reported to the Administrator Certified Nursing Assistant (CNA) 2 posted videos on social media while working at the facility. The report indicated one of the videos posted briefly showed the face of Resident B.Resident B's record was reviewed on 7/29/26 at 3:15 PM. Diagnoses included generalized anxiety disorder and depression.An admission Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident B had a Brief Interview of Mental Status (BIMS) score of 06/15 (severally impaired).In an interview, on 7/29/26 at 10 AM, the Administrator indicated someone reported a video posted on tiktok (social media) by CNA 2. The video posted included the complaints about the facility and included the face of Resident B. The Administrator indicated he observed the video and confirmed the video posted consisted of CNA 2 complaining about her work assignment, including the facility hallways and Resident B's face. The Administrator indicated he attempted to reach out to CNA 2 multiple times and was unsuccessful. The Administrator indicated staff should not take or post videos or pictures of residents or the facility as it is a violation on privacy and resident rights.In an interview, on 7/30/26, Qualified Medication Aide (QMA) 3 indicated it was a violation of abuse, privacy and resident rights to take pictures or videos of residents and post them on social media. QMA 3 indicated personal phones were only utilized during break hours in the break room or outside the facility.A policy, titled Abuse Prohibition, Reporting and Investigation, last revised 3/2026, was provided by the Director of Nursing (DON) on 7/29/26 at 3:10 PM. The policy indicated photos or recordings taken of residents was a form of exploitation and a form of abuse.This citation relates to Intake 3105761.410 IAC (Indiana Administrative Code) 16.2-3.1-27(a)(b)

Based on observation, interview and record review, the facility failed to ensure a dependent resident at risk for pressure ulcers, was provided timely care and services to prevent development and worsening of a newly identified pressure ulcer for 1 of 3 residents reviewed. The resident was not provided care over an entire shift resulting in a deep tissue injury which progressed to an unstageable pressure ulcer to the left heel (Resident J).Findings include:A report, dated 10/20/25, indicated Resident J's family had been concerned, the resident's clothing had not been changed from one day to the next. The family alleged the resident hadn't received adequate care and developed a deep tissue injury to her left heel as a result.On 10/22/25 at 9:50 A.M., Resident J was observed lying diagonally across her bed with her head right next to the wall. Her husband was present, sitting at her bedside. Her husband indicated the morning of 10/18/25, he found Resident J lying in bed, in dirty clothes worn the day before, dirty linens with dried blood, and a sore on the bottom of her heel. He alleged she had been left up in her recliner chair all night on Friday, 10/17/25 until Saturday, 10/18/25. He was sitting in her recliner chair and put the footrest of the recliner chair up. The padding of the footrest was thin. He indicated the recliner had been in their home and used on the back porch. He pulled back Resident J's covers to expose her left foot. The foot was wrapped in gauze and resting on a pressure reducing mattress (not an air mattress). A heel protector was observed off the heel, turned all the way around and halfway up her calf. When asked, Resident J denied pain to her heel. Resident J's husband indicated to the dried blood on the bottom sheet beneath where the left heel had been resting. He indicated he wasn't sure where the dried blood originated, but it had been at there for 3 days without being changed.On 10/23/25 at 9:36 A.M., Facility Wound Nurse 9 and Registered Nurse (RN) 2 were observed to change the dressing to Resident J's heel. Resident J was lying straight in bed on a pressure-relieving mattress (not an air mattress) with her head elevated. Her heel protector was sitting on her left heel correctly when the blankets were pulled back. The old dressing was removed. The dressing contained serosanguinous (bloody) drainage and grey to green slough-type drainage. Neither the old dressing nor the wound had any odor. The observed wound was on the inner left side of the left heel, approximately 3 cm round. Inside the wound, was an area of soft eschar, grey/green in color, approximately 1.5 cm in length and 0.5 cm in width. The skin surrounding the eschar tissue was pale/white, soft appearing (boggy) with streaks of red and purple. Resident J denied pain during and after the dressing change.On 10/22/25 at 11:19 A.M., Resident J's record was reviewed. Diagnoses included dementia and need for assistance with personal care.An admission Assessment, dated 9/22/25 at 2:04 p.m., indicated Resident J was admitted following completion of therapy at another facility due to a fall with right hip fracture. She required assistance to transfer and walk with a walker or wheelchair. She'd recently had right hip surgery and could bear weight as tolerated. She had a healing surgical wound to the right hip which was left open to air and required no treatment. She had no other skin impairments observed.A Braden Scale Assessment, dated 9/22/25 at 2:04 p.m., indicated the resident had slightly limited sensory perception, occasionally moist skin, walked occasionally, made frequent though slight changes in position by herself, had adequate nutrition, and had a potential problem with friction and shearing. She was assessed as mild risk for developing pressure ulcers. A care plan was to be initiated to prevent pressure ulcers from occurring. The care plan was to include application of ointment/medication to areas other than her feet.Braden Scale Assessments, repeated on 9/30/25, 10/7/25, and 10/14/25 indicated Resident J was at mild risk for developing pressure ulcers.An admission Minimum Data Set (MDS) assessment, dated 10/1/25, indicated Resident J had severely impaired cognition. She had disorganized thinking and no behaviors. The resident required maximum assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. She used a wheelchair and walker for mobility. She was frequently incontinent of bladder and always incontinent of bowel. The MDS indicated she was not at risk for developing pressure ulcers nor did she currently have any pressure ulcers or injuries.Care plans indicated Resident J required assistance with activities of daily living (ADL) including bed mobility, dressing, toileting, and transfers. She was at risk for skin breakdown. Staff were to keep her clean and dry, provide incontinent care after each incontinent episode, keep linens clean, dry, and wrinkle free.A care plan, dated 10/8/25, indicated Resident J had a history of refusing care. Staff were to approach her in a calm, relaxed manner, observe and report behaviors.An Occupational Therapy (OT) Discharge summary, dated [DATE], indicated Resident J had received OT from 9/25/25 to 10/13/25. The summary indicated upon discharge, Resident J required stand by assistance with upper body dressing, maximum assistance with lower body dressing, and was dependent for toileting. She had required encouragement to participate in therapy and perform tasks. Upon discharge, she required assistance with self-care and ADL's due to impaired cognition and motivation.A nurse note, dated 10/18/25 at 5:56 p.m., indicated Resident J's family alleged the resident was not receiving satisfactory care. The family indicated the resident had been left in her recliner chair all night, in the same clothes, same position, from 10/17/25 until 10/18/25.In an interview, on 10/23/25 at 3:17 P.M., Qualified Medication Aide (QMA) 3. QMA 3 indicated she and QMA 5 had worked the hallway overnight, where Resident J resided, from 10/17/25 to the morning of 10/18/25. She indicated she had not provided any care to Resident J during the night. She attempted, around 4:00 a.m., to get the resident to lie down in bed as she had been sitting in her bedside recliner with her feet elevated on the footrest, but she refused. QMA 3 did not indicate she had placed any pressure prevention interventions for Resident J's feet.On 10/23/25 at 3:20 P.M., QMA 5 was interviewed. She indicated she had arrived at 11:00 p.m. on 10/17/25 and had checked on Resident J. Resident J had been sitting in her bedside recliner chair, her feet elevated on the footrest, and was watching TV. When asked, the resident indicated she wasn't ready to go to bed. She was dressed in the clothes she'd worn during the day. QMA 5 checked on Resident J around 2:00 a.m. The resident was asleep in the bedside recliner chair. The QMA indicated she tried to wake up the resident to assist her into bed, but she had refused. The QMA put a blanket on the resident, turned off the lights, and left the room. Around 4:00 a.m., she went back into Resident J's room and tried to get her to get into bed, but she refused. She asked QMA 3 to try and get the resident to go to bed but she refused for QMA 3. QMA 5 indicated she had not provided any toileting or incontinence care during her shift from 11:00 p.m. to 6:30 a.m. because the resident refused. QMA 5 indicated staff tried not to upset her and if she refused care, they would try to re-approach later. When questioned about her clothes being left on rather than pajamas, she indicated she hadn't thought it was unusual because many resident's liked to sleep in their clothes. QMA 5 did not indicate she had placed any pressure prevention interventions for Resident J's feet.There was no documentation completed in the nurse notes on the dates of 10/17 or 10/18/25 to indicate Resident J had refused care during the night.Point of Care documentation, dated 10/18/25 at 3:10 a.m., indicated, during the night shift, Resident J had rolled left and right in bed; been provided with personal hygiene; her shoes taken on and off; provided lower and upper body dressing; toilet transfers; transferred to chair/bed; toileting hygiene; and oral hygiene, all with maximum assistance. The resident had no behaviors, no skin problems and had been incontinent of bladder.A nurse note, dated 10/18/25 at 11:05 a.m., indicated Resident J's family requested the nurse to assess the resident's heels. She was observed with an unstageable deep tissue injury (DTI) to her left heel measuring 2 centimeters (cm) by 2.5 cm. The DTI had irregular borders and was deep purple/red in color. An order for Skin prep, to be applied every shift, was obtained and applied to her left heel.The National Pressure Injury Advisory Panel (NPIAP) website (npiap.com) indicated a deep tissue injury (DTI) was one of the most serious forms of pressure injury. Pressure is exerted where the muscle and bone come together. A DTI is defined by damage to the tissue beneath intact skin. Treatment of DTI's include frequent re-positioning off the site of injury, good skin care, and proper support surface selection such as mattress and positioning devices to prevent prolonged pressure.Woundsource.com defined Skin prep as a liquid film-forming skin protectant. Skin prep was not recommended for open areas.A Braden Scale Assessment, dated 10/18/25 at 5:04 p.m., indicated the resident had moderate risk for developing pressure ulcers. The assessment didn't indicate new interventions were put in place to prevent worsening of her DTI or prevent new pressure ulcers from occurring.A Wound Nurse Practitioner (NP) progress note, dated 10/21/25, indicated Resident J had an open ulcer to the left heel. The wound bed was 100% soft eschar (dead skin); wound edges irregular and attached; peri wound pink without redness or induration; no odor; and no bone present. There was a small amount of serous (clear) drainage on the old dressing. Interventions were to offload, use positioning devices, and low air loss mattress.A nurse note, dated 10/21/25 at 3:26 p.m., written by Facility Wound Nurse 9, indicated Resident J had been seen by the wound NP for an unstageable pressure ulcer to the left heel. The wound measured 1.5 cm by 1.5 cm and was covered with eschar tissue. The wound NP ordered treatment to the heel: clean the area with normal saline/wound cleanser, pat dry. Apply nickel thick layer of Santyl (enzyme removal of eschar) to the wound bed, cover with ABD pad and secure with kerlix and tape. The treatment was to be done daily and as needed for soilage or dislodgement.A Medication Administration Record (MAR), dated October 2025, indicated interventions to prevent worsening of the DTI, observed on 10/18/25 by Resident J's family and reported to staff, were not put in place immediately. The MAR indicated the resident's heels were to be floated as tolerated and heel protector placed on her left heel beginning 10/21/25. Staff were to monitor the unstageable pressure ulcer to the left heel for abnormalities every shift beginning 10/21/25. An air mattress, ordered on 10/21/25 and initialed by nurses in the MAR as being present, was not observed on the resident's bed on 10/21/25, 10/22/25, or 10/23/25.Current facility policies, titled Pressure Injury Prevention and Management Policy and Skin and Wound Care Best Practices were provided by the Administrator on 10/24/25 at 10:20 A.M. New pressure injuries would not develop unless the resident's clinical condition demonstrated they were unavoidable. Residents were to be assessed for pressure injury upon admission, quarterly and with a significant change in condition using the Braden Scale for Predicting Pressure Ulcer Risk. Preventative skin care and wound treatments would be put in place to prevent avoidable skin complications. At risk residents would have their heels offloaded/suspended; re-positioned to avoid pressure to bony prominences; and provided pressure redistribution/relief devices as recommended. All standard mattresses were pressure relieving/redistributing and would be used for all residents unless provider orders were for a higher level of pressure reduction.This Citation relates to Intake 2647972.3.1-40

Based on observation, record review, and interview, the facility failed to ensure residents were adequately assessed and provider lab orders followed up on timely after a resident change in condition. The deficit practice resulted in a resident's need for hospitalization for gastrointestinal bleed and blood transfusion for 1 of 3 residents reviewed (Resident L).Findings include:A report, dated 10/16/25, alleged Resident L had a change in condition for several weeks. His condition was not assessed and charted on daily, and he was not followed closely. He had been given several IV's (intravenous fluids) and eventually was sent to the hospital for evaluation. On 10/22/25 at 12:09 P.M., Resident L's record was reviewed. Diagnoses included atrial fibrillation, chronic obstructive pulmonary disease (COPD), and dementia. A quarterly Minimum Data Set (MDS) assessment, dated 9/2/25, indicated Resident L had moderately impaired cognition. He had no mood indicators or behaviors. He was non-ambulatory and required maximum assistance with his activities of daily living (ADL). He was not receiving supplemental oxygen therapy. A care plan, dated 8/7/25, indicated Resident L was at risk for bleeding due to use of blood-thinners (anticoagulant) to treat his atrial fibrillation. The goal was for the resident to be free from signs of abnormal bleeding or bruising. Interventions included: administer medications as ordered, monitor labs as ordered, report results to the physician, and monitor for bleeding or bruising. A current physician order, dated 4/21/23, was for Eliquis (anticoagulant) 2.5 milligram tablets; give 1 tablet by mouth 2 times per day for paroxysmal (intermittent) atrial fibrillation. Progress notes indicated:On 9/24/25 at 10:30 a.m., a contracted NP was notified of the residents' weakness and moist breath sounds. New orders were given to check his labs including a complete blood count (CBC) to be done STAT (immediately). At 4:44 p.m., the hospital lab results were reported, to the NP and the resident's hemoglobin (Hgb-carries oxygen from lungs to body tissues and muscle) level was 8.4 g/dL. (Normal Hgb blood levels are 14.0-18.0 g/dL). At 11:35 p.m., Resident L was found sitting on the floor in a large amount of black tarry stool. The on-call contracted NP was notified and orders given for a STAT CBC. There was no documentation the STAT CBC lab, ordered on 9/24/25 at 11:35 p.m., was completed nor were results of the lab in the record. On 9/26/25 at 12:35 p.m., the resident was seen by the contracted NP. Resident L continued with a moist cough, need for supplemental oxygen, and poor oral intake. He had been treated during the week for acute kidney failure. A chest x-ray showed moderate heart enlargement but no pneumonia. Treatment was started for COPD exacerbation with antibiotics and steroids. Staff reported poor oral intake. The plan was to give 2 liters of normal saline subcutaneous (under the skin) at 100 ml/hr., encourage fluid intake, and continue with as needed supplemental oxygen. The NP recommended repeating labs over the weekend (9-27 and 28) and giving more fluids as needed. Continue monitoring changes in breathing or wheezing. There was no order written to repeat labs over the weekend. There were no assessments or documentation of Resident L's condition completed on 9/27/25. On 9/28/25 at 9:38 p.m., Resident L's condition was improving. He was more alert, had good oral intake and his vital signs were stable. There were no assessments or documentation of Resident L's condition completed on 9/29/25. On 9/30/25 at 6:14 p.m., the on-call contracted NP was notified of Resident L's abnormal lab of a critical Hgb level of 5.8. Orders were given to call 911 and transfer the resident to the hospital for blood transfusion and evaluation. There was no assessment or documentation completed to indicate Resident L had a change/decline in condition on 9/30/25. A contracted on-call NP communication, dated 9/30/25 at 9:33 p.m., indicated Resident L was admitted to the hospital with a gastrointestinal bleed, anemia, and acute kidney failure. On 10/23/25 at 1:23 P.M., the Director of Nursing (DON) was interviewed. She indicated she wasn't sure why labs had been drawn on 9/30/25 and wasn't able to find orders for the lab draw. When questioned, she indicated she was unable to locate STAT lab results ordered 9/24/25 at 11:35 p.m. The facility contracted with a lab who were supposed to draw routine labs, run the labs, and report results to the facility. For STAT labs, the contracted lab was to draw the labs but take the blood to the hospital to be processed and reported. On 10/23/25 at 2:25 P.M., the contracted NP was interviewed. She indicated she had been monitoring Resident L's labs for some time, especially his WBC (white blood count) for infection due to his acute illness over the past month. Resident L's hemoglobin level chronically trended between 8-10; below the normal hemoglobin level of 14.0-18.0 g/dL. She indicated labs had been drawn during the day on 9/24/25 due to the residents' continued weakness and respiratory symptoms. She reviewed the lab results reported by the lab at 2:45 p.m. via secured hospital electronic medical records. She hadn't been made aware STAT labs had been re-ordered the evening of 9/24/25 following the resident's passage of black tarry stool and had not reviewed results of those labs. On 10/23/25 at 2:45 P.M., the DON and Licensed Practical Nurse (LPN) 8 provided a copy of the lab results, ordered on 9/24/25 at 11:35 p.m. and drawn on 9/25/25 at 2:32 a.m. by the contracted lab. The DON indicated the contracted lab had not taken the blood to the hospital to be processed and had run the tests at their lab. The facility had not received results of the labs. When questioned, LPN 8 indicated labs were drawn on 9/30/25 due to an order given on 9/29/25 by the contracted NP but hadn't known the reason for the lab draw. The DON indicated it was nurses' responsibility to document assessments and follow up on labs ordered to ensure the ordering provider was aware of the lab results and resident's condition. The DON indicated the facility had no specific policy for notifying providers of abnormal lab results however, abnormal lab results could be a change in resident condition requiring provider notification. On 10/24/25 at 11:00 A.M., the contracted NP indicated she had not been notified nor had she received results of STAT labs ordered the evening of 9/24/25. She had not known the resident's Hgb had decreased to 7.7 g/dL. She indicated she should have been notified of the lab results.A Competency check-off form, titled Lab and Diagnostic Results Reporting, provided by the Administrator on 10/24/25 at 11:33 A.M., indicated nurses were to call the providers, report abnormal lab results, and document in the medical record. Providers were to be notified immediately of critical lab values and notification documented in the record.A current facility policy, titled Resident Change in Condition, was provided on 10/24/25 by the DON which indicated licensed nurses were to recognize and intervene in the event of a change in resident condition. The physician/provider was to be notified as soon as the change in condition was identified. This Citation relates to Intake 2645131. 3.1-37

Based on interview and record review the facility failed to ensure physician orders were followed for 1 of 1 resident receiving dialysis reviewed. (Resident 2) Findings include:Resident 2's record review began on 8/21/25 at 1:30 PM, diagnoses included chronic kidney disease and outpatient hemodialysis treatment.A review of Resident 2's current quarterly MDS dated indicated their BIMS (Basic Interview for Mental Status) score was 14 (cognitively intact). The MDS indicated the resident receives hemodialysis treatment 3 days a week. Resident 2's Dialysis Communication Binder included a medication list, dated 7/10/25. The medication list did not include sevelamer carbonate, ordered on 7/25/25 at 2:17 PM. A review of physician orders, dated 7/25/25 at 2:17 PM, indicated sevelamer carbonate 800mg, was to be given three times a day with meals.A review of the dialysis company medication list dated 8/21/25 indicated sevelamer carbonate 800 mg, was to be given with meals and one tablet with snacks. A review of the August 2025 Medication Administration Record (MAR) on 8/21/25 at 1:00 PM indicated 15 of 61 scheduled doses of sevelamer were not given or missing documentation. Scheduled times for medication were 8:00 AM, 12:00 PM, and 5:00 PM. The scheduled times did not include a snack dose as ordered by the dialysis company. A list of reasons the medication was not given included on hold, resident unavailable, at dialysis, or drug/item unavailable.A review of food intake measurements, dated 8/1/25 through 8/21/25 at 1:57 PM, indicated Resident 2 had received breakfast, lunch, dinner, and bedtimes snacks on the days she remained at the facility. Lunch was not offered during dialysis appointments. Resident 2 had refused breakfast on 8/4/25, 8/6/25, and 8/15/25.In an interview, on 8/21/25 at 1:25 PM, the Director of Nursing (DON) indicated staff should notify the physician when a resident missed a dose of medication. In the past, staff have sent medication with a resident to dialysis or staff have called the provider to ask for a time change for scheduled medications to ensure medications are given as ordered.Review of progress notes, dated 7/25/25 - 8/14/25, indicated there was no documentation of communication to the provider about missed doses, clarification to change the medication time, nor notes of sending sevelamer carbonate 800 mg to dialysis. A review of Resident 2's Dialysis Communication Binder dated 7/25/25 through 8/21/25 indicated the resident's dialysis company had not given the resident sevelamer carbonate during their care.A review of Resident 2 Dialysis Communication Binder Cover directed the staff to fill out communication log with any medication changes.A current policy dated 7/2/25 provided by the DON, indicated the pre-dialysis process is to administer medications as ordered by the provider. Communicate any concerns to the dialysis provider. Document in the Dialysis Communication Tool of medications administered before treatment, any additional alerts or information. The post-dialysis process indicates communication of any medications administered during or after treatment.3.1-37

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 24 resident reviewed. (Resident 75)A review of Resident 75's current quarterly MDS indicated their BIMS (Basic Interview for Mental Status) score was 15 (cognitively intact). The MDS indicated the resident did not have chronic skin abnormalities.During an observation, on 8/18/2025 at 11:25 AM, Resident 75 had an area of skin below the right knee, red in color, approximately 1 inch by 3/4 inch with satellite red areas above and below the larger area. The resident indicated this area had been going on for a month or more.A review of physician orders, dated 6/25/25, indicated that staff would monitor for signs and symptoms of abnormal bleeding or abnormal bruising. A review of physician orders, dated 06/15/2025, indicated Resident 75 was to take Eliquis 5 mg, orally, twice a day. The order was discontinued on 07/08/2025.A record review began on 8/14/2025 at 10:32 PM, indicated a physician plan for staff to monitor for skin color changes or dryness, consider lotion daily, if changes are noted consider an ultrasound to rule out clot.A record review, on 8/19/25, included skin assessments, progress notes, care plans, and a daily skin assessment for August indicated an absence of documentation for abnormal skin coloration for the resident's right lower leg.In an interview, on 08/19/2025 at 12:30 PM, RN 5 indicated the Medication Administration Record had a task to assess skin. No information about the area was communicated in nursing report. The right lower leg reddened area would be categorized as abnormal. The resident 75 has not had any recent falls or known cause of the abnormal reddened area.In an interview, on 08/19/2025 at 12:32 PM, CNA 4 indicated Resident 75 did not have any recent falls. In an interview, on 08/19/2025 at 12:49 PM, the Director of Nursing indicated she assessed the reddened area and was unsure if there was a diagnosis for the area.Progress notes, dated 8/19/25 at 1:35 PM, indicated scattered redness area on the resident's right lower leg measuring 15 cm by 2.3 cm. The resident stated she had this redness for years, it comes and goes. The resident was taking aspirin and the nurse practitioner was notified with new orders to monitor the area, keep skin moisturized, and collect a blood sample tomorrow morning. Resident 75 was made aware and agreed with the plan of care. A physician note, dated 8/19/25, identified the reddened area on the right lower leg as hemosiderin staining and for staff to monitor for pain or temperature changes.In an interview, on 08/21/2025 at 10:40 PM, the Director of Nursing indicated shower sheets for resident 75 were not available for review.A current policy, dated 9/9/25, provided by the Director of Nursing, indicated nursing assistants will look at all areas of the resident's skin and indicate abnormalities or changes and document on a shower sheet or verbally notify the charge nurse. Reportable skin conditions include reddened areas. The nurse will address any findings in the clinical record and appropriate interventions will be initiated. If shower sheets are used for documentation, the documentation will be submitted to the DON or designee. 3.1-35(a)

Based on observation, interview, and record review, the facility failed to ensure a self-administration of medication assessment was done prior to allowing a resident to self-administer medications for 1 of 1 residents reviewed. (Resident 5) Findings include: During an observation, on 8/19/25 at 12:27pm, on Resident 5's bedside table an albuterol inhaler labeled with Resident 5's name was observed. In an interview, on 8/19/25 at 12:31pm, LPN 6 indicated the Nurse Practioner indicated Resident 5 was allowed to have both the albuterol inhaler and flonase nasal spray at bedside for self-administration. LPN 6 indicated there was no order for Resident 5 to self-administer the medications. Resident 5's record was reviewed on 8/19/25 at 2:10pm. Resident 5's diagnoses included muscle weakness and paraplegia. Resident 5's quarterly Minimal Data Set assessment, dated 7/21/25, indicated her Brief Interview of Mental Status score was a 13. A score of 13 indicated a minimal decline in mental status. Resident 5's self administration assessment, dated 8/13/25, indicated Resident 5 did not want to self administer medications. The remainder of the self-administration of medication assessment was left blank. In an interview, on 08/20/2025 at 10:52 AM, the Director of Nursing (DON) indicated the facility should have done a specific self-administration of medication for Resident 5. The DON indicated Resident 5 should not have had the medications in her room without an order to indicate she could self-administer the medication and an assessment to indicate she was able to administer them herself. A policy titled, Self-Administration of Medications dated 12/1/07 and last revision date of 6/1/24. The policy indicated.2. Facility, in conjunction with the Interdisciplinary care team, should assess and determine, with respect to each resident, whether the self-administration of medications is safe and clinically appropriate based on the resident's functionality and health condition. 3. To ensure safe and appropriate self-administration, facility should educate residents to ensure that a resident is able to: 3.1 state the name, dose, strength, frequency, and purpose for use of their medications. 3.2 Understand the possible medication side effects and that they should notify facility staff if they experience any such side effects. 3.3 Correctly administer, inject, or apply all prescribed medications. 3.4 Correctly store their medications in a locked compartment.5. Facility should ensure that orders for self-administration list the specific medication(s) the resident may self-administer. 3.1-11

Based on interview and record review, the facility failed to ensure residents were adequately assessed and provider orders were followed after a change in condition post-surgery for 1 of 4 residents reviewed. The facility failed to ensure the resident was assessed and a doppler study completed timely as ordered when Resident B's leg showed a change in condition. This deficient practice resulted in hospitalization and death. (Resident B). The Immediate Jeopardy began on 3/20/25 when the facility failed to assess Resident B's change of condition. The Assistant Director of Nursing (ADON) and Minimum Data Assessment (MDS) Nurse were notified of the Immediate Jeopardy on April 29, 2025 at 3:51 P.M. The immediate jeopardy was removed on 4/30/25 but noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: In an interview on 4/29/25, Resident B's family indicated Resident B fell on [DATE]. The family indicated the fall resulted in a left hip fracture with surgical intervention on 3/11/25. The family indicated Resident B returned to the facility on [DATE]. On 3/20/25, the family received a call from the facility regarding a change of condition. The family indicated the nurse indicated Resident B's leg was red and swollen and a doppler ultrasound was ordered to rule out a blood clot. The family indicated she received no updates 3/21, 3/22 or 3/23. The family indicated on 3/24/25, Resident B was admitted to the hospital due to significant bruising and mottling without a pulse to her left leg. The family indicated the hospital indicated Resident B was not a surgical candidate and decided to elect inpatient hospice. The resident passed away on 4/8/25. Resident B's record was reviewed on 4/29/25 at 11:07 AM. Diagnosis included fracture of the left femur, type 2 diabetes mellitus and dementia. A nursing note, dated 3/10/25, indicated Resident B had a fall on 3/10/25, with resultant left hip fracture. The note indicated Resident B was sent to the hospital. A care plan, dated 3/14/25, indicated surgical hip precautions to be taken after hip surgery included encourage mobility, but did not include specific interventions to prevent blood clots. A nursing note, dated 3/14/25, indicated Resident B had surgery on 3/11/25 and returned to the facility 3/14/25. The note indicated Resident B's doctor ordered heparin three times a day (TID) for 2 weeks for deep vein thrombus prevention and initiated skilled therapy. A nurse practitioner (NP) note, dated 3/20/25, indicated Resident B was seen for left hip fracture follow up. The note indicated Resident B attempted to pull out her staples and an antibiotic was ordered. The NP noted Resident B's left leg was swollen and ordered a doppler ultrasound to rule out a blood clot. There was no doppler ultrasound order in Resident B's physician orders, on the Treatment Administration Record (TAR) or referenced in the progress notes including therapy notes between 3/20/25 and 3/ 24/25 to indicate a new order for doppler study had been received. A nursing note, dated 3/24/25 at 8:30 AM, indicated Qualified Medication Aide (QMA) 6 observed a deep purple discoloration of Resident B's posterior left thigh all the way to her ankle. The left leg was cold to touch, and the staff were unable to palpate a pedal (foot) pulse. A nursing note, dated 3/24/25 at 9:10 AM, indicated the Assistant Director of Nursing (ADON) and the NP assessed Resident B's leg on 3/24/25. Edema was noted from the left hip extending to the left foot with dark purple discoloration/mottling to the back, medial, lateral thigh and left foot up to the ankle. The note indicated Resident B complained of pain to left lower extremity and was unable to move her foot and toes. The note indicated the ADON was unable to locate a pedal [NAME] per palpation. The note indicated Resident B was sent to the hospital. An NP note, dated 3/24/25 at 9:22 AM, indicated she assessed Resident B due to changes in her left leg. The NP observed swelling, significant bruising, mottling to left leg, extended to back of thigh and wrapped around the sides with some bruising noted to foot and toes. The NP indicated she was not able to feel a pedal pulse and capillary refill was greater than 3 seconds. The note indicated doppler ultrasound was ordered but not completed and indicated Resident B was sent to the hospital. Hospital records, dated 3/24/25 - 4/8/24 were reviewed on 4/29/25 at 2:50 PM. An Emergency Department (ED) note, dated 3/24/25, indicated Resident B was brought to the hospital via ambulance for a cold, pulseless left leg and foot. The medics indicated the staff at the facility were unable to answer questions because the staff was not familiar with Resident B. The facility staff indicated the last time Resident B's left leg was seen normal was Thursday, 3/20/25. The ED note indicated a physical exam showed Resident B's left leg was swollen, mottled and cold. No pulses were present in the thigh, behind the knee or behind the ankle on palpitation or with doppler. The ED note indicated Resident B was consulted by 3 cardiology doctors. The doctors indicated Resident B was not a candidate for surgical intervention as the left leg was extremely ischemic and beyond effective surgical intervention. The note indicated the family was updated and indicated they would like admission to inpatient hospice. The hospital admission diagnosis included heparin - induced thrombocytopenia, other acute pulmonary embolism without acute cor pulmonale (heart involvement) and arterial embolism and thrombosis of lower extremity. An ultrasound, dated 3/24/25 at 6:17 PM, indicated Resident B had an occlusive thrombus (blood clot) extending greater than 5 cm in length and less than 3 cm away from the bend in the knee with edema present in the left leg. The report indicated extensive left lower deep vein thrombus. A CAT (CT) Scan, dated 3/24/25, indicated Resident B had a pulmonary embolism involving the left mainstem bronchus (big airway in the lung) as well multiple blood clots of the left upper lobe, left lower lobe and right middle lobe. An inpatient hospice note, dated 3/25/25 - 4/8/25, indicated Resident B was admitted with a diagnosis of critical limb ischemia of left lower extremity and closed displaced fracture of greater trochanter of left femur. The note indicated Resident B passed away on 4/8/25. In an interview, on 4/29/25 at 10:45 AM, Registered Nurse (RN) 2 indicated she observed Resident B's left leg on 3/20/24. The leg was red, swollen, warm to touch. RN 2 indicated she notified the NP. RN 2 indicated on 3/22 and 3/23, Resident B expressed pain with little to no difference appearance from 3/20. The leg remained swollen, redness, warm to touch, with no discoloration. RN 2 indicated on 3/22/25 she checked the order status for the doppler ultrasound through the mobile ultrasound company website. RN 2 indicated the order was still pending, so she submitted the STAT order request. RN 2 indicated the doppler ultrasound was not completed on 3/22 nor 3/23. RN 2 indicated she did not communicate with the NP regarding Resident B's status or lack of doppler ultrasound. RN 2 indicated when a STAT request is sent through the website, the company was onsite within 24-48 hours. RN 2 indicated she was unsure if the mobile company was open on the weekends. RN 2 indicated the nurse who took the order from the NP was responsible for entering the order in the resident's health record and submitting a request on the website. Progress notes dated 3/20/25 through 3/24/25 did not include any assessment of Resident B's left lower extremity, any vital signs, or any documentation of redness, pain, swelling, or to address pedal pulses. In an interview, on 4/29/25 at 11:10 AM, the ADON indicated the NP ordered a doppler ultrasound for Resident B on 3/20/25. The ADON indicated the nurse was responsible for entering the order into Resident B's chart as well as a request on the mobile doppler website. The ADON indicated the order was not entered into Resident B's chart on 3/20/25. The ADON also indicated the order through the website was not entered until 3/22/25 and was not completed. The ADON indicated the mobile doppler company was not open on the weekends so the ultrasound would have been completed on the following Monday. The ADON indicated the nurse should have reached out to the NP when the ultrasound was not available, or the resident had a change of condition. The ADON indicated on 3/21/24 Resident B's leg was still red but less swollen than 3/20/25. The ADON indicated during assessment on 3/24/25, Resident B was noted to have a swollen left leg, discoloration and absent pedal pulse. The ADON indicated Resident B was sent to the hospital, went to inpatient hospice and passed away. The ADON indicated staff should document on resident condition, physician orders to follow, and staff actions to prevent blood clots, but there was no documentation. In an interview, on 4/29/25 at 10:31 AM, RN 5 indicated when a change of condition was observed, she reached out to the NP for next steps. RN 5 indicated signs/symptoms of a blood clot would include redness, swollen, warm to touch, increased pain and absent or weak pedal pulses. In an interview, on 4/29/25 at 10:42 AM, Licensed Practical Nurse (LPN) 3 indicated signs/symptoms of a blood clot included redness, swelling and pain. LPN 3 indicated when a resident had a change of condition, she reached out to the NP for direction. In an interview, on 4/29/25 at 12 PM, RN 4 indicated she worked on 3/20/25. RN 4 indicated the NP ordered a doppler ultrasound but was unsure if the request was submitted into the mobile doppler website. RN 4 indicated STAT requests are completed within 48-72 hours. RN 4 indicated she was unsure if the mobile doppler company was open on the weekends. A current policy, last revised 5/27/2024, titled Resident Change in Condition was provided by the ADON on 3/24/25 at 4/29/25. The policy indicated a significant change of condition is a decline or improvement in a resident's status that would not normally resolve without intervention. The policy indicated the physician/provider were updated of resident's change of conditions, including a need to alter the medical treatment/orders. The policy also indicated a change of condition was documented in the resident's health record. The Immediate Jeopardy that began on 3/20/25 was removed and the deficient practice corrected on 4/30/25 when the facility re-educated all licensed nurses on facility policies for change of condition identification, assessments, documentation and following physician orders but will remain at the lower scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy. This tag relates to Complaint IN00458344. 3.1-37

Based on interview and record review, the facility failed to ensure 1 of 3 residents reviewed were assessed and findings reported to the physician related to a change in condition. (Resident C). Findings include: On 3/31/25 at 10:23 A.M., Resident C's record was reviewed. Diagnoses included colostomy status, recurrent small bowel obstructions and congestive heart failure (CHF). A hospital note, dated 9/17/24, indicated the resident had been sent to the hospital with symptoms of abdominal pain, distention, and nausea developed the morning of 9/6/24. The resident denied vomiting but had indicated output in her colostomy bag had abruptly stopped. A CT scan indicated the resident had a small bowel obstruction in the right lower abdomen. She was admitted to the hospital for treatment of the obstruction. Medical records indicated she had a left hemicolectomy (removal of left side bowel) with a colostomy due to a perforated bowel (years prior) and had been treated for a small bowel obstruction on 3/17/23 and 5/24/24. A hospital Emergency Department (ER) Provider Note, dated 3/24/25 at 6:32 a.m., indicated Resident C, had a history of CHF requiring continued oxygen use at 2 liters per minute by nasal cannula, colostomy with multiple abdominal surgeries and recurrent small bowel obstructions. Resident C came to the ER for nausea, vomiting and shortness of breath. The resident had complained of increased fatigue and decreased oral intake. Physical exam indicated Resident C was ill-appearing, was positive for confusion, had dry mucous membranes, fast heart and respiratory rates, decreased blood pressure, abdominal distention, and tenderness over the right side of her abdomen. CT x-rays of her chest, abdomen, and pelvis indicated the resident had right sided pneumonia and small bowel obstruction. Resident C was admitted to the medical intensive care unit (ICU) with acute illness that posed a threat to her life and bodily functions. A hospital Discharge Summary, dated 3/25/25 at 1:17 p.m., indicated the residents' condition worsened with respiratory and circulatory failure and she passed away. The final discharge diagnosis and cause of Resident C's death was small bowel obstruction. An annual Minimum Data Set (MDS) assessment, dated 1/3/25, indicated Resident C had no cognitive impairment and no behaviors of rejecting care. She had a colostomy with no constipation. Care plans indicated: -Revised 2/15/25: the resident was at risk for impaired skin integrity as she required a colostomy related to history of colon resection due to cancer. The goal was to maintain the skin integrity around the stoma and have no signs or symptoms of complications related to the colostomy. Interventions included: monitor skin for irritation around the stoma; empty and cleanse the ostomy pouch on a routine basis; and change the colostomy bag as ordered. The care plan did not indicate specific signs and symptoms for staff to monitor related to identification of small bowel obstructions such as nausea, vomiting, abdominal pain, or lack of output in her colostomy pouch. Physician orders for routine medications to maintain bowel function and prevent constipation/lack of stool in the colostomy pouch were: -Miralax powder 17 grams by mouth 3 times per day. -Linzess 72 micrograms by mouth 1 time per day. -Senna laxative 8.6 milligram tablet by mouth 2 times per day. A Medication Administration Record (MAR), dated March 2025, indicated Resident C's colostomy bag was to be changed 1 time every 3 days and skin barrier appliance changed 1 time every 7 days. Documentation indicated the bag and skin barrier changes were completed as ordered. A Nurse Practitioner (NP) progress note, dated 3/7/25 at 6:27 a.m., indicated Resident C was seen for chronic illness management. The resident indicated stool output in her colostomy was normal without any issues. An NP progress note, dated 3/17/25 at 8:36 a.m., indicated Resident C was seen for pain management and follow up of routine labs. The resident had chronic pain in her back, legs and abdomen relieved with her routine prescribed medications. The resident had a colostomy and denied any changes with stool output due to narcotic medication use. Prescriptions for Lyrica-used to manage neuropathic pain and Tramadol-used on as needed basis for pain, were given and refilled. There were no further NP progress notes or nurse progress notes from 3/18/25 through 3/23/25. Bowel movement records, dated 3/20/25 at 11:32 a.m. indicated Resident C had a medium amount of stool in her colostomy bag. On 3/21, 3/22, 3/23, and 3/24/25, the records indicated there was no stool in her colostomy bag. A nurse progress note, dated 3/24/25 at 3:49 a.m., indicated at 2:15 a.m., Resident C had been having nausea and vomiting for the past 24 hours. She had been administered Zofran (anti-nausea/vomiting medication) per as-needed orders, but it had not been effective. The resident was weak, skin pale and cool to touch, and she had no stool in her colostomy bag since 3/23/25. Her blood pressure was low at 99/56, pulse 99, respirations 24, and her oxygen saturation was 85% (normal oxygen saturation is >90%) with oxygen on at 3 liters per minute per nasal cannula. The resident requested to go to the hospital. The on-call NP was notified and orders given to transport to the hospital. The EMS arrived at 2:45 a.m. and the resident transported to the hospital. On 3/31/25 at 12:45 P.M., Qualified Medication Aide (QMA) 2 was interviewed. She indicated she had worked on 3/22/25 and 3/23/35, 10:00 p.m. to 6:00 a.m. During those 2 nights, she cared for Resident C who had been ill with nausea and vomiting. QMA 2 indicated she had been told the resident had been vomiting since Friday 3/21/25 but hadn't wanted to go to the hospital. Resident C had a large emesis on the morning of 3/23/25. It was reported to her, when she returned to work, the resident had continued with vomiting all day on 3/23/25. She reported the vomiting to the nurse in charge. On 3/31/25 at 1:00 P.M., QMA 4 was interviewed. She indicated she had worked 3/21, 3/22, and 3/23/25. On 3/21/25, she worked 10:00 to 6:00 a.m. and was told in report, Resident C had begun vomiting earlier in the day. During her shift on 3/21/25, Resident C had a small emesis colored like spit or sputum. On 3/22/25, she began her shift at 6:00 p.m. and worked until 6:00 a.m. 3/23/25. In report at the beginning of her shift, the off-going QMA 2 reported the resident was still vomiting and had been given Zofran by Licensed Practical Nurse (LPN) 7 earlier in the day 3/22/25. QMA 4 indicated she'd intended to give the resident more Zofran for the nausea but hadn't found an order for the medication. QMA 4 returned on 3/23/25 for night shift but had not worked with Resident C as she was scheduled on another wing. On 3/31/25 at 2:00 P.M., LPN 7 was interviewed. She indicated she worked on 3/22/25 and 3/23/25, from 6:00 a.m. until 6:00 p.m. When she received report on 3/22/25, she had not been informed Resident C had been vomiting or had been sick. On 3/22/25, at approximately 3:00 p.m., Resident C reported to LPN 7, she wasn't feeling good and wanted to lie down. On 3/23/25, she was told in report the resident had vomited 1 time during the night. During her shift (6:00 a.m. to 6:00 p.m.) on 3/23/25, Resident C had 2 more episodes of vomiting. LPN 7 indicated she had not contacted the on-call NP but had put a note in the NP's folder to be seen on Monday. When questioned, LPN 7 indicated she had not been aware the resident had a history of small bowel obstructions as she was new to the facility. She indicated she had not administered Zofran to the resident becasue the resident had no orders for the medication. On 3/31/25 at 2:07 P.M., LPN 9 was interviewed. She indicated she worked 3/22/25 and 3/23/25, on the night shift (6P-6A). She was scheduled to work on the memory care unit but was responsible for covering the QMA's scheduled on the other hall. She indicated QMA 2 reported to her Resident C had been vomiting over the past 2 days and was ill. LPN 9 assessed the resident and obtained her vital signs. Resident C was very ill and when asked, agreed to go to the hospital. LPN 9 indicated, she reported the information to the on-call NP and hospital staff the resident had been sick with nausea and vomiting the past 24 hours; she had no stool in her colostomy bag; and had been given as needed Zofran as ordered, which had not been effective in relieving the resident's symptoms. On 3/31/25 at 3:53 P.M., the Assistant Director of Nursing (ADON) was interviewed. She indicated she had not been made aware of Resident C being ill with nausea and vomiting, only that she had been sent to the hospital. When questioned, the ADON indicated the NP/Physician should have been notified immediately of the resident's symptoms due to her previous small bowel obstructions resulting in hospitalization s. A current facility policy, titled Resident Change in Condition was provided, on 3/31/25 at 4:00 P.M., by the ADON which indicated the following: Resident Change in Condition: The nurse will recognize and intervene in the event of a change in resident condition. The physician and family will be notified as soon as the nurse had identified the change in condition and the resident is stable. A Significant change of condition is a decline or improvement in the resident's status that 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical intervention; and/or one that 2. Impacts more than one area of the resident's health status This Citation relates to Complaint IN00456458. 3.1-37

Based on interview and record review, the facility failed to ensure medications brought from home were reconciled and securely stored for 2 of 3 residents reviewed (Resident B and Resident F). Findings include: A complaint, submitted to the Indiana Department of Health on 1/31/25, alleged Resident B had brought medications to the facility, but the medications were not returned to him upon discharge. While at the facility, he alleged he told nursing staff what medications he needed but they refused to give him the medication unless he brought in his home medications. He had someone go to his home, retrieve the medicaitons, return, and give the medications, Nexium (for acid reflux) and Mitagare (brand name for Colchicine used to treat gout) to a staff member. The resident was then discharged with his medications except for 2 he had brought from home. After returning home, Resident B alleged he had been unable to find the 2 medications and had erroneously been given a bag containing 22 bottles of another resident's medication (Resident F). The resident notified facility staff who went to his home to collect the bag of medications belonging to the other resident but were unable to find his 2 missing medications. Resident B then contacted the sheriff's department and reported the 2 missing medications. 1. On 2/25/25 at 10:50 A.M., Resident B's record was reviewed. Diagnoses included fall with fractured right femur requiring surgical repair, gastro-esophageal reflux disease (GERD), and gout. The resident was admitted from the hospital, following right hip replacement, for short-term rehabilitation services. Hospital discharge medication orders, dated 1/14/25, included Colchicine (Mitagare 0.6 mg oral capsule)-take 1 capsule by mouth daily for gout, Esomeprazole (Nexium 40 mg oral delayed release capsule, 1 capsule by mouth daily, brand name only) for GERD, and Pantoprazole 40 mg 1 tablet by mouth daily. A Nurse Practitioner (NP) note, dated 1/16/25 at 6:55 a.m., indicated the resident was seen for a post-hospital visit. The resident had gout and was prescribed Allopurinol and Colchicine daily, however, he indicated these 2 medications hadn't worked well and he needed the brand name of Colchicine, which was Mitagare, to manage his gout. The plan was to continue Allopurinol and Colchicine for gout and discontinue Nexium as he was also prescribed Pantoprazole which was duplicate therapy. An NP note, dated 1/20/25 at 7:15 a.m., indicated the resident was seen for a 2nd post-hospital visit. Resident B complained about not having Mitagare to treat his gout and his left lower extremity was beginning to hurt. He indicated if he went 7 days without that medication, he would want to cut his leg off because of the pain. The resident took Allopurinol and Colchicine daily but had indicated the Colchicine was ineffective. The change from Mitagare to the generic Colchicine was due to a pharmacy interchange but if he had Mitagare at home, he could bring it to the facility and staff would administer. Additional concerns he had was about the Nexium he was taking for GERD. He indicated he was getting Omeprazole 1 tablet but required 2 to equal the strength of Nexium (he was prescribed pantoprazole and nexium at the facility). Nexium was to be discontinued and the Pantoprazole continued. The plan indicated if the resident was able to provide Mitagare, the order could be changed from Colchicine (generic) to Mitagare (brand name). A nurse note, dated 1/20/25 at 9:30 a.m., indicated Resident B had been refusing Colchicine because it wasn't the correct medication. He refused the generic form of Nexium and indicated he needed the brand name of these medications. A Medication Administration Record (MAR) dated January 2025, indicated the resident had been prescribed and had taken Colchicine and generic Nexium daily on 1/15, 1/16, 1/17, 1/18, 1/19, 1/21 and 1/22/25 and had refused on 1/20/25 after stating they were not the correct medications. He was administered Mitagare 0.6 mg-1 tablet by mouth daily on 1/23 and 1/24/25 and the brand name Nexium daily on 1/23 and 1/24/25. The MAR indicated both Mitagare and Nexium were from his home supply. Resident B's medical record did not indicate when his home supply of Mitagare and name brand Nexium had been brought into the facility nor amount of medication he supplied from home. On 2/25/25 at 11:05 A.M., Licensed Practical Nurse 5 (LPN) was interviewed. She indicated she had discharged the resident from the facility on 1/24/25. The resident had 2 bottles of medication stored in the upper drawer of the secured nurses medication cart. 1 bottle was Mitagare 0.6 mg tablets and 1 bottle was Nexium 40 mg delayed release capsules. She removed the medications from the medication cart and placed them in a facility blue bag on the day of discharge. She indicated the resident had 2 of the facility blue bags filled with medications to take home with him. She didn't know when the bottles of medication had been brought in or how much medication had been in the bottles. LPN 5 indicated she had gone over discharge instructions, including his medications, and told him when he was ready to leave, he could pick up the medication in the 2 blue bags sitting on the nurses desk at the nurses station. She did not indicate what time she had gone over the discharge instructions or when the blue bags containing medications had been placed on the nurses desk. LPN 5 indicated next to Resident B's 2 blue bags, was a Walmart bag filled with an unknown number of bottles of Resident F's medications, brought from Resident F's home. The bag of medications was being picked up by Resident F's family member. LPN5 indicated she was not at the nurse's desk when Resident B left the facility and did not see who had picked up the bags of medications. She indicated all 3 bags were removed. A progress note, dated 1/24/25 at 6:28 p.m., indicated Resident B had discharged with a friend, all his belongings and medications sent home with him. Refer to F609. 2. On 2/25/25 at 3:12 P.M., Resident F's record was reviewed. Diagnoses included chronic pain syndrome and weakness. Prior to admission, she'd been hospitalized for acute respiratory issues and was receiving rehabilitation services with plans to go back home. Neither Resident F's progress notes nor admission assessments indicated home medications had been brought to the facility. An MAR, dated January 2025, listed medications prescribed and administered by staff. The MAR did not indicate any medications were from Resident F's home supply. Progress notes, dated 1/17/25 through 2/4/25, did not indicate home supplied medications had been returned to the resident. Resident F's record did not indicate Resident F's home medications had been erroneously given to another resident discharged home. A discharge assessment, dated 2/4/25, did not indicate home supplied medications had been returned to the resident. Resident F's record did not indicate her home medications had been erroneously given to another resident discharged home. On 2/25/25 at 12:05 P.M., the Administrator and Assistant Directors of Nursing (ADON 8 and ADON 9) were interviewed. The Administrator indicated staff didn't know what happened to Resident B's 2 bottles of missing medications and she wasn't aware 3 bags of medications had been left unsecured on the nurse's station desk. Both ADON's indicated neither Resident B's nor Resident F's medications should've been left unsecured at the nurses station. Medications brought in from home by residents were to be documented in the resident record when received, when returned to the resident, and kept securely stored. ADON 8 indicated there had been no documentation in the record of the number of medications placed in a bag to be returned to Resident F's family. The Administrator indicated she had been notified of the missing medications reported to the sheriff's office. Prior to being notified of the police report, she indicated, on 1/28/25, the Director of Nursing (DON) had picked up Resident F's medications from Resident B's home and the facility offered to pay for the missing medications but had received no response from the resident. Current facility pharmacy policies, provided by the Administrator on 2/25/25 at 10:45 A.M., indicated the following: -Medication Brought into the Facility policy stated: Procedure: Facility staff should not administer medications .brought to facility by a resident .without physician/prescriber's order .Facility staff should return any unused medications brought into the facility by the resident .to the resident's family .A facility nurse should store unused non-controlled substance medications securely -Loss or Theft of Medications policy stated: Where facility staff suspect theft or loss of medications, staff should take such actions as required by applicable law and facility policy. Appropriate actions may include, without limitation: 1. Immediately reporting suspected theft of loss of drugs to supervisor/manager or Director of Nursing for appropriate investigation and follow up; and 2. Investigating and reconciling discrepancies This Citation relates to Complaint IN00452515. 3.1-25

Based on interview and record review, the facility failed to ensure an allegation of missing medication was reported for 1 of 3 residents reviewed (Resident B). Findings include: A complaint, submitted to the Indiana Department of Health on 1/31/25, alleged Resident B had brought medications to the facility during his stay. The allegations included the medications were not returned to him upon discharge. While at the facility, he alleged he told nursing staff what medications he needed but they refused to give him any medication unless he brought in his home medications. He had someone go to his home and return with the medication. The home medication was given to a staff member to administer. The resident was then discharged home. After returning home, Resident B alleged he had been unable to find the 2 medications he had brought to the facility from home. Resident B notified the facility of the missing medications. The facility was unable to find the 2 missing medications brought from home. Resident B then contacted the sheriff's department and reported the 2 missing medications. The missiong medications were Nexium (for acid reflux) and Mitagare (brand name for Colchicine used to treat gout). Resident B indicated both medications (90 pills each) had been filled in December 2024. On 2/25/25 at 10:50 A.M., Resident B's record was reviewed. Diagnoses included fall with fractured right femur requiring surgical repair, gastro-esophageal reflux disease (GERD), and gout. The resident was admitted from the hospital for short-term rehabilitation services. A Medication Administration Record (MAR) dated January 2025, indicated the resident was administered Mitagare 0.6 mg-1 tablet by mouth daily on 1/23 and 1/24/25 for gout and the brand name Nexium daily on 1/23 and 1/24/25. The MAR indicated both Mitagare and Nexium were from his home supply. On 2/25/25 at 11:05 A.M., Licensed Practical Nurse 5 (LPN) was interviewed. She indicated she had discharged the resident from the facility on 1/24/25. The resident had 2 bottles of medication, supplied from home, stored in the upper drawer of the secured nurses medication cart. 1 bottle was Mitagare 0.6 mg tablets and 1 bottle of Nexium 40 mg delayed release capsules. She removed the medications from the medication cart and placed them in a facility blue bag on the day of discharge. She indicated the resident had 2 of the facility blue bags filled with medications to take home with him. LPN 5 indicated she had gone over discharge instructions, including his medications, and told him when he was ready to leave, he could pick up the medication in the 2 blue bags sitting on the nurses desk at the nurses station. She was not at the nurse's desk when Resident B left the facility and did not see who had picked up the bags of medications. On 2/25/25 at 12:05 P.M., the Administrator was interviewed. She and the Director of Nursing (DON) had been made aware Resident B's 2 missing medications. On 1/28/25, the DON offered to replace his 2 missing medications becasue the facility had not found the Nexium or the Mitagare. Resident B did not accept the offer and did not return phone calls to the facility. The Administrator indicated staff hadn't known what happened to the 2 bottles of missing medications and she hadn't been aware medications had been left unsecured on the nurse's station desk when the medications had gone missing. She was notified by the manager on duty, on 2/1/25, a police report had been filed regarding the 2 missing medications and a police officer was in the building to follow up on the report. The Administrator indicated she had not reported the incident but should have according to the facility policy. A current facility policy, titled Indiana Resident Abuse Policy, was provided by the Administrator on 2/25/25 at 10:45 A.M., and stated: The facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone .Allegations of misappropriation of resident property must be reported immediately .The facility will contact the police for any allegation of misappropriation of resident property .Complete reporting per state specific procedure This Citation relates to Complaint IN00452515. 3.1-28(c)

Based on interview and record review, the facility failed to ensure an allegation of abuse and injury of unknown origin was reported for 1 of 3 residents reviewed for abuse (Resident F). Findings include: An anonymous complaint, reported to the Indiana Department of Health, dated 11/12/24, alleged Resident F had been hit by a visitor and was found with a black eye the following day. On 12/6/24 at 1:15 P.M., Resident F's record was reviewed. Diagnoses included vascular dementia with agitation, impulsiveness, delusional disorder, anxiety disorder, and major depressive disorder. She resided on the secured memory care unit. 1. A nurse progress note, dated 10/20/24 at 5:00 p.m., indicated a nurse manager notified the floor nurse Resident F had wandered into another resident's room and was hitting their visitor on the shoulder. In response, the visitor grabbed Resident F's shoulder to get her out of the room. The situation was reported to the Administrator and witness statements were obtained by the nurse manager. Witness statements indicated: -On 10/20/24 at unknown time, the Minimum Data Set (MDS) nurse was asked to go to the secured memory care unit after reports Resident F had been hit by another resident's visitor. The MDS nurse went to the peer's room and spoke with the visitor who confirmed the events. The visitor indicated they had stepped between the 2 residents when Resident F entered the room. Resident F hit the visitor on the shoulder. The visitor told Resident F not to hit and leave the room. Resident F hit the visitor on the other shoulder. The visitor then grabbed Resident F by the shoulders and removed her from the room. Resident F had no observed injuries at the time and continued to roam the halls without issues. -On 10/20/24 at unknown time, a peer's visitor wrote he had been near the door of his loved one's room, when Resident F moved the STOP sign banner across the doorway and came into the room, directly in front of him. The visitor told the resident to leave as did the other resident. Resident F hit the visitor in the left chest/shoulder. The visitor told her Do not hit me-leave. Resident F hit him in the right chest/shoulder in response. The visitor grabbed Resident F's upper arms near her shoulders, moved her backwards towards the door and told her to leave. The resident left the room and went across the hall. There was no further documentation completed, no reporting the incident as required, nor further investigation of the incident. In an interview, on 12/6/24 at 1:51 P.M., the MDS nurse indicated on 10/20/24, he told the nurse who documented the incident in the resident's record and reported the incident to the Administrator. 2. On 10/21/24 at 7:00 a.m., a nurse progress note indicated Resident F had been observed with a 1 inch laceration above her right eye and a 2 inch skin tear on her right hand above her thumb. Both areas were cleansed but the resident was observed to get frustrated with first aid attempts. Resident F showed no signs of distress or discomfort but was unable to tell nurse how the injuries occurred and she'd had no recent falls. A Focused Head to Toe Observation, dated 10/21/24 at 12:09 p.m., indicated Resident F was involved in a possible altercation. During the assessment, the resident was anxious/nervous/restless. She had right eyelid bruising, a scrape in her eyebrow, and right wrist skin tear. There was no further documentation indicating the incident had been reported, the cause of the resident's injuries nor was the resident able to tell staff how the injuries had occurred. On 12/6/24 at 3:30 P.M., the Administrator indicated both incidents should have been reported to her immediately as well as the State agency, and investigations started. A current policy, titled Indiana Resident Abuse Policy, was provided by the Administrator on 12/6/24 at 11:00 A.M. which indicated the following: It is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, and exploitation of residents, misappropriation of resident property and injuries of unknown source. Facility staff must immediately report all such allegations to the Administrator/Abuse Coordinator. The Administrator/Abuse Coordinator will immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in this policy .Abuse includes actions such as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse includes .verbal abuse, physical abuse .and injuries of unknown origin .Injury of unknown source is when both the following conditions are met: a. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident AND b. The injury is suspicious because of the extent of the injury, location of the injury .All allegations of Abuse, Neglect, Involuntary Seclusion, Injuries of Unknown Source .must be reported immediately to the Administrator, Director of Nursing and to the applicable State Agency .Protect the Resident .If a person not on staff is accused of Abuse .the facility will take action to protect the resident including, but not limited to, contacting the third party and addressing the issue directly with him/her, preventing access to resident during the investigation, and/or referring the matter to the appropriate authorities This Citation relates to Complaint IN00447189. 3.1-28(c)

Based on interview and record review, the facility failed to ensure a thorough investigation of allegation of abuse and injury of unknown source was completed for 2 of 3 residents reviewed for abuse (Resident F and Resident G). Findings include: An anonymous complaint, reported to the Indiana Department of Health, dated 11/12/24, alleged Resident F had been hit by a visitor and was found with a black eye the following day. On 12/6/24 at 1:15 P.M., Resident F's record was reviewed. Diagnoses included vascular dementia with agitation, impulsiveness, delusional disorder, anxiety disorder, and major depressive disorder. She resided on the secured memory care unit. An annual Minimum Data Set (MDS) assessment, dated 9/6/24, indicated Resident F had severely impaired cognition and rarely spoke. She had behaviors of inattention continually present and disorganized intermittant thinking behaviors which changed in severity. Staff assessment of her mood indicated she had little interest or pleasure in doing things, trouble concentrating, and trouble falling asleep almost daily. She had no wandering behaviors, no verbal or physical behaviors, and had not rejected care. She was independent with eating, walking and transfers, had no falls in the past 3 months, required maximal assistance with personal hygiene and bathing, and was dependent for toileting and dressing. Care plans, revised on 12/5/24 and 12/6/24, included: -Psychosocial well-being: Resident F resided on a secured unit due to dementia. She exhibited exit seeking tendencies, was an elopement risk, and had episodes of wandering in and out of others room at times, were difficult to redirect. Interventions included: attempt to redirect when wandering; encourage daily participation in activities and social events; and encourage family visits. -Behavioral symptoms: The resident was at risk for elopement and wandering. She wandered without purpose, wandered into other resident rooms, and disregarded STOP signs across other residents doorways. Interventions were to keep resident occupied; calmly redirect her; divert her attention; and relocate her to a different area. A nurse progress note, dated 10/20/24 at 5:00 p.m., indicated a nurse manager notified the nurse Resident F had wandered into another resident's room and hit their visitor in the shoulder. In response, the visitor grabbed Resident F's shoulder to get her out of the room. The situation was reported to the Administrator. Witness statements were obtained by the nurse manager from the visitor and staff present. Witness statements indicated: -On 10/20/24 at unknown time, the MDS nurse was approached by Certified Nurse Aide 2 (CNA) and asked to go to the secured memory care unit. CNA 2 indicated Resident F had hit Resident G's visitor. Resident G's visitor removed Resident F from the room by grabbing her shoulders. CNA 2 went into Resident G's room to find out what happened when the visitor re-enacted the incident by grabbing CNA 2's shoulders. CNA 2 told the visitor not to touch her but he still grabbed her by the shoulders. The MDS nurse went to Resident G's room and spoke with the visitor who confirmed the events. The visitor indicated they had stepped between Resident G and Resident F when she entered the room. Resident F hit the visitor on the shoulder and was told not to hit and leave the room. Resident F hit the visitor on the other shoulder and then the visitor grabbed her by the shoulders and removed her from the room. Resident F had no observed injuries at the time and continued to roam the halls without issues. -On 10/20/24 at unknown time, Resident G's visitor wrote he had been near the door of Resident G's room, when Resident F moved the STOP sign banner across the doorway and came into the room, directly in front of him. The visitor told the resident to leave as did Resident G. Resident F hit the visitor in the left chest/shoulder. The visitor told her Do not hit me-leave then she hit him in the right chest/shoulder. The visitor grabbed Resident F's upper arms near her shoulders, moved her backwards towards the door and told her to leave. The resident left the room and went across the hall. There was no further documentation completed regarding further investigation of the incident including protection of Resident F or others who could wander into Resident G's room. Confidential interviews, conducted during the survey, indicated Resident G's visitor had grabbed the resident by the shoulders and moved her backwards towards the door. The visitor had not put Resident G's call light on nor summoned staff for help. After the incident, Resident G's visitor was not asked to leave the facility nor were his visits restricted. Visitors were not allowed to grab or push residents around when visiting the facility. Action of grabbing or pushing could be indicative of abuse. There was no documentation completed from 10/20/24 at 5:00 p.m. until 10/21/24 at 7:00 a.m. when a nurse note indicated Resident F had been observed with a 1 inch laceration above her right eye and a 2 inch skin tear on her right hand above her thumb. Both areas were cleansed but the resident was observed to get frustrated with first aid attempts. Resident F showed no signs of distress or discomfort but was unable to tell nurse how the injuries occurred and she'd had no recent falls. The Assistant Director of Nursing (ADON) and Medical Nurse Practitioner (NP) were notified. A Focused Head to Toe Observation, dated 10/21/24 at 12:09 p.m., indicated Resident F was involved in a possible altercation. During the assessment, the resident was anxious/nervous/restless. She had right eyelid bruising and scrape in her eyebrow, and right wrist skin tear. A nurse progress note, dated 10/21/24 at 3:31 p.m., indicated an order was given to apply steri-strips to the resident's skin tear on her right wrist. The scrape above her right eye was superficial and left open to air. A Wound Care NP progress note, dated 10/22/24 at 11:49 a.m., indicated the resident was seen following a fall and sustaining abrasions. She was pleasantly confused and wandered around the memory care unit. Her right eye was dark purple and blue around the rim with slight swelling noted. She had a right lateral skin tear with wound edges flat and attached. Assessment/Plan: Right hand skin tear-okay to leave open to air. Right orbital (eye) hematoma-staff to monitor. A nurse progress note, dated 10/22/24 at 5:23 p.m., indicated bruising to the resident's right eye remained purple in color and she denied pain/discomfort. A Psychiatric NP progress note, dated 10/22/24 at 7:19 p.m., indicated Resident F was seen for follow-up. She was observed wandering the unit and intruding into other resident's rooms. Despite multiple attempts by staff, she'd been difficult to redirect. The Assessment/Plan was Unspecified fall: The resident recently had an unwitnessed fall, likely due to her impulsivity and intrusive wandering. It was unclear exactly what happened during the incident. The Psychiatric NP progress note didn't indicate the resident had been involved in an altercation with a visitor prior to her injuries being observed or if the 2 incidents were related. A Interdisciplinary (IDT) note for skin integrity, dated 10/24/24 at 12:15 p.m., indicated Resident F had returned from a walk during mealtime with a laceration above her right eye and right hand. Steri-strips were applied to the right wrist skin tear. Her right forehead scrape was superficial and left open to air. Resident F had no signs of psychosocial distress; continued to walk, pace, and participate in activities of choice. The IDT note didn't include an investigation of the injury of unknown origin nor mention of the altercation between Resident F and the visitor on 10/20/24. There was no documentation to indicate Resident F had been assessed for injury following the incident and being grabbed on the shoulders by a visitor. On 12/6/24 at 2:30 P.M., the ADON was interviewed. She indicated the altercation between Resident F and Resident G's visitor had not been reported to her as documented in the record. She had been told of the injury to the resident's right eye and wrist and had called the night shift nurse on 10/21/24 at 1:30 p.m. to see if the nurse had seen any injuries to the resident or if she had fallen through the night. The night shift nurse indicated she hadn't seen any injuries or skin issues and staff hadn't reported any to her. Resident F had laid on a recliner chair in the dayroom for most of the night and had no known falls. She was unaware of any further investigation into either incident. On 12/6/24 at 2:50 P.M., Licensed Practical Nurse 3 (LPN) was interviewed. She indicated she served as the facility's in-house wound nurse. On Monday, 10/21/24, she had gone to the memory care unit to see if the nurse needed any assistance. She observed Resident F with a black eye which looked as if someone had hit the resident which had shocked her. The nurse, on duty, had indicated she saw it when she first arrived to the facility that morning, had immediately reported it to the Assistant Director of Nursing (ADON) and medical NP. LPN 3 indicated, late morning, she had been asked to perform a head to toe skin assessment which she had done with staff assistance. She indicated it had been very brief because of the resident's resistance to having her clothes removed. She observed Resident F with a black/purple right eye with a swollen eyelid. She had an abraised area in her right eyebrow which measured 0.2 centimeters (cm) by 0.1 centimeters. A skin tear to her right wrist, measured 2 cm by 0.2 cm, was cleansed, steri-strips applied followed by antibiotic ointment. She indicated she hadn't been told how the resident got the injuries nor been involved in investigating their cause. LPN 3 had not known about the altercation on 10/20/24 between the resident and Resident G's visitor, but hadn't seen any bruises on the resident's arms during her brief assessment. On 12/6/24 at 3:30 P.M., the Administrator indicated both incidents should have been investigated immediately. A current policy, titled Indiana Resident Abuse Policy, was provided by the Administrator on 12/6/24 at 11:00 A.M. which indicated the following: It is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, and exploitation of residents, misappropriation of resident property and injuries of unknown source. Facility staff must immediately report all such allegations to the Administrator/Abuse Coordinator. The Administrator/Abuse Coordinator will immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in this policy .Abuse includes actions such as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse includes .verbal abuse, physical abuse .and injuries of unknown origin .Injury of unknown source is when both the following conditions are met: a. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident AND b. The injury is suspicious because of the extent of the injury, location of the injury .All allegations of Abuse, Neglect, Involuntary Seclusion, Injuries of Unknown Source .must be reported immediately to the Administrator, Director of Nursing and to the applicable State Agency .Once the Administrator and DOH are notified, an investigation of the allegation or suspicion will be conducted .The person investigating the incident should generally take the following actions: Interview the resident, accused, and all witnesses .If there are no direct witnesses, then the interviews may be expanded. For example, to cover all employees on the unit, or, as appropriate, the shift. For Injuries of Unknown Source, the investigation will generally involve talking with both the shift on duty when the injury was discovered and prior shifts as well. Obtain written statements from the resident, if possible, the accused, and each witness .Documentation: Evidence of the investigation should be documented This Citation relates to Complaint IN00447189. 3.1-28(c)

Based on interview and record review, the facility failed to ensure monitoring and assessment related to recurrent urinary retention for 1 of 1 residents reviewed (Resident E). Findings include: On 10/15/24 at 2:15 P.M., Resident E's record was reviewed. Diagnoses included dementia, chronic obstructive pulmonary disease (COPD), and anxiety disorder. An annual Minimum Data Set (MDS) assessment, dated 6/3/24, indicated Resident E had severely impaired cognition, was always incontinent of bladder and bowel and was dependent on staff for transfers on and off the toilet and toileting hygiene. A urinary care area assessment (CAA), dated 6/4/24, indicated the resident was incontinent of bladder and bowel and a care plan had been initiated to prevent/minimize complications. A care plan, revised on 7/24/24, indicated the resident was incontinent of bowel and bladder. The goal was for Resident E to receive assistance with toileting, be comfortable, clean, dry and free from skin breakdown. Interventions, dated 12/19/23, were: administer medications per physician order; assess resident's pattern of episodes of incontinence; monitor for redness, irritation, skin excoriation and breakdown; and provide incontinence care as needed. A nurse progress note, dated 8/2/24 at 9:52 a.m., indicated the resident was constantly yelling out for help but was unable to tell staff what he needed help with. The Nurse Practitioner (NP) was notified and order given for one time dose of anti-anxiety medication. -At 1:09 p.m., Resident E was observed perspiring and having anxiety. His oxygen saturation levels were low at 82% (Normal is >90%). He was given oxygen and began to calm down. His daughter was informed and indicated he could become hypoxic (low oxygen) and had orders for oxygen when his happened because it created anxiety for him. The NP ordered a STAT chest x-ray and supplemental oxygen to be on continuously until the chest x-ray results were in. -At 4:01 p.m., the NP and resident's daughter were notified of the normal chest x-ray results. He became anxious again, as his daughter was leaving the facility and began yelling out for staff to help him. The NP ordered Ativan (anti-anxiety) by mouth every 8 hours as needed (PRN) for 14 days in addition to his routine dose of Ativan given daily at 5:00 p.m. An NP progress note, dated 8/5/24 at 3:23 p.m., indicated Resident E had been seen for follow up of worsening anxiety from 8/2/24. A urinalysis was ordered on 8/2/24, then successfully collected on 8/5/24 to rule out an infection worsening his anxiety. A nurse progress note, dated 8/6/25 at 6:00 a.m., indicated the resident was straight cathed for not having any urine output with a distended abdomen. 1000 milliliters of urine was removed. The NP was notified of his urinary retention and an order given to administer 1 dose of antibiotic intramuscularly for urinary retention. The order included a urine for culture (obtained and taken to hospital on 8/5/24) and to obtain labwork. The resident displayed anxiety. He had a low oxygen level of 84%. Oxygen was applied and his oxygen level increased and he was given PRN Ativan for the anxiety. An NP progress note, dated 8/9/24 at 6:08 p.m., indicated the resident was seen for follow up of anxiety. The note indicated his x-rays, lab work and urinalysis were all unremarkable. There was no documentation or follow up of the resident's urinary retention. There was no abdominal assessment or documentation of urine output monitoring. There was no documentation in the nurse notes, NP progress notes or care plan addressing the urinary retention observed on 8/6/24. NP progress notes and nurse progress notes, from 8/8/24 at 6:00 a.m. until 8/28/24, indicated Resident E had intermittent episodes of anxiety, a fast heart rate and low oxygen levels. The resident was not monitored or assessed for cause of the urinary retention or reoccurrence of the condition. Vital signs obtained 8/28/24 indicated Resident E had a low grade temperature of 98.8. Hospital records, dated 8/28-8/30/24, indicated the resident had been seen in the emergency room due to lethargy, shortness of breath, low oxygen blood levels, and not eating or drinking well. On arrival to the hospital, on 8/28/24, his heart rate was elevated, respirations were fast and hard, oxygen level low, temperature elevated at 101 degrees, and he had abnormal lab results with a high white blood count (indicated infection). A CAT scan x-ray was done of his pelvis which showed marked distention of the urinary bladder with mild enlargement of both kidneys due to back up of urine from the bladder. A urinalysis showed pus and bacteria in his urine and blood cultures were positive with E. Coli bacteria. Resident E was diagnosed with sepsis due to E. Coli bacteremia from a urinary tract infection and urinary retention. A copy of Resident E's documentation of bladder incontinence, dated August 2024, indicated there was no output documented for 1 to 2 shifts on 9 of the 22 days between 8/6 and 8/28/24. On 10/15/24 at 3:38 P.M., Resident E's daughter was interviewed. She indicated the resident had been admitted to hospice following his hospitalization . When asked, she indicated the resident had no history of urinary retention. She alleged chronic issues with her father's toileting and personal hygiene and her belief these issues contributed to his infection and death. On 10/15/24 at 3:00 P.M., the Director of Nursing (DON) and Regional Director of Clinical Services (RDCS) were interviewed. They indicated there was no facility policy for assessing and monitoring residents for urinary retention. The DON indicated the Certified Nurse Aids (CNA) documented, each shift, resident's urinary output by charting continent or incontinent. This Citation relates to Complaint IN00444452. 3.1-37

Based on observation, interview, and record review, the facility failed to ensure services were effectively provided to identify, monitor, and treat an area of facility-acquired skin impairment and failed to ensure interventions were implemented to provide effective pressure relief to the wound for a resident admitted without skin impairment for 1 of 4 residents reviewed for pressure injuries. (Resident 243) This deficient practice resulted in the facility-acquired skin impairment deteriorating to a stage three pressure injury with infection that required antibiotic therapy. Findings include: Resident 243's record was reviewed on 9/17/24 at 10:46 AM. Diagnoses included unspecified focal traumatic brain injury with loss of consciousness status unknown, type 2 diabetes mellitus with diabetic polyneuropathy, and paresthesia of skin. A hospital discharge summary, dated 9/1/24 at 12:25 PM, indicated no skin rashes or lesions were present on Resident 243's skin. An admission assessment, dated 9/1/24 at 5:52 PM, indicated Resident 243's skin was warm, dry, and intact, had normal color and turgor with two abrasions noted on the left knee. No pressure ulcers were indicated on the admission skin assessment. A section of the admission assessment labeled care plan included selections of continue current care plan, initiate care plan and plan of care updated. None of the selections indicated a care plan was initiated, or interventions were implemented. A Braden Scale assessment, dated 9/1/24 at 5:52 PM, included in the admission assessment indicated Resident 243 had a slightly limited ability to respond meaningfully to pressure or discomfort, his skin was occasionally moist, and required a linen change about once a day. The assessment indicated Resident 243 was bedfast, was able to make frequent slight position changes, and had adequate meal intakes. The assessment indicated friction and shear were not an apparent problem. Intervention and care plan actions were blank with no interventions selected for pressure ulcer prevention. A weekly skin assessment, dated 9/2/24 at 2:09 PM, was blank with no indication whether skin conditions were present or not. A skilled nursing note, dated 9/3/24 at 2:34 PM, indicated skin impairment was present, but no corresponding wound assessment was available for review. The type, characteristics, and location of skin impairment was not specified on the assessment. A skilled nursing note, dated 9/4/24 at 4:23 PM, indicated Resident 243's skin was intact with no impairment. No skilled nursing notes, progress notes or wound assessment records for 9/5/24 were available for review. A skilled nursing note, dated 9/6/24 at 3:42 AM, indicated Resident 243's skin was intact with no impairment. No skilled nursing notes, progress notes or wound assessment records for 9/7/24 were available for review. A skilled nursing note, dated 9/8/24 at 1:51 AM, indicated skin impairment was present, but no corresponding wound assessment was available for review. The type, characteristics, and location of skin impairment was not specified on the assessment. Resident 243's current admission Minimum Data Set (MDS) assessment, dated 9/8/24, indicated his Basic Interview for Mental Status (BIMS) score was 12 (mild cognitive impairment). The MDS indicated Resident 243 was dependent on staff to roll back and forth in bed and move from a lying to sitting position in bed. The MDS indicated Resident 243 did not have recorded occurrences of rejection of care. The MDS indicated he was at risk for development of pressure ulcers and had no current pressure ulcers. The comprehensive plan of care, dated 9/3/24 through 9/9/24, did not include documentation to indicate a plan of care to provide pressure relief to the left elbow skin impairment was developed. Resident 243's current care plan, initiated 9/9/24, titled Skin Integrity? indicated Resident 243 was at risk for skin breakdown related to incontinence, impaired mobility, diabetes mellitus, and indicated the resident had a problem of risk for skin breakdown. Interventions included: remove the headboard from the bed and place an air mattress; assess for presence of risk factors, treat, reduce, and eliminate factors to extent possible; avoid shearing resident's skin during positioning, transferring, and turning; conduct a systematic skin inspection, pay particular attention to bony prominences; keep clean and dry as possible; minimize skin exposure to moisture; keep linen dry and wrinkle free; pressure reducing cushion to wheelchair; pressure reducing mattress to bed; report any signs of skin breakdown(sore, tender, or broken areas); and use moisture barrier product to perineal area. A skilled nursing note, dated 9/9/24 at 10:38 PM, indicated Resident 243's skin was intact with no impairment. A progress note, dated 9/10/24 at 8:55 AM, indicated Nurse Practitioner (NP) 5 had been notified of an open area on the left elbow NP 4 had addressed earlier and a bandage was in place. A Wound Management Detail Report, dated 9/10/24 at 10:11 AM, indicated the facility-acquired skin impairment on the left elbow was a Stage III (three) pressure ulcer measured 2.0 centimeters (cm) length (L) by 1.8 cm width (W) by 0.0 cm depth (D), had light exudate (drainage), 20 precent granulation tissue and 80 percent slough (necrotic tissue). The report indicated the ulcer had well defined wound edges and edema (swelling) of the skin surrounding the wound. A skilled nursing note, dated 9/10/24 at 10:53 AM, indicated skin impairment was observed but no corresponding wound assessment was available for review. The type, and location of skin impairment was not specified on the assessment. A progress note, dated 9/10/24 at 11:26 AM, indicated NP 4 had been notified of a skin tear on the left elbow by nursing staff. She indicated the left elbow wound had full thickness loss, with 80 percent slough in the wound bed, 20 percent granulation tissue and a small amount of serosanguinous exudate (blood-tinged drainage) with blanchable redness surrounding the area. NP 4 provided orders to cleanse the wound, pat dry, apply Medi-honey to the wound bed, cover with a foam dressing, change every other day and as needed upon soilage or dislodgement. The Centers for Medicare and Medicaid Services (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) User's Manual Version 1.18.11 October 2023 Section M0300C, page M-13, indicated, .Stage 3 [three] Pressure Ulcer .Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. Untimed Physician orders, dated 9/10/24, indicated Resident 243's pressure sore should be measured with progress documented weekly. Untimed Physician's orders, dated 9/10/24, indicated an air mattress was ordered. A Treatment Administration Record (TAR), dated September 2024, indicated beginning 9/10/24 at 2:00 PM, through 9/18/24, staff should change Resident 243's position every two hours or more often, and pressure should be avoided to the affected area. A skilled nursing note, dated 9/11/24 at 9:23 AM, indicated a skin impairment was observed and indicated Resident 243 had no orders for any type of dressing. No description of the left elbow ulcer or assessment details were available for review. A skilled nursing note, dated 9/12/24 at 11:25 PM, indicated a skin impairment was observed and indicated Resident 243 had no orders for any type of dressing. No description of the left elbow ulcer or assessment details were available for review. No skilled nursing notes, progress notes or wound assessment records for 9/13/24 were available for review. No skilled nursing notes, progress notes or wound assessment records for 9/14/24 were available for review. A skilled nursing note, dated 9/15/24 at 7:00 AM, indicated skin was intact without impairment, and Resident 243 had no orders for any type of dressing. The September 2024 TAR indicated the resident should have an air mattress and staff should measure and document wound progress weekly. The record did not include documentation to indicate staff measured the left elbow wound or the wound progress was evaluated between 9/10/24 and 9/17/24. A skilled nursing note, dated 9/16/24 at 3:59 AM, indicated a skin impairment was observed, but Resident 243 had no orders for any type of dressing. No description of the left elbow ulcer or assessment details were available for review. A Braden Scale assessment, dated 9/16/24 at 12:58 PM, indicated Resident 243 had very limited ability to feel or communicate pain, had very moist skin, required linen change at least once a shift, and was chairfast with very limited ability to make frequent or significant changes in position. The assessment indicated Resident 243 had adequate meal intakes, and shearing and friction were a problem. The assessment indicated Resident 243 was at high risk for skin breakdown. The assessment indicated no interventions or care plan changes were made to increase pressure relief for Resident 243's left elbow. A skilled nursing note, dated 9/17/24 at 12:20 AM, indicated a skin impairment was observed, but Resident 243 had no orders for any type of dressing. No description of the left elbow ulcer or assessment details were available for review. A Wound Management Detail Report, dated 9/17/24 at 10:38 AM, indicated a Stage III pressure ulcer on the left elbow measured 2.0 cm (L) by 1.5 cm (W) by 0.0 cm (D), moderate serous (clear) exudate and 80 percent covered by slough. The left elbow ulcer had well defined wound edges and edema (swelling) of the skin surrounding the wound. A progress note, dated 9/17/24 at 11:41 AM, indicated NP 4 determined there was a decline in the left elbow ulcerated area with evidence of cellulitis. She indicated an antibiotic would be started to treat the cellulitis. No description of the left elbow ulcer or assessment details were documented in the notes. Physician's orders, dated 9/17/24, indicated to give doxycycline hyclate (an antibiotic) 100 milligrams twice daily for ten days. An untimed progress note, dated 9/18/24, indicated an ABD pad may be substituted for the foam dressing ordered to the left elbow due to foam dressing not being available one time only. During an observation on 9/18/24 at 10:25 AM, Resident 243 was observed lying on his back in bed with his left arm propped on a pillow and covered with a sheet. Registered Nurse (RN)2 entered the room carrying an abdominal (ABD) pad and a package of Medi-honey (a treatment to dissolve dead tissue in a wound). She indicated she was not prepared, returned a few minutes later carrying a bottle of wound cleanser and was accompanied by the Infection Preventionist (IP). She approached the resident with the wound cleanser when the IP prompted her to don a gown prior to beginning the procedure. After donning the gown and gloves, RN 2 pulled the sheet back and cleansed the wound. The tip of Resident 243's elbow had a nickel-sized, brown centered, round wound surrounded on all edges by yellow slough with bright red skin surrounding the immediate edges and swollen, pink skin surrounding two to three inches of the arm. RN 2 performed hand hygiene, changed her gloves and applied a piece of Medi-honey to the wound bed, touching the wound bed with her gloved hand in the process. She then picked up the dressing, placed it on the wound, secured it in place without performing hand hygiene use or applying clean gloves after touching the wound bed. According to medihoney.com an article, titled Manufacturer's Guideline, dated January 2024, indicated Medi-honey was used to promote a moist wound environment to aid and supports autolytic debridement (dissolves dead tissue). During an interview on 9/18/24 at 10:25 AM, Resident 243's wife indicated he had an infected left elbow, and the nurse was going to return to the room to perform a dressing change within the next few minutes. Resident 243's wife indicated she was concerned about Resident 243's elbow because she reported to the nurses that it had looked infected and was warm to touch several days before a Nurse Practitioner saw it and ordered an antibiotic. During an interview on 9/18/24 at 10:45 AM, the IP indicated hand hygiene should be done before each procedure, after removing any dressing, and after wound care is complete. She indicated she would have to review the policy to see if hand hygiene and glove change is required after touching the wound during the packing of a treatment product. During an interview on 9/19/24 at 10:22 AM, CNA 3 indicated the facility did not use a written reporting system for CNA staff to notify the nurse of skin concerns. She indicated she informed her nurse verbally sometime during her shift over that weekend and she believed the nurses were aware of the area on the elbow prior to that because it had been there for a while. She could not recall when she first observed the area on the elbow. She indicated the area looked like a scab but could not recall the size or what the skin around it looked like. During an interview, on 9/19/24 at 1:18 PM, Nurse Practitioner 5 indicated on 9/10/24 an unidentified CNA asked if she needed to order a bandage for Resident 243's left elbow. She indicated the elbow had an area around the size of the end of her thumb (about the size of a dime) with slough in the center. She indicated it did not appear to be a result of a skin tear. She indicated the area was positioned on a pressure point and was the result of pressure. She indicated she was not aware of any skin impairment on the left elbow prior to that encounter. A current policy titled Clean Dressing Change Policy, dated 3/10/24, provided by the IP on 9/18/24 at 1:00 PM, indicated hand hygiene and donning new gloves should occur if a wound is touched during the assessment process. A current policy titled Skin and Wound Care Best Practices, last revised 6/10/22, provided by the IP, on 9/18/24 at 3:07 PM, indicated pressure reduction and redistribution should be provided to residents determined to be at risk. The policy indicated full body skin assessments should be conducted upon admission, with a second full body assessment conducted within the first 24 hours of admission. Staff should complete a Weekly Skin Check and review nursing assistant's shower sheet skin reviews. The policy indicated pressure injuries and wounds should be treated with evidenced based interventions as ordered by the provider. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview and record review, the facility failed to ensure a prescribed medication was provided for 1 of 4 residents reviewed (Resident 64). Findings include: On 9/19/24 at 9:11 AM, Licensed Practical Nurse (LPN) 8 was observed preparing medication for Resident 67. LPN 8 was unable to locate the medication Xtandi (a cancer medication) in the medication cart. The medication was not available in the facility medication dispensary machine. In an interview on 9/19/24 at 9:19 AM, LPN 8 indicated in the event of an unavailable medication, the resident's prescribing physician and the pharmacy should be notified. Resident 67's record was reviewed on 9/19/24 at 10:30 AM. Diagnoses included bone cancer, prostate cancer and bladder cancer. Resident 67's Admission Minimum Data Set, (MDS) dated [DATE], indicated the resident's Brief Interview for Mental Status (BIMS) score was 3 (severe cognitive impairment). Resident 67's Medication Administration Record (MAR), dated 9/1/24 through 9/19/24, indicated the resident was to be administered Xtandi 1 time a day beginning on 9/11/24. The MAR indicated the resident had been administered Xtandi on 9/12/24, 9/14/24, 9/17/24 and 9/18/24. The MAR indicated the resident had not been administered Xtandi on 9/13/24 due to the medication being on order. The MAR indicated Resident 67 had not been administered Xtandi on 9/15/24, but no reason for the medication not being administered was documented. The MAR indicated Resident 67 had not been administered Xtandi on 9/16/24 due to the medication being unavailable. Resident 67's progress notes, dated 9/11/24 through 9/18/24 did not indicate the pharmacy or the prescribing physician had been notified of Xtandi being unavailable. In an interview on 9/19/24 at 11:37 AM, the Director of Nursing (DON) indicated Resident 67's wife was to supply Xtandi to the facility. The DON indicated 9/19/24 was the first day the medication had been unavailable. The DON indicated Resident 67's wife did not supply a dose for 9/19/24 as the resident was to be discharged on [DATE]. A current facility policy, dated 12/1/07 and revised on 8/1/24, provided by the DON on 9/19/24 at 11:20 AM indicated the facility should notify the resident's physician if a medication is unavailable from the pharmacy. The policy indicated the nurse should document the circumstances surrounding the missed on the MAR and in the progress notes if a missed dose is unavoidable. 3.1-25(a) and (b)(1) and (c)

Based on interview, and record review the facility failed to ensure interventions were followed to prevent falls for 1 of 24 residents reviewed (Resident 22). Findings include: During an interview on 9/17/24 at 2:13 PM, Resident 22 indicated she had been in the facility for about a month and was concerned because she fell 3 times since she was admitted . She indicated she had just fallen the evening before during a transfer with the sit to stand lift. She indicated her knees gave out during the transfer and as her body lowered toward the bed, the bed moved away because the wheels were not locked, causing the staff to lower her to the floor. Resident 22's record was reviewed on 9/20/24 at 10:15 AM. Diagnoses included drug-induced polyneuropathy, repeated falls, unsteadiness on feet, and muscle weakness, generalized. Resident 22's current Admission Minimum Data Set (MDS), dated [DATE], indicated her Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact). The MDS indicated the resident needed substantial assistance transferring from a chair to a bed and bed to chair. Resident 22's current care plan titled At risk for falls . indicated the resident had a problem of being at risk for falls, with a goal date of 11/26/24. Interventions included keep bed in lowest position with brakes locked, and obtaining a physical therapy consult for transfer training. The care plan did not indicate to use any type of lift for transfer or the number of staff required for transfer. During an interview on 9/20/24 at 10:54 AM, the therapy director indicated upon admission and as needed, therapy staff evaluates a resident's transfer status and gives recommendations to nursing. She indicated therapy had recommended nursing transfers with Resident 22 be conducted using a Hoyer (full-body mechanical lift). She indicated therapy had not at any time approved the nursing staff to use the sit to stand lift without therapy assistance since admission. Resident 22's current care plan titled Resident requires staff assistance to complete ADLS (activities of daily living) with a goal date of 11/26/24 indicated therapy recommendations should be followed. A therapy note, dated 9/9/24, Physical Therapy Assistant (PTA) 7 performed a sit to stand transfer with nursing staff. The note indicated Resident 22 was able to maintain a standing position for around 10 seconds. The note indicated Resident 22 used the sling for increased support and displayed limited standing tolerance. A physician's order, dated 9/10/24, indicated staff may use a Hoyer lift when fatigue was present. Progress notes, dated 9/17/24 at 1:57 AM, indicated at 8:30 PM, Resident 22 was transferring using the stand-up lift, the bed locks were not activated and the bed slid away causing the resident to slide down to the floor. In an interview on 9/20/24 at 11:01 AM, Certified Nurse Aide (CNA) 6 indicated a resident's transfer status should be found on the care plan. She indicated Resident 22 had been using a sit to stand lift but changed to a Hoyer lift around a week prior because her legs were too weak to use a sit to stand lift. CNA 6 indicated she had no knowledge of a Kardex or care card to direct staff care of the residents. In an interview on 9/20/24 at 11:08 AM, the Director of Nursing (DON) indicated transfer status was found on the Kardex for CNAs and therapy recommendations should be followed. She indicated Resident 22's bed should have been locked prior to her transfer. A current policy titled Mechanical Lift Policy dated 7/1/24 provided by the DON indicated a resident's transfer status should be determined upon admission, quarterly, and as needed with any change in the resident's transfer ability. The policy indicated the decision should be based on nursing judgement or therapy recommendation. 3.1-45(a)2

Based on observation, interview and record review, the facility failed to ensure nephrostomy incision care was provided for 1 of 2 residents reviewed (Resident Z). Findings include: A report to the Indiana Department of Health indicated Resident Z's nephrostomy dressing had not been changed since the resident's admission to the facility on [DATE]. Resident Z's record was reviewed on 9/18/24 at 4:01 PM. Diagnoses included prostate cancer, bladder cancer, bone cancer, end stage kidney disease, urinary tract infection (UTI) and artificial openings of the urinary tract status of bilateral (both sides) nephrostomy (tube surgically place into the kidney) tubes. Resident Z's physician orders did not include orders for nephrostomy tube site care. An Admission Observation, dated 9/3/24 at 11:36 PM, indicated Resident Z was occasionally incontinent (unable to control) of urine and occasionally used a urinal. Resident Z did not have a urinary catheter (drainage tube). Resident Z did not have any surgical incisions. A Skilled Nursing Note, dated 9/7/24 at 11:44 PM, indicated Resident Z had a urinary catheter. Resident Z did not have a surgical incision. A Skilled Nursing Note, dated 9/8/24 at 5:41 PM, indicated Resident Z did not have a urinary catheter. Resident Z had surgical incisions for bilateral nephrostomy tubes. The incisions were intact and well approximated. The resident did not have any dressing change orders. The physician and family had been notified of the skin condition. A progress note, dated 9/11/24 at 4:31 PM, indicated Resident Z's daughter had voiced concern related to a nephrostomy tube being displaced 2 inches. The daughter was offered verbal assurance the nephrostomy tube was fine since it was still draining, and the nursing staff would monitor the tube. Resident Z's nephrostomy tube exchange scheduled for 9/30/24 was entered and transportation was notified. A Skilled Nursing Note, dated 9/14/24 at 12:48 AM, indicated Resident Z did not have a urinary catheter. Resident Z did not have a surgical incision. A Skilled Nursing Note, dated 9/17/24 at 2:25 AM, indicated Resident Z did not have a urinary catheter. Resident Z did not have a surgical incision. A Skilled Nursing Note, dated 9/19/24 at 1:13 PM, indicated Resident Z had a urinary catheter. The resident had an order for a dressing and the dressing was dry and intact. Resident Z's Care Plan, dated 9/4/24, indicated the resident had nephrostomy tubes to divert urine. The target goal was to avoid skin breakdown and maintain proper drainage through 12/4/24. Interventions included reporting complications and stoma (opening) care as needed. The Care Plan did not indicate Resident Z required dressing changes of the nephrostomy tube insertion sites. In an interview on 9/19/24 at 11:37 AM, the Director of Nursing (DON) indicated they were not aware of Resident Z's nephrostomy care needs as they had worked in the facility for less than 1 week. The DON was made aware the resident did not have physician orders for nephrostomy care. The DON was made aware Resident Z's hospital discharge summary did not include dressing change instructions. The DON indicated the nursing staff should have contacted the physician for dressing change orders. The DON indicated the nurses were responsible for dressing changes. The DON indicated they did not know if the nurses or the nurse assistants were responsible for emptying the nephrostomy drainage bags. On 9/19/24 at 11:52 AM, the DON provided Resident Z's Kardex (care plan summary for nurse assistants). A care plan approach, dated 9/18/24, indicated the resident had nephrostomy tubes. In a phone interview on 9/19/24 at 11:59 AM, Resident Z's daughter indicated Resident Z had nephrostomy (drains kidneys) tubes in both kidneys. Resident Z's daughter indicated they had cared for Resident Z at home for 18 months prior to the resident's hospitalization . The daughter indicated they were instructed at the hospital to change the nephrostomy dressing every 3 or 4 days. The daughter indicated they did not believe Resident Z's dressing had been changed since they had been admitted to the facility. The daughter indicated Resident Z had been hospitalized for a severe kidney infection. The daughter indicated they would change the dressing but was told the nurse would do the dressing changes. In an interview on 9/20/24 at 11:43 AM, Resident Z's daughter indicated they were concerned about the condition of the right nephrostomy tube. The daughter indicated the right sutures had gotten caught on the bed during a therapy transfer pulling the nephrostomy tube out approximately 2 inches. During an observation on 9/20/24 at 11:43 AM, A tan, plastic covered adhesive bandage was observed at the right nephrostomy site. The right nephrostomy tube bandage was missing a quarter sized portion of the tan, plastic covering. The right nephrostomy tube bandage was labeled 9/1/24. The right nephrostomy tube sutures were hanging freely below the bandage. A tan adhesive bandage was also observed at the left nephrostomy site. The left nephrostomy tube bandage was observed to be creased and the label was not legible. In a phone interview on 9/20/24 at 3:03 PM, Resident Z's urology nurse indicated the resident's nephrostomy tube insertion sites should be cleansed with soap and water and covered with drain sponges every 3 to 7 days. The urology nurse indicated the loose sutures were not harmful if the tube was draining properly. The urology nurse indicated nephrostomy tubes were sutured internally, and the external sutures were for reinforcement. On 9/23/24 at 11:13 AM, Certified Nurse Aide (CNA) 9 assisted Resident Z with leaning forward in their wheelchair. The right nephrostomy tube bandage was observed to be missing a quarter sized portion of the tan, plastic covering. The right nephrostomy tube bandage was labeled 9/1/24. CNA 9 indicated they could not read the date on the left nephrostomy tube bandage. The left nephrostomy tube bandage was observed to be creased, and the label was not legible. An undated current facility policy, provided by the DON on 9/23/24 at 1:10 PM, indicated wounds were to be assessed and new dressings applied as ordered by the physician. A current facility policy, dated 1/27/11 and revised 12/14/21, provided by the DON on 9/23/24 at 1:10 PM, indicated the nurse should review all referring facility information to determine appropriate admission orders. The physician should review and confirm the orders. The nurse should document the date, time, and the confirming physician's name. A current facility policy, dated 1/27/11 and revised 6/27/24, indicated the nurse may contact the physician to request additional orders based on the resident's medical treatment needs. This citation relates to Complaint IN00443537. 3.1-41(a)(1)

Based on observation, interview and record review, the facility failed to prevent a non-pressure related wound from resting directly on the floor for 1 of 2 residents reviewed (Resident E). This resulted in Resident E's wound becoming infected requiring antibiotics. Findings include: On 1/24/24 at 11:01 A.M., Resident E was observed seated in a wheelchair next to her bed. Her bare feet was in direct contact with the floor with no barrier. The right foot was wrapped with a gauze dressing from the midfoot to above her ankle. Her right pant leg was pulled up and her calf was visible. The exposed calf was red in color with thick white scales of skin. The exposed forefoot skin was swollen, reddened with thick scales. There were old non-skid strips beneath her feet. There were numerous food and skin particles beneath her feet and across the floor. The mattress on her bed was stained and had no linens on it. On 1/24/24 at 1:20 P.M., the resident was observed still seated in her wheelchair next to the bed. Black socks had been put on and covered the forefoot of both feet. The right foot gauze dressing remained in direct contact with the floor. Her bed remained without bedding. When questioned, the resident indicated she couldn't sit in the recliner chair and elevate her feet because the path was too narrow between her bed and window. She had to back herself into the chair with her walker and staff assistance. It wasn't safe for her to do this so she was unable to elevate her legs. She indicated she'd had an episode of confusion the other night and thought she had been in another home. She was taking antibiotics for her wound, had some diarrhea and indicated that could be what was causing the confusion. -At 3:05 P.M., Resident E was observed still seated in her wheelchair with feet in direct contact on the floor and black socks pulled over both forefeet. She appeared to be sleeping with her eyes closed. On 1/25/24 at 9:57 A.M., Resident E was observed seated in her wheelchair with both feet flat on the ground. On her right foot, she wore a sock over the forefoot while the gauze dressing on her heel wound was in direct contact with the floor. On her left foot, she wore a blue slipper. She indicated she hadn't felt well all night and felt confused at times. She complained of having diarrhea again and her mattress was bare of linens. She indicated staff told her they were going to get a stool culture to check for infection due to the antibiotics she was taking. On 1/25/24 at 1:50 P.M., LPN 4 left the resident's room carrying a stool sample. She indicated staff had just laid the resident down after the resident had a very large watery stool and would return to the room to complete the resident's wound care. -At 1:57 P.M., Resident E was observed lying in bed with gray colored skin. She indicated she hadn't felt good. LPN 4 and the LPN 5 (facility wound care nurse) assisted the resident to turn to her side and pulled up her leg pant. On the bed sheet, where the right heel had sat, was red-brown wet drainage and the gauze dressing around the right heel was saturated with red-brown drainage. LPN 4 removed the saturated dressing and a very large wound engulfing the entire swollen right heel was observed. The wound was round and approximately 5 inches around. The wound bed was gray to green in color and appeared very moist. In the center of the wound was an elevated eschar (necrotic-dead skin tissue) cap, black in color. On the outer edge of the circular shaped wound, was an area of pale gray moist and soft appearing tissue. Surrounding the entire wound were deep scales of thickened, dry and reddened skin extended onto the resident toes. The wound itself and drainage had a strong foul odor. The resident had been given pain medication prior to the dressing change and denied pain during the procedure. On 1/24/24 at 1:00 P.M., Resident E's record was reviewed. Diagnoses included diabetes with polyneuropathy and peripheral vascular disease with an arterial ulcer to her right heel since 8/4/23. A Doppler study, done on 8/23/23, indicated the resident had arterial stenosis (blood vessels which are narrowed or blocked) to 3 arteries in her right leg. There were no nursing assessments of the wound available for review. A quarterly MDS (Minimum Data Set) assessment, dated 11/29/23, indicated the resident was alert and oriented without cognitive impairment. She had no behaviors or rejection of care. She had no functional impairment to her upper or lower extremities but had impaired balance and weakness due to effects of childhood illness. She walked very short distances using her walker or wheelchair along with maximal assistance from staff. She was dependent on staff for putting on and taking off her footwear. She had an arterial ulcer which was being treated. Care plans were as follows: 12/1/23-Resident had skin breakdown. The goal was to have no further skin breakdown. Interventions included: turn and reposition as indicated; pressure reducing cushion to wheelchair and pressure reducing mattress; and float heels when in bed as the resident allows. 12/1/23-Resident with actual skin impairment: right heel arterial wound, surgical wound to top of head, and moisture associated skin disorder to buttocks. The goal was for areas to heal without signs or symptoms of infection. Interventions were: diet as ordered; complete skin checks and assessment per protocol; follow physician orders and treatments as indicated; refer to registered dietician; and use pressure reducing devices as indicated. 1/3/24-Resident with infection to right heel ulcer: the goal was for the ulcer to heel. Interventions included: assess for pain every shift; encourage activity as tolerated; encourage to be out of bed as tolerated; provide medications and antibiotics as ordered; monitor the right heel ulcer; and notify physician of changes. Wound Management Detail Reports, dated 11/6/23, 11/13, 11/20, 11/27, 12/5, 12/11, and 12/18/23, indicated the right heel wound had remained stable with daily treatment and dressing changes. The wound remained approximately the same size of 6 cm (centimeters) by 6 cm with black eschar and no drainage. The peri wound was consistently described as pink. A Wound Management Detail Report, dated 12/26/23 at 6:48 p.m., indicated the wound was stable but had light serosanguineous (blood and serum) drainage with no odor. The resident was encouraged to elevate the right leg when able to. A Wound Management Detail Report, dated 1/2/24 at 7:56 p.m., indicated the wound had purulent (pus) drainage, the peri wound was pink to red, with a mild odor. The medical NP was notified and ordered lab work, an x-ray to be done of the right foot to check for a bone infection, and a course of antibiotics. The resident was encouraged to elevate the right leg when able to. On 1/2/24 the medical NP ordered doxycycline (an antibiotic)100 mg po BID for 10 days. A Wound Care note by the Wound NP (Nurse Practitioner), dated 1/3/24, indicated the resident had been seen for care of her chronic arterial wound. The wound measured 6 cm by 6.5 cm and was covered with an eschar cap that was starting to lift up with open edges to the wound. The wound had a small amount serosanguineous drainage without odor and wound bed was 20% slough and 80% eschar. Assessment and Plan: x-ray of the foot was negative for osteomyelitis (bone infection) per LPN 5. Orders were given to change the treatment and continue with the antibiotics as ordered by the house NP. The right heel was to be offloaded (pressure off of heel) at all times. Wound Management Detail Reports, dated 1/8/24 at 6:23 p.m. and 1/15/24 at 10:48 p.m., indicated the right heel wound measured 6.5 cm by 7 cm with seropurulent drainage with mild odor. The resident was encouraged to elevate the right leg when able to. A Wound Care note by the Wound NP, dated 1/19/24, indicated the resident's right heel wound measured 6.5 cm by 7 cm and had a small amount of serosanguineous drainage with odor. The wound bed had 30% slough, 60% eschar and 10% granulation tissue. Edges of the wound were open and the eschar cap was lifting. Skin surrounding the wound was reddened and the wound was worsening in size, increased drainage and wound odor. Assessment and Plan: X-ray reordered by Medical NP as well as venous ultrasound. Treatment to wound was changed and right leg was to be offloaded at all times. On 1/25/24 at 10:55 A.M., CNA 6 (Certified Nurse Aid) was interviewed. They indicated the resident still walked with assistance to the bathroom but was very shaky and last week had almost fallen while being assisted. CNA 6 indicated the resident wasn't able to sit in her recliner chair because she had to back up with the walker to get to the chair which was not safe. On 1/25/24 at 2:42 P.M., the Infection Control Nurse was interviewed. She indicated Resident E's right heel wound and it's dressing should not be sitting directly on the floor. A current facility policy, titled Skin and Wound Care Best Practices was provided by the Director of Nursing on 1/25/24 at 2:15 P.M., which stated: Skin Care and Pressure Injury Prevention: Provide pressure reduction/redistribution for those at risk: offload/suspend heels for at risk residents .Pressure injuries and wounds will be treated with evidence-based interventions as ordered by the provider .All clinical staff will receive education on pressure injury prevention and treatment .with focus on education staff in the importance of basic care such as skin care and protection and pressure redistribution WebMD.com indicated aterial wounds are slow to heal, the goals are to remove contact irritation and pressure and dressing should be kept dry and clean. This tag relates to Complaint IN00425543. 3.1-37

Based on interview and record review the facility failed to provide the resident with a written explanation of the Notice of Transfer or Discharge, Bed Hold Policy, and the Bed Hold Policy Notice within 24 hours of a hospital transfer for 4 of 19 residents reviewed. (Resident 14, Resident 1, Resident 8, and Resident T). Findings include: 1.Resident 14's record was reviewed on 08/14/23 at 1:45 PM. Diagnoses included cerebral infarction affecting left dominant side, hemiplegia, chronic kidney disease stage 3, anemia, atherosclerotic heart disease of native coronary artery without angina pectoris, and type 2 diabetes mellitus. A review of Resident 14's current quarterly Minimum Data Set (MDS) assessment indicated he was unable to complete the Basic Interview for Mental Status (BIMS) assessment but was able to recall staff names/faces and was in a nursing home; his cognitive skills for daily decision making were severely impaired. The MDS indicated the resident had no speech. A review of Resident 14's Notice of Transfer or Discharge form dated 4/13/23 was reviewed. The form had an unrecognizable signature with no date or time. The form did not indicate when the copy had been provided during the transfer process, mailed to the resident or resident representative. A review of Resident 14's Notice of Transfer or Discharge form dated 4/19/23 was reviewed. The form had an unrecognizable signature with no date or time. The form did not indicate when the copy had been provided during the transfer process, mailed to the resident or resident representative. A review of Resident 14's Notice of Transfer or Discharge form dated 6/6/23 was reviewed. The form had an unrecognizable signature with no date or time. The form did not indicate when the copy had been provided during the transfer process, mailed to the resident or resident representative. A review of Resident 14's progress notes, dated 4/11/23 through 6/8/23, did not contain any indication of resident or representative notification of the Notice of Transfer or Discharge form, the Bed Hold Policy, or Request for Hearing and Appeal Rights. 46756 2. Resident 1's record was reviewed on 8/14/23 at 9:42 AM. Diagnoses included hemiplegia effecting left, non-dominant side, type 2 diabetes mellitus with unspecified complications, and gastroparesis. Resident 1's current annual Minimum Data Set (MDS) dated [DATE] indicated her BIMS (Basic Interview for Mental Status) score was 15 (cognitively intact). Progress notes dated 5/23/23 at 6:07 PM indicated Resident 1 experienced a decline in cognitive functioning, vital signs and she was sent to the hospital. A progress note dated 5/23/23 at 6:39 PM indicated Resident 1's son was notified of the transfer to the hospital. A bed hold policy was not discussed in any progress notes on 5/23/23 and 5/24/23. A review of a Notice of Transfer or discharge date d 5/23/23 did not identify the date and time of family notification of the transfer, discharge, or the bed hold policy. 3. Resident 8's record was reviewed on 8/11/23 at 9:24 AM. Diagnoses included chronic kidney disease, stage 4, retention of urine, unspecified, and benign prostatic hyperplasia with lower urinary tract symptoms. Resident 8's current quarterly Minimum Data Set (MDS) dated [DATE] indicated his BIMS (Basic Interview for Mental Status) score was 14 (cognitively intact). Progress notes dated 6/20/23 at 12:24 PM indicated Resident 8 had been sent to the hospital for a change in level of consciousness. The progress note did not indicate the bed hold policy was discussed when the family was notified. A bed hold policy was not documented as discussed in any progress notes on 6/20/23 and 6/21/23. A Notice of Transfer or discharge date d 6/20/23 did not identify the date and time of family notification of the transfer or discharge and bed hold policy. 3. Resident T's record was reviewed on 8/15/23 at 11:30 AM. Diagnoses included type 2 diabetes mellitus without complications, cognitive communication deficit and adult failure to thrive. Resident T's current annual Minimum Data Set (MDS) indicated her BIMS (Basic Interview for Mental Status) score was 6 (cognitively impaired). Progress notes dated 8/5/23 at 6:14 PM indicated Resident T's feeding tube had been pulled out and she was sent to the hospital for replacement. The progress note did not indicate the bed hold policy was discussed when the family was notified. A bed hold policy was not documented as discussed in any progress notes on 8/5/23 and 8/6/23. A review of a Notice of Transfer or discharge date d 8/6/23 did not identify the date and time of family notification of the transfer, discharge and bed hold policy. In an Interview on 08/16/23 09:45 AM, the DON indicated upon transfer from the facility to another facility the nursing staff should ensure the resident, or their representative received a transfer/discharge notice within 24 hours signed and dated and that information would be documented in the chart by Social Services or designee. A current policy titled Resident Discharge/Transfer Letter Policy, revised 4/19/23, provided by the DON on 8/15/23 at 2:45 PM indicated Social Services or designee would document in the chart all discharge/transfer reasons and any notices given to the resident or the guardian/sponsor. This citation is related to complaint IN00414546. 3.1-12(a)(25)(26)

Based on observation, interview, and record review the facility failed to ensure assessment and consent for self-administration of medication was obtained prior to self-administration of medication for 1 of 8 residents reviewed (Resident 1). Findings include: During an observation and interview on 8/11/23 at 9:38 AM, a one-ounce clear plastic cup was observed on Resident 1's food tray filled about half full of pills and capsules. Resident 1 indicated staff did not always watch her take her medication because it took her a long time to take her medicine. Resident 1 indicated she did not wish to self-administer her medication and believed staff should watch her because she had difficulty at times due to gastroparesis. Resident 1's record was reviewed on 8/14/23 at 9:42 AM. Diagnoses included hemiplegia effecting left, non-dominant side, type 2 diabetes mellitus with unspecified complications, and gastroparesis. Resident 1's current annual Minimum Data Set (MDS) dated [DATE] indicated her BIMS (Basic Interview for Mental Status) score was 15 (cognitively intact). Resident 1's current care plan titled Resident has Potential for Nausea and Vomiting due to Gastroparesis indicated the resident had a problem of nausea and vomiting, with a goal date of 7/27/23 Interventions included administration of medications by facility staff. Physician orders dated 6/1/23 indicated Resident 1's fish oil 1200 mg capsule should be administered by staff. Orders dated 6/2/23 indicated Resident 1's anastrozole 1 mg tablet, aspirin 81 mg tablet, calcium carbonate with vitamin d 600-10 mg-mcg tablet, linaclotidine 290 mg capsule, loratadine 10 mg tablet, myrbetriq 50 mg tablet, florastor 250 mg capsule, and rytery 48.75-195 mg capsule should be administered by staff. Orders dated 6/7/23 indicated Resident 1's venlafaxine HCl ER 75 mg capsule should be administered by staff. Orders dated 6/8/23 indicated Resident 1's lotrel 10-40 mg capsule should be administered by staff. Orders dated 7/20/23 indicated Resident 1's buspirone HCl 10 mg tablet should be administered by staff. A medication self- administration assessment was not available for review. In an interview on 8/11/23 at 9:43 AM, Registered Nurse 21 indicated she was new to the facility and did not know which residents could self-administer their medication. She indicated she should have watched Resident 1 take her medication when she did not know for certain that she was able to self-administer. A current policy titled Self-Administration of Medication, last revised on 1/28/23, provided on 8/15/23 at 8:40 AM indicated a resident should express desire to self-administer medication and demonstrate the ability to do so safely prior to self-administering medications. 3.1-11

Based on observation, interview and record review, the facility failed to provide adequate staff and assistive devices to prevent a fall for 1 of 3 residents reviewed for accidents. This deficient practice resulted in a fall with fracture, pain, and increased anxiety (Resident M). Findings include: A facility reported incident to the Indiana Department of Health, dated 3/13/23 at 1:22 p.m., indicated Resident M rolled out of bed while being assisted with care. She was sent to the hospital where x-rays indicated a tibia/fibula left ankle fracture. On 3/27/23 at 9:43 A.M., Resident M's record was reviewed. Diagnoses included acute fracture of left tibia and fibula from fall, anxiety disorder, major depressive disorder, and mild cognitive impairment. A quarterly MDS (Minimum Data Set) assessment, dated 12/23/22, indicated the resident had moderately impaired cognition. She had no behaviors of rejecting care. She required extensive assistance from 2 staff for bed mobility and toileting. She was always incontinent of bladder, frequently incontinent of bowel, and was non-ambulatory. Care plans indicated the following: -The resident had a self-care deficit related to impaired mobility, cataracts, and failure to thrive (last revised 8/4/21). The goal was for her needs to be met. Interventions included: assist with activities of daily living (ADL), dressing, grooming, toileting, feeding, and oral care; bed mobility with assist; dressing/grooming with assist; and toileting with assist. The care plan hadn't indicated the number of staff required to assist the resident to perform ADL's safely. -The resident was at risk for falls due to history of falls, injuries, and multiple risk factors (last revised 8/4/21). The goal was for the resident to have no fall related injuries. Interventions included: bed in the lowest position; call bell within reach; provide assistance with toileting as needed; and implement preventative fall interventions/devices. -The resident was incontinent of bladder (initiated 8/3/21). The goal was for her to receive assistance with toileting. Interventions included: provide incontinence care as needed. The care plan hadn't indicated the number of staff required to assist the resident with incontinent care while in bed or out. On 3/27/23 at 10:05 A.M., Resident M was observed lying in her bed. The left side of the bed was against the air conditioning unit. The unit's level was below the window. There were quarter bedrails on both sides of the bed. The resident had a flat affect and complained of pain in her left ankle. She indicated she didn't remember the fall that had occurred from bed and wasn't sure how she had gotten back into bed after falling. -1:47 P.M., the resident was observed lying in her bed. The bed had been moved away from the air conditioning unit with an approximate distance of 3 feet between the bed and unit. The Unit Manager (UM), indicated the bed brakes were locked. She tried to move the bottom of the bed which did not move however, when she moved the head of the bed, it was able to move despite the bed brake being on. The resident was observed to have purse lipped breathing and indicated she was having a lot of pain in her left ankle. She indicated she would be much better after the cast was removed from her ankle. Progress notes indicate the following: -3/13/23 at 3:12 a.m., a head to toe evaluation for an occurrence was completed. The nurse had been called to the resident's room where she'd had a witnessed fall from bed. A CNA (Certified Nurse Aide) indicated she had been changing the resident and as she rolled her to the side of the bed, the resident let go and slid out of the bed. A left ankle X-ray was ordered and the resident given Tylenol for pain. The left ankle was elevated on a pillow and ice applied. She complained of throbbing pain to her left ankle at a pain level of 4 out of 10 with 10 being the worst. The nurse indicated the resident needed side rails to hold onto during bed changes. -7:36 a.m., a fall follow-up note indicated the resident was alert and oriented with neurological checks within normal limits. She complained of throbbing pain in her left ankle and rated her pain at a 8 out of 10 with 10 being the worst. -8:00 a.m., the resident had dark purple bruising to the left lateral ankle. The bruising measured 5 centimeters by 6 centimeters. -11:20 a.m., an Interdisciplinary team progress note indicated on 3/13/23 at 2:38 a.m., the resident was being given incontinent care when she rolled towards the window and fell from the bed. Physical assessment had shown there was an acute injury with swelling around the left ankle. X-ray of the left ankle was ordered. The resident had increased complaints of pain and requested to go to the hospital. She was to be transferred to the hospital for evaluation and treatment of the left ankle injury. -3:09 p.m., quarter bed rails were applied to both side of the resident's bed to assist with bed mobility and positioning. -4:22 p.m., the resident returned from the hospital. She had increased anxiety and stated I just don't like hospitals; they make me very anxious. She received routine anti-anxiety medication but was not due for the next dose until 8:00 p.m. The psychiatric Nurse Practitioner (NP) was notified and ordered a one time dose of Buspar 5 mg (a different anti-anxiety medication) with the hope the resident's anxiety would be reduced until it was time for her usual anti-anxiety medication at 8:00 p.m. -8:44 p.m., an NP progress note indicated Resident M was seen for a post hospital visit. The resident had sustained a fall from bed while receiving care from staff. She had been to the hospital and returned with a soft cast in place to the left ankle. She was complaining of pain at a level of 9 out of 10, was anxious, and observed to be shaking from the pain. She had an order for as needed pain medication with recommendation to make this a routine order. -3/14/23 at 4:54 a.m., the resident was given an opioid pain medication-Norco 5-325 milligrams (mg) 1 tablet by mouth every 6 hours as needed for pain level of 8 out of 10. -11:41 a.m., fall follow-up documentation indicated the resident had pain in her left ankle which was rated at 7 out of 10. Her pain medication was ordered to be given routinely every 8 hours. -3/15/23 at 9:51 a.m., a psychiatric NP progress note indicated the resident was seen for an increase in anxiety status post fall. Since her fall with fracture, she'd had an increase in anxiety. She was observed to move her hands constantly, was fidgety and restless. She told the NP that she was more anxious and worried but shared no further information. Her mental status exam indicated she was alert and oriented to self, place, and time. She had fair eye contact and was anxious, restless, and fidgety. The plan was to start her on a second anti-anxiety medication-Buspar 5 mg tablets by mouth 3 times per day due to increased, observed anxiety since fall with fracture. -At 2:45 p.m., a fall follow up indicated the resident's pain level was 0 out of 10. The note indicated the NP had discontinued the resident's routine Norco and ordered Percocet 5-325 mg by mouth every 8 hours due to ineffectiveness of Norco for pain management. The NP's note indicated the resident had been on Norco 5-325 mg tablets-1 tablet every 8 hours but her pain had not been controlled. -3/17/23 at 11:07 a.m., an NP progress note indicated the resident had an episode of hypoxia (low blood oxygen) early in the morning and her oxygen level had dropped to 66% on room air (normal is >90%). She was placed on oxygen. The NP suspected the hypoxia had been due to the change in narcotics. Due to the resident's uncontrolled pain, she was being sent STAT to the orthopedic's office for evaluation. The Percocet was discontinued and the routine Norco re-started for pain management. The resident's routine Ativan (anti-anxiety medication) was to be held for 1 week while she was on narcotics. An Orthopedic progress note, indicated the resident had been seen on 3/17/23 and a short leg cast applied to her left ankle. During the visit, the resident was observed with an elevated blood pressure of 160/100 and pulse at 104. -3/22/23 at 7:14 a.m., a psychiatric NP progress note indicated the resident was visited for follow up of increased anxiety following a fall with fracture and not eating. The resident had not been eating, had complaints of her stomach not being right, increase in pain, and multiple fixations on changes. During the visit, the resident indicated she was trying to eat but her stomach was in knots. The plan was to continue her Ativan as ordered and increase her Buspar to 10 mg 3 times per day by mouth. On 3/27/23 at 10:00 A.M., Nurse 2 was interviewed. She indicated CNA's referred to the Kardex, located on IPADs, to direct them how to care for a resident and how the CNA's were to document care they provided. She indicated the Kardex should indicate how many staff members were required to assist a resident with ADL's such as bed mobility, transfers, and incontinent care. A Kardex report, dated 3/12/23, before the resident's fall and used by CNA's to provide care to Resident M, had interventions for activities, safety, care, skin care, activities of daily living, devices, and daily routine. The Kardex report hadn't indicated the number of staff required to provide care to the resident. On 3/27/23 at 11:16 A.M., a witness statement was provided by the Unit Manager indicated CNA 3 worked the night shift on 3/12-3/13/23 and cared for Resident M. The CNA was changing the resident's brief and had rolled her onto her left side facing the window. As the CNA pushed the bed pad and brief under the resident, the resident let go of the bed and her body started rolling off. The CNA tried to grab her so she wouldn't fall but the resident's entire body rolled off the bed and landed on the air conditioner unit. CNA 3 moved the bed away from the air conditioner unit so she could turn the resident on her back. The resident's right leg was extended in front of her but her left leg was underneath her and she was sitting on it. CNA 3 pulled the resident beneath her arms away from being between the wall and air conditioner unit. The CNA got the resident's left leg out from underneath her and extended her left leg. The resident's left ankle was swollen immediately. CNA 3 then went to get the night supervisor. On 3/27/23 at 2:26 P.M., Nurse 5, was interviewed. During the interview, she indicated on 3/13/23 at approximately 2:40 a.m., she was summoned to Resident M's room. When she came into the room, she saw Resident M on the floor, between the bed and air conditioner unit, with her head towards the head of the bed. She and CNA 3, along with a mechanical hoyer lift, got the resident off the floor and back into bed. The resident complained of pain in her left ankle. The ankle was swollen and discolored. Nurse 5 indicated the resident's ankle and foot hit the air conditioner as she fell over the side of the bed. The resident did not have side rails or transfer rails on her bed. The nurse indicated when staff assisted the resident to turn over for incontinence care, the resident would reach over the side of the bed and hold on to the bed frame to support herself. When questioned, the nurse indicated either 1 or 2 staff members could assist the resident with bed mobility and incontinence care. A current policy, titled Fall Prevention and Management Policy was provided by the unit manager on 3/27/23 at 2:13 P.M. The policy indicated: Residents will be assessed for fall risk(s) on admission, quarterly, after any fall, and as needed. If risks are identified, preventive measures will be put in place and care planned. All falls will be reviewed and investigated .Individualized interventions will be implemented based on this assessment and care planned accordingly .Falls will be reviewed by an interdisciplinary team and any new interventions identified will be implemented and the care plan updated as necessary. Such review should include results of the new fall risk assessment, discussion with resident and/or any witnessing parties as to potential causal factors, review of the environment where the fall occurred, and discussion as to any new interventions which may help to prevent further falls The deficient practice was corrected by 3/14/2023 after the facility implemented a systemic plan that included the following actions: an audit was completed to ensure resident assistance was clear on CNA Kardex and appropriate fall prevention devices were in place for residents at high risk, the staff was reeducated regarding giving care accoring to the Kardex, and m onitoring was initiated and completed regarding observations of giving care according to the Kardex. This Federal tag relates to Complaint IN00403968. 3.1-45(a)

Based on observation, record review and interview the facility failed to ensure a wheelchair was secured during transportation to avoid an accident for 1 of 4 residents reviewed. This resulted in a fracture to Resident T's thoracic spine. Findings include: An observation on [DATE] at 8:56AM of Van Driver 2 with Resident S, indicated the driver was walking around Resident S and bending down (out of site of windows) several times. Driver then moved Resident S to rear of van. Driver went outside and operated lift to lower Resident S to the ground. Resident S was secure on the lift. An interview with the Director of Nursing (DON) on [DATE] at 9:05 A.M. indicated Resident T's injury was not a C7 fracture as reported; Resident T's fracture was of the T7 (thoracic rather than cervical fracture) vertebra. DON indicated the incident occurred on [DATE] when Van Driver 4 was taking Resident T to a doctors appointment. A signed statement from Van Driver 4 indicated he was taking Resident T to an appointment on [DATE] at 9:30AM. Van Driver 4 indicated he secured Resident T tot he middle section of the Van using 3 of 4 hooks. He did not use the 4th hook (Right front) due to a concern of the strap rubbing on Resident T's incision. Van Driver 4 stated when the light changed from red to green he began to go, and Resident T yelled out. He also heard a loud bang sound. Van Driver 4 then pulled over. He noted Resident T flipped backwards in the wheelchair. Van Driver 4 indicated Resident T's seat belt and the back 2 wheel hooks had remained secured. The front hook was no longer secured. Van Driver 4 indicated he palpated Resident T's back, assisted the resident back into the wheelchair, then securing him in the same fashion. Van Driver 4 indicated he took Resident T to the hospital and alerted the facility administrator. A hospital history and physical dated [DATE] at 10:01PM indicated Resident T's complaint was back pain. A scan showed a transverse, non-displaced fracture of Resident T's Thoracic number 7 vertebral body. The hospital paperwork indicated a neuro spine surgeon was consulted and he requested additional testing. An extensive surgical history indicated Resident T had previous back surgery. A record review on [DATE] started at 9:32AM, indicated all residents with use of transportation were interviewed if interviewable per BIMS scores by social services; or had a skin assessment (if BIMS score indicated non interviewable) by nursing to ensure no recent injuries. Interviews were documented and signed by residents. Of the 10 interviews, only 1 resident indicated they had safety concerns. The skin assessments (documented and signed by a nurse) noted no areas of concern. The transporation appointment book was reviewed to ensure all transported residents had been interviewed or had skin assessments. The incident occurred on [DATE] and was reviewed by QAPI on the same day. The resident interviews and skin assessments were also done on [DATE]. A statement from maintenance director indicated he checked all straps, seat belts, lift, and other safety features on [DATE]. There were inservice and competencies for all existing van drivers on [DATE]. An interview with Resident S, (BIMS score 15; indicated the resident was interviewable) on [DATE] at 11:25AM, indicated she goes out with family in a private wheelchair accessible van and therefore knows the need to use all 4 straps. Resident S indicated Van Driver 4 on multiple occasions only used 2 straps. She had asked Van Driver 4 to use all straps as appropriate, yet he made an excuse she was perfectly safe. Resident S indicated she did feel safe. Resident S further indicated she never filed a complaint or grievance with nursing facility nor alerted any other staff member. An interview, with Resident R (BIMS 15, indicated resident was interviewable) on [DATE] at 11:42AM, indicated she was last in the van on an outing with activities. Resident R demonstrated how she was strapped into the van using a seatbelt and all 4 chair straps. Resident R indicated Van Driver 4 and the activities aide both only used 2 straps. Resident R indicated Van driver 4 always strapped her into the van correctly to ensure she would not move by wiggling her wheelchair. Resident R indicated she always felt safe and secure during transport with all drivers. An observation, on [DATE] at 11:57AM with the Administrator, Van Driver 2 was observed unhooking 4 straps from a wheelchair. Observed all straps in working order with no noted worn or distressed spots. Van Driver 2 was fluently able to explain how and why to secure both ambulatory and wheelchair bound residents. Writer requested a log of van maintenance checking safety features; Administrator indicated the documentation unable to be obtained due to maintenance director was unavailable. An interview with Nurse 3 indicated the residents had never made her aware of any safety concerns. Nurse 3 indicated when she was given information of a concern from a resident she would first suggest they fill out a grievance and then she would ask if she could talk with management regarding the concern. A review of Van Driver 4's employee file indicated there was no job specific training regarding strapping chairs for transport. Van Driver 4's drivers license was not expired. There was no documentation of first aid training, wheelchair safety or transfers. A current policy was received from DON titled Van/Bus Driver Resident Transfer Policy with a last revision date of [DATE]. The policy indicated that the driver was not to provide physical assistance to residents; drivers were never allowed to manually lift resident from floor or lift from wheelchair; in event of emergency driver was to first notify emergency management then contact administrator; and driver must view training module and successfully complete written competency before initiating duties as a van or bus driver. This Federal citation is realted to Complaint IN 848. 3.,d+[DATE](a)(2)

Based on interviews and record reviews, the facility failed to have an effective immunization program in place to ensure residents were offered pneumococcal vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations for residents over the age of 65 for six of eight residents sampled for immunizations. The facility's failure to have an effective immunization program related to pneumococcal vaccinations placed all residents over the age of 65 and any resident with an immunocompromising condition at likely risk for serious harm or death related to the development of pneumonia. The Immediate Jeopardy began on [DATE] when the R6 developed pneumonia after the facility failed to offer R6 the pneumococcal vaccination. Substandard Quality of Care (SQC) was identified at 42 CFR 483.80 Infection Control. On [DATE] at 2:36 PM, the facility Administrator was notified and issued an Immediate Jeopardy at F883, Influenza and Pneumococcal Immunizations. The removal plan for the Immediate Jeopardy was validated on [DATE] through interviews and documentation reviews. The facility was notified that the Immediate Jeopardy was removed on [DATE] at 7:30 PM. After the Immediacy was removed, the noncompliance remained at a lower scope and severity level of no actual harm with the potential for more than minimal harm that was not Immediate Jeopardy. Findings include: Review of the Centers for Disease Control and Prevention (CDC) website titled, Pneumococcal Vaccination: Summary of Who and When to Vaccinate, revealed There are 2 types of pneumococcal vaccines available in the United States: Pneumococcal conjugate vaccine (PCV13 or Prevnar13®) and Pneumococcal [MEDICATION NAME] vaccine (PPSV23 or [MEDICATION NAME]®) . CDC recommends pneumococcal vaccination for adults 19 through [AGE] years old who have certain medical conditions or who smoke .CDC recommends you: Give 1 dose of PCV13 and 1 dose of PPSV23. Administer PCV13 first, then give the PPSV23 dose at least 8 weeks later .For anyone with any of the conditions listed below who has not previously received the recommended pneumococcal vaccines .HIV infection, [MEDICAL CONDITION] or nephroti[DIAGNOSES REDACTED] .CDC recommends you: Give 1 dose of PCV13 and 2 doses of PPSV23. Administer PCV13 first, then give the first PPSV23 dose at least 8 weeks later. Give the second dose of PPSV23 at least 5 years after the first dose of PPSV23 .For anyone with any of the conditions listed below who has not previously received the recommended pneumococcal vaccine: Alcoholism, Chronic [MEDICAL CONDITION], Chronic liver disease, [MEDICAL CONDITION], (including [MEDICAL CONDITIONS], and asthma), (and) Diabetes mellitus .CDC recommends you: Give 1 dose of PPSV23 .CDC recommends pneumococcal vaccination for all adults [AGE] years or older .All adults [AGE] years or older should receive 1 dose of PPSV23. In addition, clinicians should consider discussing PCV13 vaccination with their adult patients [AGE] years or older .and who have never received PCV13 before .For adults [AGE] years or older .who want to receive PPSV23 ONLY: Administer 1 dose of PPSV23. Anyone who received any doses of PPSV23 before age 65 should receive 1 final dose of the vaccine at age 65 or older. Administer this last dose at least 5 years after the prior PPSV23 dose .For adults [AGE] years or older who .want to receive PCV13 AND PPSV23: Administer 1 dose of PCV13 first then give 1 dose of PPSV23 at least 1 year later .If the patient already received PPSV23, give the dose of PCV13 at least 1 year after they received the most recent dose .The following adults aged > [AGE] years are potentially at increased risk of exposure to PCV13 serotypes may consider regularly offering PCV13 to their patients aged > [AGE] years who have not previously received PCV13: Persons residing in nursing homes or other long-term care facilities . https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html Review of the CDC website titled, Pneumonia Can Be Prevented-Vaccines Can Help revealed, CDC data showed that in the United States during 2017: 3 million people were diagnosed with [REDACTED]. Approximately 50,000 people died from pneumonia. Most of the people affected by pneumonia in the United States are adults. Vaccines and appropriate treatment (like antibiotics and [MEDICAL CONDITION]) could prevent many of these deaths . https://www.cdc.gov/pneumonia/prevention.html Review of the CDC website titled Causes of Pneumonia revealed, .Common Causes of Pneumonia. Viruses, bacteria, and fungi can all cause pneumonia. In the United States, common causes of [MEDICAL CONDITION] pneumonia are influenza, respiratory [MEDICAL CONDITION] (RSV), and [DIAGNOSES REDACTED]-CoV-2 ([MEDICAL CONDITION] that causes COVID-19). A common cause of bacterial pneumonia is Streptococcus pneumoniae (pneumococcus) .Healthcare-associated pneumonia is when someone develops pneumonia during or following a stay in a healthcare facility. Healthcare facilities include hospitals, long-term care facilities, and [MEDICAL TREATMENT] centers . https://www.cdc.gov/pneumonia/causes.html Review of the facility's policy titled Pneumococcal Vaccine Policy-Resident revised [DATE], revealed Policy: All residents will be offered the pneumococcal vaccine to aide in preventing pneumococcal infections. (e.g., pneumonia) .D) Pneumococcal vaccine will be administered to residents (unless medically contraindicated, already given, or refused) per facility's physician-approved pneumococcal protocol .G) Administration of the pneumococcal vaccination or revaccinations will be made in accordance with the current Centers for Disease Control and Prevention recommendations: a. Initial Vaccination .I) Infection Preventionist will track resident immunizations . 1. Review of R4's undated Admission Record, located in the Electronic Medical Record (EMR) under the profile tab revealed R4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review of the admission record revealed R4 was [AGE] years old. Review of R4's Informed Consent For Pneumococcal Vaccine document, dated [DATE], located in the paper medical record, revealed R4's representative gave consent for the vaccination. Review of the medical record revealed no documented evidence R4 ever received the pneumococcal vaccination. Review of the facility's Antibiotic Use Tracking Log dated [DATE], revealed R4 had the infection [DIAGNOSES REDACTED]. Continued review of the tracking log revealed the pneumonia [DIAGNOSES REDACTED]. 2. Review of R6's undated Admission Record located in the EMR, under the profile tab, revealed R6 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review of the admission record revealed R6 was [AGE] years old. Review of the facility provided untitled document, dated [DATE], revealed a list of residents who were eligible and were not offered a pneumococcal vaccination from [DATE] to [DATE]. Continued review of the list revealed R6 was identified as a resident who was not offered the vaccine. Review of R6's Report of COVID-19 POC Testing dated [DATE], revealed R6 tested positive for COVID-19. Review of R6's Progress Notes dated [DATE], revealed .Resident sent to hospital . Review of R6's Post Discharge Orders, Medication Orders, Referrals, Appointments, and Infection/Isolation Status (resident's most recent hospital admission) dated [DATE], revealed .primary [DIAGNOSES REDACTED]. Review of the facility's Antibiotic Use Tracking Log dated [DATE] revealed R6 had the infection [DIAGNOSES REDACTED]. Continued review of the tracking log revealed the pneumonia [DIAGNOSES REDACTED]. Further review of the log dated [DATE] revealed R6 was again diagnosed with [REDACTED]. Review of the facility's Antibiotic Use Tracking Log dated [DATE], revealed R6 had the infection [DIAGNOSES REDACTED]. Continued review of the tracking log revealed the pneumonia [DIAGNOSES REDACTED]. 3. Review of R7's undated Admission Record located in the EMR under the profile tab, revealed R7 was admitted on [DATE] with [DIAGNOSES REDACTED]. Continued review of the admission record revealed R7 was [AGE] years old. Review of the facility provided untitled document, dated [DATE], revealed a list of residents who were eligible and were not offered a pneumococcal vaccination from [DATE] to [DATE]. Continued review of the list revealed R7 was identified as a resident who was not offered the vaccine. Review of R7's Report of COVID-19 POC Testing dated [DATE], revealed R7 tested positive for COVID-19. Review of R7's Progress Notes dated [DATE], revealed .Resident is having issues and has been sent out to the local hospital. Review of R7's untitled hospital records/progress notes Assessment/Plan dated [DATE] revealed .Observation for now .bilateral pneumonia due to COVID-19 . Continued review of the hospital records/progress notes dated [DATE] revealed Discharge Disposition: pending clinical improvement. Overview. Patient (R7) is seen for evaluation and management of Acute hypoxic [MEDICAL CONDITION] COVID-19 pneumonia . 4. Review of R8's undated Admission Record, located in the resident's EMR under the profile tab, revealed R8 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the facility provided untitled document, dated [DATE], revealed a list of residents who were eligible and were not offered a pneumococcal vaccination from [DATE] to [DATE]. Continued review of the list revealed R8 was identified as a resident who was not offered the vaccine. Review of R8's Report of COVID-19 POC Testing, dated [DATE], revealed R8 tested positive for COVID-19. Review of R8's hospital physician progress notes [REDACTED]. Principal Problem: Pneumonia due to COVID-19 virus . 5. Review of R1's undated Admission Record, located in the EMR under the profile tab, revealed R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review of the admission record revealed R1 was currently residing on the facility's COVID-19 positive unit. The admission record also revealed R1 was [AGE] years old. Review of R1's Report of COVID-19 POC Testing, dated [DATE], revealed R1 tested positive for COVID-19. Review of R1's Informed Consent For Pneumococcal Vaccine document dated [DATE], located in the paper medical record, revealed R1's representative gave consent to receive the pneumococcal vaccination. Review of the medical record revealed no documented evidence that R1 ever received the pneumococcal vaccination. 6. Review of R3's undated Admission Record located in the EMR, revealed R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review of the admission record revealed R3 was [AGE] years old. Review of R3's Informed Consent For Pneumococcal Vaccine document dated [DATE], located in the paper medical record, revealed R3 gave consent to receive the vaccination. Review of the medical record revealed no documented evidence that R3 ever received the pneumococcal vaccination. During an interview on [DATE] at 10:26 AM, the Assistant Director of Nursing/Infection Preventionist (ADON/IP) verified that although consents for the pneumococcal vaccine were obtained no residents had received the vaccination in the year of 2020. Continued interview revealed there had not been any pneumococcal vaccinations ordered from the pharmacy for the year of 2020. During an interview on [DATE] at 11:17 AM, the ADON/IP revealed in October of 2020. she completed an audit of all residents in the facility who were due and/or eligible for the pneumococcal vaccination and started obtaining consents; however, the residents did not receive the pneumococcal vaccinations. When asked what happened that the residents did not receive the vaccination, the IP stated, it just fell through the crack. The IP also stated her audit only included residents that the facility had not previously obtained consents for; meaning any resident that had been offered the vaccination prior to [DATE], was not included in the audit because she assumed, they received the vaccination. When asked if she had a system for tracking immunizations, the IP stated, no. During an interview on [DATE] at 12:17 PM, the Administrator stated it was his expectation the facility would have followed its policy related to pneumococcal vaccinations. During an interview on [DATE] at 12:50 PM, the Medical Director revealed it was his expectation residents would be up to date on all immunizations. The Medical Director also stated, if a resident gets pneumonia it could be life threatening; however, pneumonia with COVID-19 would then be duel infections. The surveyor verified that the following actions were implemented to remove the immediacy: Review of the education provided and interview with the facility nurses revealed education related to ensuring the pneumococcal vaccination was offered to all eligible residents and when consented to, the vaccination is ordered, administered, and documented that it was administered. Also reviewed the facility's audit of all residents in the facility and verified the facility was obtaining consent and ordering the pneumococcal vaccination. Additionally, review of the facility's tracking tool revealed no concerns.

Based on observation, interview and record review, the facility failed to identify the presence of a pressure ulcer and failed to follow care plan interventions to prevent development of new pressure ulcers in a resident identified as being at risk for pressure ulcer development. The facility's failure resulted in development of an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the ulcer bed) pressure ulcer (Resident #59). Findings include: On 10/31/16 at 1:00 P.M., Resident #59's record was reviewed. The record indicated [DIAGNOSES REDACTED]. On 10/25/16 at 2:20 P.M., Resident #59 was observed lying in her bed on an incontinence pad. Resident #59's bed and wheelchair smelled strongly of urine. On 10/26/16 at 2:26 P.M., Resident #59 was observed lying in her bed on a cloth incontinence pad. A bottle of periwash was observed lying in the bed, under Resident #59's left shoulder. Resident #59's bed and wheelchair smelled strongly of urine. On 10/27/16 at 9:01 A.M. through 9:24 A.M, Resident #59 was observed sitting in her w/c (wheelchair) in the TV room. On 10/27/16 at 9:24 A.M. through 11:03 A.M, during continuous observation Resident #59 was not observed to be re-positioned. On 10/27/16 at 11:03 A.M., Resident #59 was propelled from the activity room to the TV room. Resident #59 appeared to be sleeping in her w/c, with her eyes closed. On 10/27/16 at 11:14 A.M., LPN #2 (Licensed Practical Nurse) propelled Resident #59 down to her room. LPN #2 was observed to pull Resident #59 up and over in her w/c by pulling up on Resident #59's pressure relieving device sitting below her buttocks. LPN #2 indicated Resident 59's pressure relieving device in the w/c needed to be repositioned. LPN #2 left the room and returned with CNA #5. On 10/27/16 at 11:17 A.M., LPN #2 and CNA #5 were observed to stand Resident #59 up while LPN #2 and CNA #5 repositioned the residents pressure relieving device in the w/c. Resident #59 was sat back down into her w/c. Resident #59 smelled strongly of urine and no incontinence care was given at this time. Resident #59 was then propelled down the hallway and to the dining room for lunch. On 10/28/16 at 10:14 A.M., Resident #59 was observed sitting in her w/c in her room. Resident #59 smelled strongly of urine. On 10/28/16 at 10:20 A.M., CNA #6 and CNA #7 were observed to transfer Resident #59 into bed. Resident #59's pants were observed to have a large wet area on the back left side. After transferring Resident #59 into bed and positioning her on her right side, CNA #6 donned gloves and provided pericare due to fecal incontinence. Resident #59 was observed with thick, yellow colored cream between her buttocks which extended up to her coccyx. CNA #6 wiped the cream off with a moist towel. Resident #59 was observed to have a wound between her buttocks near her coccyx which appeared the size of a dime. The wound was covered with a thick yellow slough with slight redness to edges which was surrounded by pink tissue. CNA #6 and CNA #7 indicated they were not aware Resident #59 had a wound. Using the same gloves worn when removing fecal incontinence, CNA #6 removed a white barrier cream from Resident #59's bedside stand and applied the cream to the wound on the resident's coccyx area. On 10/28/16 at 11:18 A.M., the ADON (Assistant Director of Nursing) was interviewed. During the interview, the ADON indicated she was not aware that Resident #59 had a wound on her bottom but that the DON (Director of Nursing) monitors all wounds. On 10/28/16 at 11:26 A.M., the DON was interviewed. During the interview, the DON indicated she was not aware that Resident #59 had any wounds or open areas. On 10/28/16 at 11:41 A.M., the DON and LPN #2 were observed to examine the wound on Resident #59's coccyx area. The DON and LPN #2 indicated they were not aware Resident #59 had a wound on her coccyx. On 10/28/16 at 11:54 A.M., the facility's Regional Nurse Consultant was observed to examine Resident #59's wound on her coccyx. The nurse consultant indicated Resident #59 had a previous stage 2 pressure ulcer to this area which had closed up in April 2016. On 10/31/16 at 9:32 A.M., Resident #59 was observed lying in bed on her right side. The DON was observed to view Resident #59's wound by lifting back a piece of the dressing which covered the coccyx wound. The wound was observed to be moist with a thin slough tightly adhered to the edges of the wound with slight redness at the edges of the wound. Resident #59 smelled strongly of urine. The pressure relieving device sitting in Resident #59's w/c, was noted to have liquid droplets of fluid on the blue portion of the device. The pressure relieving device smelled strongly of urine. The DON indicated the room, resident, and pressure relieving device smelled strongly of urine and indicated would have the pressure relieving device cleaned. On 10/31/16 at 10:27 A.M., LPN #1 was interviewed. During the interview, LPN #1 indicated staff should prevent shear and friction when repositioning dependent residents to prevent pressure ulcers and open areas from occurring. LPN #1 indicated shear and friction were prevented by lifting dependent residents rather than pulling them over. Further, LPN #1 indicated when repositioning a dependent resident in the w/c, two staff members should lift the resident by the pads seated below their bottoms rather than pulling them over. On 10/31/16 at 10:31 A.M., during an interview, the DON indicated she was not aware if the facility had a policy on prevention of friction and shearing when moving a dependent resident at risk for pressure ulcer development as she was Just the interim DON and am not sure what all the facility policies are. On 10/31/16 at 10:43 A.M., Resident #59 was observed lying in bed on her right side. Resident #59 continues to smell of strong urine as does the pressure relieving device in her w/c. A quarterly MDS, dated [DATE] indicated Resident #59 required extensive assistance of two staff members for transfers, bed mobility and toileting and had no current pressure ulcers present. A plan of care with a focus problem dated 1/28/15, indicated Resident #59 was at risk for impaired skin integrity related to weakness, dementia, and history of pressure area. The goal, dated 5/19/16, indicated Resident #59 would be free from further breakdown and her pressure wound would remain closed. Interventions included, but were not limited to, inspect skin during routine care daily (dated 1/28/15), and skin assessment per routine and as needed (dated 1/28/15). A plan of care with a focus problem dated 1/28/15, indicated Resident #59 was at risk for complications associated with urinary incontinence. The goal, dated 1/28/15, indicated Resident #59 would remain free from skin breakdown due to incontinence and brief use. Interventions included, but were not limited to, incontinence care, wash, rinse, and dry perineum, change clothing prn (as needed) after incontinence episodes (dated 1/28/15). A Braden Scale Pressure Ulcer Risk Assessment, dated 8/2/16, indicated Resident #59 had a problem with friction and shear and required moderate to maximum assistance in moving, frequently slides down in bed or chair and requires frequent repositioning with maximum assistance. On 10/31/16 at 10:56 A.M., the DON provided a copy of Resident #59's wound assessment, dated 10/28/16, completed by the DON, which indicated the following: wound type is pressure, unable to determine stage of wound, located on the coccyx and measures 2.0 cm (centimeters) by 0.5 cm.; the wound was identified on 10/28/16 and was not present on admission; wound bed appearance is pink and black; and wound status is deteriorating. In the comments section, the DON indicated appearance does not represent slough. However, it does represent as tough, dry, dead tissue with areas of wound bed present that appears pink. On 10/31/16 at 10:56 A.M., the DON also provided a copy of the facility's current wound management policy, dated October 2015 which indicated the following: POLICY: To provide safe and evidence based skin and wound are for all intact and non-intact skin areas including, acute, chronic, and surgical wounds .PROCEDURE .b. Provide pressure prevention for those at risk .iii. Resposition frequently to avoid pressure to bony prominences .Frequent wound shifts when in chair .Definitions .Unstageable (wounds)-full thickness tissue loss in which the base of the ulcer is covered by slough .in the wound bed. 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure the abuse prohibition policy was implemented for 2 of 3 residents reviewed in a sample of 6 (Resident #X and Resident #Z). This resulted in feelings of anxiety and fearfulness regarding safety of belongings for Resident #Z. Findings include: 1. Resident #Z's record was reviewed 7-7-2016 at 10:11 AM. Resident #Z's [DIAGNOSES REDACTED]. In an interview on 7-5-2016 at 9:46 AM, Resident #Z indicated resident items are not safe in the facility and personal property had been taken. Resident #Z further indicated the necklace taken from her was not very valuable, but her (family member) had given it to her, and the sentimental value could not be over stated. Resident #Z was identified as interviewable on 7-5-2016 at 8:39 AM by LPN #2 and in an interviewable list dated 7-4-2016 provided on 7-5-2016 at 10:21 AM. A review of Resident #Z's quarterly Minimum Data Set ((MDS) dated [DATE] indicated her Brief Interview for Mental Status (BIMS) score was 12 out of a possible 15. This indicated Resident #Z had a slight cognitive deficit. A review of an incident reported to the Department of Health on 5-23-2016, indicated resident had reported a necklace missing. The report indicated a room search had been completed and the police notified. Further, staff were reeducated about misappropriation of resident property and Resident #Z was reminded to use the locked drawer in her room. In an interview on 7-7-2016 at 11:04 AM, Resident #Z indicated the theft of the necklace made her fearful for the safety of other personal items in her room. I am afraid my things are not safe Sometimes I lose sleep over it. My (family member) gave that necklace to me. I try to make sure the key (to the locked drawer) is hidden, but I can't be sure. 2. Resident #X's record was reviewed 7-6-2016 at 1:59 PM. Resident #X's [DIAGNOSES REDACTED]. In an interview on 7-5-2016 at 10:02 AM, Resident #X indicated her credit card had been stolen from her purse in April. Resident #X indicated she had kept her card in her purse inside a drawer (pointed to and opened drawer), but had known something was wrong when she returned to her room after a meal to find her purse on top of the cabinet (pointed to top of cabinet a demonstrated how the purse was positioned). Resident #X indicated she was very upset over the theft as the person had cleaned out her bank account leaving her with no way to pay bills. A review of Resident #X's quarterly MDS dated [DATE] indicated her BIMS score was 15 out of a possible 15. This indicated Resident #X was alert, oriented, and able to answer questions appropriately. A review of an incident reported to the Department of Health on 5-19-2016, indicated numerous charges had been made on the card the resident had no knowledge of. The report further indicated the police department had been notified and were working on the case. A current policy dated 9-2005 titled Preventing Resident Abuse provided on the table on 7-6-2016 at 9:00 AM indicated: Our facility will not condone any form of resident abuse This Federal tag is related to Complaints IN 414 and IN 476. 3.1-27(a)(3)

Based on interview and record review, the facility failed to administer an anti-coagulant medication as ordered by the physician, resulting in a significant medication error of [MEDICATION NAME] not being given for 5 days resulting in the resident having a stroke for 1 of 3 residents reviewed for medication administration. (Resident B) Findings include: The clinical record for Resident B was reviewed on 7/27/15 at 9:50 a.m. [DIAGNOSES REDACTED]. Resident B was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment indicated Resident B was cognitively intact. A physician order, dated 7/10/15, indicated for oral [MEDICATION NAME] (anti-coagulant medication) 5 mg (milligrams) was to be given one time daily until 7/12/15. A physician order, dated 7/10/15, indicated a laboratory order for [MEDICATION NAME] Time (PT) and International Normalized Ratio (INR) was to be drawn on 7/13/15. Review of the 7/13/15 laboratory value for the PT and INR, indicated the PT level was 21.4 seconds. The normal range is between 9.5-11.5 seconds. The INR level was 2.0. The normal range is between 0.9 and 1.1. The laboratory report indicated the Nurse Practitioner (NP) was notified of the results and indicated to continue the same dose until the following Monday (7/20/15). Review of the PT/INR/[MEDICATION NAME] ([MEDICATION NAME]) Flowsheet, provided by the Director of Nursing on 7/27/15 at 12:24 p.m., indicated the current INR level of 2.0, current PT result of 21.4 and current dose of 5.0 mg daily. The NP was notified and the dosage amount was continued. The next laboratory draw for the PT and INR was scheduled for 7/20/15. LPN #1 signed the flowsheet. Review of the July Medication Administration Record (MAR), Resident B received 5 mg of [MEDICATION NAME] on 7/10, 7/11 and 7/12/15. No additional [MEDICATION NAME] was marked as given after 7/12/15. On 7/17/15, a Computed Tomography (CT) scan was ordered for Resident B related to dizzy spells and stroke like symptoms. Following the CT scan, Resident B was sent from the radiology center to a local emergency room . Review of the E-Transfer, dated 7/17/15 at 3:49 p.m., indicated Resident B was transferred for stroke, [MEDICAL CONDITION] (TIA) and [MEDICAL CONDITION]. A current health care plan problem/need, dated 6/13/15, indicated anticoagulant use. The interventions for the plan included, but were not limited to, administer medications as ordered, monitor labs as ordered and monitor for signs or symptoms of bleeding. During an interview with the Director of Nursing (DON) and Administrator at 1:45 p.m., the Administrator indicated after the resident was sent to the hospital, a family member stopped by to inquire about the [MEDICATION NAME] dose and administration. The facility was aware there was a problem on 7/17/15 during review of the MAR and [MEDICATION NAME] flowsheet. The facility realized LPN #1 did not put the order in the computer to continue [MEDICATION NAME] 5 mg daily. LPN #1 was currently on bereavement leave. The Administrator indicated they did not have a current update from the hospital related to Resident B per family request. The DON indicated the Minimum Data Set (MDS) coordinator was responsible for [MEDICATION NAME] audits and she was not caught up on her auditing on 7/13/15. During an interview on 7/27/15 at 1:55 p.m., the MDS coordinator indicated on 7/13/15 she was doing a new admission and the auditing did not get done. She was not aware there was a problem until the facility notified her on 7/17/15. The facility reported the error to the Indiana State Department of Health on 7/17/15. As of 7/27/15, Resident B had not returned to the facility. Review of a current facility policy, dated February 2011, provided by the Director of Nursing on 7/27/15 at 2:30 p.m., titled Anticoagulation Protocol indicated the following: POLICY: As part of the initial assessment and ongoing, the physician and staff will identify individuals who are currently anticoagulated. Treatment will be monitored and residents will continue to have a productive quality of life. PROCEDURE: .b. The Nurse will obtain an order from the physician for any pertinent labs for monitoring of the anticoagulant therapy. 2. After the nurse obtains anticoagulation order from the physician, the nurse will place the anticoagulation medication on a separate anticoagulation MAR. (Exception: eMAR centers will enter order according to PCC guidelines.) .5. The Nurses are responsible for reviewing the PT/INR/[MEDICATION NAME] Flow Sheet. .b. The Nurses will compare current physician order [REDACTED]. This federal tag relates to Complaint IN 338. 3.1-25(b)(9)