Every finding on record at Heritage Pointe of Fort Wayne

Based on observation, interview, and record review the facility failed to ensure enhanced barrier precautions were maintained for 1 of 1 resident reviewed related to infection control (Resident 158). Findings include: During an observation, on 2/4/25 at 2:11 PM, Resident 158's door was closed and had a large rack containing bags of isolation gowns, N-95 masks, and boxes of gloves hanging on the outside of the door. Signage was posted on the door indicating the room was in isolation, provided instructions for application of gowns, gloves and N-95 masks. During an observation, on 2/4/25 at 2:18 PM, Certified Nurse Aide (CNA) 2 approached the door to Resident 158's room, applied a gown, surgical mask and gloves, knocked on the door, entered the room and approached Resident 158. According to CDC face mask guidelines, dated March 1, 2024, surgical masks are not appropriate for protection from the COVID 19 infection. Resident 158's record was reviewed on 2/4/25 at 12:45 PM. Diagnoses included COVID-19 infection and chronic systolic heart failure. Resident 158's current admission Minimum Data Set (MDS) dated [DATE] indicated their Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact). Resident 158's current care plan titled I require isolation . indicated the resident had a positive COVID-19 diagnosis, with a goal date of 2/17/25. Interventions included using transmission based (droplet) isolation precautions. Physician orders dated 2/4/25 indicated transmission- based precautions including an N-95 mask were required to enter the room. In an interview, on 2/4/25 at 2:22 PM, the Assistant Director of Nursing indicated all employees entering a COVID positive room must wear an N-95 mask. A current policy, titled COVID-19 Infection Prevention and Control, dated 3/28/20, provided by the Assistant Director of Nursing on 2/7/25 at 11:11 AM, indicated residents testing positive for COVID-19 require the use of proper personal protective equipment including N-95 masks if available. 3.1-18(a)

Based on interview and record review, the facility failed to ensure an allegation of physical abuse was reported for 1 of 3 residents reviewed for abuse (Resident B). Findings include: An anonymous complaint reported to the Indiana Department of Health, dated 11/15/24, alleged on 11/12/24, Resident B had reported to her family, a Certified Nurse Aide (CNA 3) had been rough while providing incontinent care. The resident alleged she slapped CNA 3 to stop hurting her and the CNA slapped her back. Resident B slapped the CNA a second time and CNA 3 slapped the resident back a second time. The incident had been reported to the Director of Nursing (DON) but the complainant alleged there had been no follow up to the reported altercation. On 12/12/24 at 11:15 A.M., Resident B's record was reviewed. Diagnoses included recurrent urinary tract infections (UTI), dementia, and cerebral atherosclerosis (Arteries in the brain become hard, thick, and narrow due to buildup of plaque inside the artery walls). A significant change in condition Minimum Data Set (MDS) assessment, dated 10/12/24, indicated the resident had moderately impaired cognition with no behaviors. She required moderate assistance to being dependent with all activities of daily living (ADL). A nurse progress note, dated 11/11/24 at 8:06 a.m., indicated the resident had complained of discomfort while urinating and had increased incontinence. She was observed with a functional decline and had voiced some intermittent confusion. A nurse progress note, dated 11/12/24 at 11:20 p.m., indicated a urinalysis had been sent out to the hospital on 11/11/24 and facility was waiting on results. There was no documentation or follow-up completed in the resident's record regarding the resident's allegation of being slapped by CNA 3 the morning of 11/12/24. On 12/12/24 at 1:25 P.M., the DON was interviewed. She indicated she had spoken with both family members on the phone on 11/12/24, and had initiated an investigation but had not reported the incident as required for an allegation of abuse. On 12/12/24 at 3:09 P.M., Resident B's family member was interviewed. The family member indicated, the morning of 11/12/24, she had been in to visit the resident, who reported to her, CNA 3 had been rough with her and slapped her twice. The family member indicated she was told of this and told another family member who immediately reported to the DON. At the time of the allegation, the family member believed the resident was cognitively aware, able to accurately describe what had occurred and who the CNA was, however, the resident would not be able to describe the incident at this time due to overall decline in condition. A current facility policy, titled Abuse, Neglect and Exploitation, was provided on 12/12/24 at 11:00 A.M. by the DON, which stated the following: .Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking .Identification of Abuse, Neglect and Exploitation .possible indicators of abuse include, but are not limited to: Resident, staff or family report of abuse .Reporting/Response: The facility will have written procedures that include: Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframe's This Citation relates to Complaint IN00447537. 3.1-28(c)

Based on interview and record review, the facility failed to ensure a thorough investigation of alleged physical abuse was conducted for 1 of 3 residents reviewed for abuse (Resident B). Findings include: An anonymous complaint, reported to the Indiana Department of Health, dated 11/15/24, alleged on 11/12/24, Resident B had reported to her family, a Certified Nurse Aide (CNA 3) had been rough while providing incontinent care. The resident alleged she slapped CNA 3 to stop hurting her and the CNA slapped her back. Resident B slapped the CNA a second time and CNA 3 slappeded her back a second time. The incident had been reported to the Director of Nursing (DON) but the complainant alleged there had been no follow up to the reported altercation. On 12/12/24 at 11:15 A.M., Resident B's record was reviewed. Diagnoses included recurrent urinary tract infections (UTI), dementia, and cerebral atherosclerosis (Arteries in the brain become hard, thick, and narrow due to buildup of plaque inside the artery walls). A significant change in condition Minimum Data Set (MDS) assessment, dated 10/12/24, indicated the resident had moderately impaired cognition with no behaviors. She required moderate assistance to being dependent with all activities of daily living (ADL). A care plan, revised 11/25/24, indicated the resident had anxiety with episodes of agitation and yelling at staff during care. Interventions included: If agitated and yelling at others, offer 1:1 conversation and reassurance, explain the behavior wasn't appropriate and ask to stop-initiated 11/25/24. A care plan, revised on 12/3/23, indicated the resident had bladder and bowel incontinence. Interventions included: Offer care in pairs-initiated 11/15/24. A nurse progress note, dated 11/11/24 at 8:06 a.m., indicated the resident had complained of discomfort while urinating and had increased incontinence. She was observed with a functional decline and had voiced some intermittent confusion. A nurse progress note, dated 11/12/24 at 11:20 p.m., indicated a urinalysis had been sent out to the hospital on 11/11/24 and facility was waiting on results. There was no documentation or follow-up completed in the Resident B's record regarding the resident's allegation of being slapped by CNA 3 the morning of 11/12/24. On 12/12/24 at 1:25 P.M., the DON was interviewed. She indicated, on 11/12/24, she had spoken with family members on the phone. They reported an alleged altercation between Resident B and CNA 3 had occurred that morning. After speaking with family, she called and spoke with staff who had worked on night shift and the morning of 11/12/24. On 11/12/24, she spoke with CNA 3 by phone. CNA 3 indicated when she went to get Resident B up for the morning, she noticed the resident was more agitated by the tone of her voice. CNA 3 had trouble rolling the resident in bed and tried to get her to put her hand on the side rail to help with rolling. Resident B would not keep her hand on the side rail where placed but denied slapping the resident or being hit by the resident. CNA 3 indicated the resident was tearful at breakfast but had calmed down after talking with her. The resident was unable to say why she had been crying. The DON indicated, after speaking with CNA 3 by phone, she had not suspended the CNA because she had determined there was no abuse that occurred. There were no interviews conducted with other residents who were cared for by CNA 3 nor skin assessments completed on non-interviewable residents to check for injuries of unknown source. CNA 3 came back into work her next scheduled day (11/13/24) and provided care to Resident B. The DON indicated the family had requested CNA 3 not provide care to the resident and was no longer assigned to care for her. When asked, the DON indicated CNA 3 should have been suspended and not allowed to return to duty until a thorough investigation had been completed. A current facility policy, titled Abuse, Neglect and Exploitation, was provided on 12/12/24 at 11:00 A.M. by the DON, which stated the following: .Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking .Identification of Abuse, Neglect and Exploitation .possible indicators of abuse include, but are not limited to: Resident, staff or family report of abuse .Investigation of Alleged Abuse, Neglect and Exploitation: An immediate investigation is warranted when suspicion of abuse .are reported .Written procedures for investigations include: Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations .Providing complete and thorough documentation of the investigation .Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm as well as additional abuse, during and after the investigation. Examples include by are not limited to: Responding immediately to protect the alleged victim and integrity of the investigation; examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; increased supervision of the alleged victim and residents; room or staffing changes to protect the resident from the alleged perpetrator; protection from retaliation; providing emotional support and counseling to the resident; and revision of resident's care plan .as a result of an incident of abuse This Citation relates to Complaint IN00447537. 3.1-28(d)

Based on observation, interview, and record review the facility failed to ensure opened items were dated, labeled and baking pans were thoroughly dried prior to storage in the facility kitchen. 54 of 54 residents residing in the facility consumed food prepared in the kitchen. Findings include: During an observation and interview on 2/29/24 at 9:18 AM, a bag of tilapia fillets on a shelf inside the walk- in freezer had been opened and was sealed shut with a Ziploc style closure. The bag was not marked with the date on which it was opened. The Director of Dining Services (DDS) indicated the bag should have been labeled with an open date. A metal container filled with french fries, covered loosely with a piece of plastic wrap was observed on the shelf of the walk-in cooler. The DDS indicated he was unable to find a date indicating when the container was filled and prepared. A plastic container containing cupcakes was observed on the shelf in the freezer. The sticker that had sealed the package was torn. There were 2 cupcakes and 2 open spots in the container with smears of red frosting. The DDS indicated the cupcakes should have been labeled and dated. During an observation and interview on 2/29/24 at 9:32 AM Chef 3 separated 4 baking sheets. Upon separation, liquid present on the pans dripped to the floor. Chef 3 indicated the baking sheets should have been air dried prior to stacking and storing. During an interview on 3/1/24 at 12:04 PM, the DSS indicated all 54 residents in the nursing facility consumed food prepared in the kitchen. A current policy titled Freezer Storage Life of Foods dated January 2023 provided by the DDS at 12:39 PM on 3/1/24 indicated when a case of food was partially used and the remaining food was exposed to the air, the remaining food should be relabeled as opened and used within 3 months. A current policy titled Sanitation and Infection Prevention/Control dated January 2023 provided by the DDS at 12:39 PM on 3/1/24 indicated all food contact surfaces including pots, and dishes should be air dried and not stacked when wet. 3.1-21(i)(2) 3.1-21(i)(3)

Based on interview and record review the facility failed to ensure staff competency for 1 of 1 staff reviewed. (Activity Assistant) In an interview with Activity Assistant 1, on 10/20/23 at 11:38 AM, he indicated on 10/4/23 he was attempting to assist Resident Q to scoot forward in her seat to transfer to her wheelchair, to go to an activity. He indicated he was aware he was not to assist in transfers for residents. He identified a transfer was from sitting to standing or from laying to sitting. The Activity Assistant indicated, I wish I would have stopped and thought prior to assisting her. The Activity Assistant indicated he was simply attempting to give her a steady hand while she scooted forward in her chair. He indicated he was unable to complete the transfer and got a CNA from the hall to do the task. The Activity Assistant indicated he did not have any prior training as a home health aid, CNA (Certified Nurse Assistant), or any other training on transfers or direct patient care. In an interview with Resident Q, on 10/20/23 at 12:31 PM, she indicated on 10/4/23 the activity guy was assisting her from her chair into her wheelchair. Resident Q indicated he was not trained to assist. Resident Q stated she was unaware she was bleeding until later when she was in an activity. Resident Q sustained a skin tear during the attempted transfer. The skin tear measurements were 6 cm x 8 cm. Resident Q's record review, began on 10/20/23 at 2:10PM, indicated diagnoses included hypertension, muscle weakness, and anxiety. In an interview with the Executive Director (ED), on 10/20/23 at 1:36PM, he indicated he was unable to produce a completed job specific orientation for Activity Assistant 1 from the incident on 10/4/23. The job description for Activity Assistant did not include assisting with transfers. The job description was signed by Activity Assistant 1 on 4/10/22. Activity Assistance 1's references indicated he worked previously at a nursing home with excellent reviews. Activity Assistant 1's resume did not include any certifications for CNA, HHA (Home Health Aid), or any other related certifications. Activity Assistant 1's resume indicated 3 years experience in a skilled nursing facility in the activities department. No policy or procedure for transfers by Ativity Assistants was made available at time of exit. Thos citation is related IN00418966 3,1-17(a)

Based on record review and interview the facility failed to ensure monitoring of opioid medication side effects for 4 of 4 residents reviewed (Resident 3, Resident 38, Resident 48, and Resident 201). Findings include: 1) Resident 201's record review began on 03/15/23 at 9:21 AM. Diagnoses include traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, muscle weakness, type 2 diabetes mellitus with diabetic neuropathy, and major depressive disorder. A Minimum Data Set (MDS) assessment dated [DATE] indicated Resident 201 had a BIMS (brief interview for mental status) score of 14 (cognitively intact). The MDS indicated resident 201 received opioid pain medication 2 out of the prior 7 days of the assessment period. A physician's order dated 02/22/23 indicated Tramadol HCL (hydrochloride) oral tablet 50MG was to be given 1 tablet by mouth every 6 hours as needed for pain. Start date 02/22/23 1430, DC date, 03/13/23. A subsequent physician's order indicated Tramadol HCL oral tablet 50MG was to be given 0.5 tablet by mouth every 6 hours as needed for pain. Start date 03/13/23. There were no care plans regarding opioid medication for Resident 201. A review of the Medication Administration Record (MAR) indicated Resident 201 received Tramadol HCL 50MG 1 tablet on 02/27/23 and 02/28/23. There were no orders to monitor for the side effects of opioid administration. 2) Resident 38's record review began on 3/14/23 at 12:17 PM. Diagnosis included dementia, anxiety, depression, vitamin deficiency, arthritis, and non displaced fracture. The current annual MDS (Minimal Data Set) for Resident 38 dated 2/1/23 indicated a BIMS (Brief Interview for Mental Status) score was a 6. A score of 6 indicated significant cognitive decline. Section J for Health Conditions addressed pain management. The pain assessment indicated Resident 38 receives pain medication routinely and has pain frequently. The assessment indicated Resident 38 rated her pain a 2 at the worst point in the previous 5 days of the assessment period. Section N of the assessment for Medications indicated Resident 38 received opioids for 7 of 7 days in week prior to assessment period. Resident 38's physician orders included to monitor for side effects of the following medications; antidepressant, antipsychotic, and diuretics. There were no orders to monitor for side effects of opiod medications. Resident 38 had the following order for opioid medication started on 2/1/22, give Norco 5-325 1 tablet by mouth one time a day for pain management. A review of Resident 38's medication administration record for Norco was documented as given for the time period of 2/1/23 to 3/13/23. A review of Resident 38's progress notes indicated there were no non medication interventions for pain documented for the period of 30 days. A review of Resident 38's current care plan indicated the focus of pain with the following interventions: medication as ordered, monitor for side effects, and use non-drug interventions. 3) Resident 48's record review began on 03/13/23 at 11:10 AM. Resident 48's diagnosis included dementia, spinal stenosis, compression fracture of lumbar spine, and lower back pain. Resident 48's admission MDS (Minimal Data Set) dated 2/14/23 indicated a BIMS score of 3, indicated a significant impairment of cognitive status. Section J for Health Conditions indicated Resident 48 received pain medication routinely. Pain frequency was documented at occasionally with the highest pain rating in 5 days of the assessment period as 4. Section N in the data set for Medications indicated Resident 48 received opiods 6 of the 7 days in the prior week of the assessment period. Resident 48's physician orders included to monitor for side effects of the following medications; antipsychotic and diuretics. Resident 48 did not have physician orders to monitor for side effects of opioid medication. Resident 48 had a physician order for Norco 5-325 one tablet as needed for pain on 2/7/23 and 2/8/23; it was not documented as given. Resident 48 had an order for Norco5-325mg three times a day for chronic pain on 2/9/23. A review of Resident 48's medication administration record (MAR) documented Resident 48 was administered Norco three times a day from February 9th through March 13th. During this review period Resident 48's pain level was documented as below: A review Resident 48's progress notes indicated there were no non medication interventions for pain documented for the period of 30 days. 45930 4. Resident 3's record was reviewed on 3/14/23 at 1:56 PM. Diagnoses included unspecified diastolic (congestive) heart failure, anxiety disorder, unspecified, major depressive disorder, single episode, unspecified, chronic pain syndrome, primary osteoarthritis, unspecified site, scoliosis, unspecified, rheumatoid arthritis, unspecified. A Minimum Data Set (MSD) assessment, dated 1/23/2023, indicated Resident 3 had a brief interview for mental status (BIMS) score of 13 (cognitively intact). The MDS assessment indicated Resident 3 received scheduled pain medication and prn (as needed) pain medication or prn pain medication was offered and declined. The MDS assessment indicated Resident 3 received opioid pain medication 2 of 7 days prior to the MDS assessment. A physician's order, dated 12/28/22, indicated Fentanyl (an opioid pain medication)72-hour patch 12 micrograms (mcg)/hour (hr.), apply 1 patch transdermally (on the skin) every 72 hrs. for chronic pain. Rotate the site (place the patch in a different area of the body) and remove per schedule. Resident 3's record did not include an order to monitor for adverse (harmful) side effects of opioids. A current care plan, dated 7/19/22, indicated Resident 3 had potential for pain related to decreased mobility, weakness, and osteoarthritis (a type of arthritis that occurs when the flexible tissue at the ends of bones wears down). The goal indicated Resident 3 would maintain comfort to the highest degree possible through the next review. The interventions included use a cervical collar (neck support brace) prn, monitor and assess Resident 3 for pain every shift, administer medication as ordered, monitor for side effects, perform nondrug interventions (use means other than medication to help relieve pain- massage, position change, etc.). Resident 3's Progress Notes, dated February 1-28, 2023, indicated no documentation for monitoring for side effects of opioid medication. Resident 3's Progress Notes, dated March 1-15, 2023, indicated no documentation for monitoring for side effects of opioid medication. Resident 3's Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated February 2023, indicated Resident 3 had a Fentanyl 12mcg/hr. patch applied on 2/2/23 at 11:35 AM, 2/5/23 at 7:37 AM, 2/8/23 at 8:17 AM, 2/11/23 at 8:15 AM, 2/14/23 at 9:56 AM, 2/17/23 at 7:55 AM, 2/20/23 at 8:43 AM, 2/23/23 at 10:23 AM, and 2/26/23 at 8:36 AM. Resident 3's MAR and TAR, dated March 2023, indicated Resident 3 had a Fentanyl 12mcg/hr. patch applied on 3/1/23 at 9:36 AM, 3/4/23 at 9:07 AM, 3/7/23 at 7:41 AM, 3/10/23 at 9:42 AM, and 3/13/23 at 7:10 AM. Resident 3's MARs and TARs, dated February 2023 and March 2023, indicated no documentation for monitoring for side effects of opioid medication. In an interview on 3/16/23 at 10:20 AM, RN 9 indicated she monitored for adverse side effects when a resident received blood pressure medication, any new medication, and any behavior medication. RN 9 did not indicate she monitored for adverse side effects when a resident received an opioid pain medication. RN 9 indicated an order or alert note would indicate a resident needed monitored for side effects of a medication. RN 9 indicated residents were monitored for adverse side effects every shift. Documentation of the monitoring for adverse side effects was done on the MAR and TAR and any specific observations of adverse side effects were documented in a health status progress note. In an interview on 3/16/23 at 11:00 AM, LPN 3 indicated residents were monitored for adverse side effects if they received antianxiety medication (relieve/control anxiousness), antipsychotic medication (relieve/control symptoms of hallucinations-thinking something is present when it's not, paranoia- unjustified suspicion or mistrust , hearing voices, delusion-false beliefs, anxiety) , an anticoagulant (blood thinner), a sedative (cause sleepiness), a hypnotic (cause sleepiness), an antidepressant (control anxiety and feeling severe sadness), a diuretic (used to get rid of excess fluid in the body, water pill), or insulin (used to treat high blood sugar). LPN 3 indicated she did not know if they had to monitor for adverse side effects if a resident received an opioid medication. She indicated she would check with other staff. LPN 3 indicated there were templates on the computer program to indicate a resident needed to be monitored for adverse side effects of a medication. These templates needed to be added to the orders by the nurse when the order for the medication was entered. LPN 3 indicated there was a reference guide in the narcotic books listing the medications that required a resident to be monitored for adverse side effects. Documentation was done on the MAR and TAR to indicate the resident was being monitored for adverse side effects of the medication. Documentation of the observed adverse side effects was done in a progress note and the doctor or Nurse Practitioner (NP) would be notified. In an interview on 3/16/23 at 11:12 AM, LPN 3 indicated monitoring for adverse side effects of a medication was considered a nursing measure. Nurses would notify the doctor/NP if adverse side effects were observed. An order to monitor for adverse side effects of opioid medication would have to be entered as an order when the order for the medication was placed. A current policy, titled Opioid Overdose Management, dated 10/2022, was provided by the Executive Director (ED) on 3/16/23 at 11:44 AM. The policy indicated it was the policy of the facility to recognize and treat opioid overdose per current standards of practice. The compliance guidelines indicated .4. The facility will train all staff to recognize the signs of opioid overdose and respond to it according to facility policy. 5. If a resident exhibits any of the following overdose symptoms, the facility will call 911, initiate basic life support, if indicated, and administer naloxone as per facility protocol and manufacturer's instructions: a. extremely pale face or clammy to the touch, b. limp body, c. blue or purplish color to fingernails or lips, d. vomiting or making gurgling noises, e. inability to awaken or speak, f. breathing or heartbeat slows or stops This policy did not indicate specific guidelines for monitoring a resident, receiving an opioid medication, for adverse side effects. A current policy, titled Medication Error and Adverse Reaction Reporting, dated 1/2020, was provided by the ED on 3/16/23 at 11:55 AM. The policy indicated medication errors and adverse drug reactions shall be documented in the resident's clinical record and reported to the resident's attending physician. The procedure indicated .1. In the event of a medication error or adverse reaction, nursing personnel should first take whatever immediate action is necessary to protect the resident's safety and welfare. 2. Notify the attending physician promptly of the error or significant adverse drug reaction (heavy sedation, extrapyramidal symptoms-(restlessness, muscles contract involuntarily, tremors, stiff muscles, involuntary facial movements), agitation, psychotic manifestations-(delusions, hallucinations, nonsense speech, inappropriate behavior for the situation), severe cramping, nausea, vomiting, diarrhea, allergic manifestations-(swelling, rash, itching, shortness of breath), and ataxia-(impaired balance or coordination). 3. Implement physician's orders and monitor the resident closely for 24 hrs., or as directed by the physician. 4. Document the following in the resident's clinical record. Clearly describe the error or adverse reaction. Limit documentation to the facts; avoid opinions This policy did not indicate specific guidelines for monitoring a resident receiving an opioid medication for adverse side effects. In an interview on 3/16/23 at 11:55 AM, the ED indicated the facility did not have any other policies regarding the monitoring for adverse side effects of medication. The policies provided did not address any medications requiring monitoring for adverse side effects other than opioids. The policies provided did not indicate specific guidelines for monitoring for adverse side effects of medication, the frequency of monitoring, and the documentation of monitoring and observations. 3.1-48(a)(3)

Based on observation, interview, and record review the facility failed to document and monitor behaviors to for 2 of 3 residents reviewed. (Resident 38 and Resident 48). Findings include: 1) An interview with LPN 2 (Licensed Practical Nurse) on 03/13/23 at 11:03 AM indicated Resident 38 frequently refused to get up until closer to lunch. LPN 2 indicated Resident 38 did not stay up late or wander, she simply was unwilling to participate in life at times. LPN 2 indicated the behavior was normal for Resident 38. LPN 2 indicated Resident 38 did have some behaviors, but they were not overly aggressive or disruptive. Resident 38's record review began on 03/15/23 at 10:26 AM. Diagnosis included dementia, anxiety, depression, vitamin deficiency, and malnutrition. Resident 38's current annual MDS (Minimal Data Set) dated 2/1/23 indicated BIMS (Brief Interview for Mental Status) score was a 6. A score of 6 indicated significant cognitive decline. Section D for mood indicated no problems with mood regarding interest or pleasure in doing things, feeling down or depressed, trouble falling or staying asleep, feeling tired or low energy, poor appetite, or overeating, feeling bad about self, or thoughts of better off dead, or hurting self in some ways in the 14 days prior to the assessment. Section E for Behavior indicated Residnet 38 had no hallucinations or delusions, physical behaviors towards others, verbal behaviors directed towards others, nor other behavior symptoms not directed towards others. The assessment further indicated Residnet 38 had no rejection of care. A review of Resident 38's progress notes included on December 23, 2022, the Social Worker (SW) indicated she was informed by the staff Resident 38 refused to get out of bed, was tearful and making negative statements. Staff indicated to the SW Resident 38 had periods of crying, being tearful when speaking of husband and how much she missed him. The documented note indicated when the SW inquired about statements Resident 38 stated oh I was just kidding. The note indicated Resident 38 woke up excited about an idea to share with her husband and then remembered he was no longer living. A progress note dated 12/22/22 indicated Resident 38 had some tearful episodes, was staying in bed later and not getting up until the afternoon, sometimes after 2pm. The note indicated Resident 38 was grieving for her husband and her first Christmas without him. A progress note dated 12/29/22 indicated Resident 38 slept in, was having some sadness over loss of husband, and moving slowly. A progress note dated 1/30/23 indicated Resident 38 had no behaviors noted during the assessment period. A progress note dated 2/16/23 indicated Resident 38 refused care and medications. Resident 38 stated let me lie down and die and throw me in the streets. A psych prescriber indicated Resident 38 did not take part in any conversation and nursing was to monitor. A physician note dated 2/22/23 indicated to continue to monitor behaviors. A progress note dated 3/6/23 indicated Resident 38 was tearful and upset regarding missing her husband when she recalls he was no longer living. A progress note dated 3/6/23 indicated the resident stated to a CNA (Certified Nursing Aid) I just want to die. Resident 38 indicated she was not a harm to herself she was just ready to go. A physician note dated 3/6/23 indicated recent statements of wanting to die, no plans, thoughts, or intent to harm herself. The resident continued to [NAME] the loss of her husband. The staff were to continue to provide support as Resident 38 continued to [NAME]. Resident 38's current care plan indicated she had focus of verbal aggression. An intervention listed was to monitor/record occurrence of target behavior symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc. and document per facility protocol. There was no behavior tracking for aggression, tearfulness, refusal of care, or statements of wishing to die in Resident 38's behavior tracker. There were no documented specific problems related to trauma triggers, symptoms, or approaches. No behavior plan was provided. A follow up interview with LPN 2 and observation of Resident 38 on 3/16/23 at 10:35AM indicated Resident 38 was sitting in her room slightly disheveled with her head in between her hands. LPN 2 indicated this was Resident 38's normal, therefore it was not considered a behavior and not documented or tracked. LPN 2 indicated Resident 38 refused to get up and refused care including showers. In an interview on 3/16/23 at 2:34PM, SS 5 (Social Services) indicated the MDS section for mood was to evaluate for depression along with verbalization of depression. Answers positive for depression would be cause to investigate. SS 5 indicated the psychologist for the facility indicated talk therapy was not appropriate for people who have low BIMS scores due to need for carry over from session to session. SS 5 indicated they have a behavior notes template to address what was occurring before behavior, what interventions were tried, and what was found to be helpful. SS 5 indicated she looks at all progress notes for the last 24 hrs. when she begins her day. SS 5 indicated she cannot depend on the notes being in behavior notes format. SS 5 indicated despite if the behavior was known or frequent it required documentation and tracking to determine behavior plan needs. SS 5 indicated Resident 38 was seen by a psych prescriber every Tuesday, Resident 38 was not a threat to self or others, and that Resident 38 did not receive therapy for the trauma of losing her husband. 2) During an observation on 03/13/23 from 9:30AM to 11:45AM, Resident 48 was making loud non articulate noises. As Resident 48 sat at a table with the assistance of 2 staff and gait belt she stated I made it; showing the ability to speak clearly and softly. Resident 48's record review began on 03/13/23 at 11:10 AM. Resident 48's diagnosis included dementia, PBA (pseudobulbar affect), and lower back pain. Resident 48's current admission MDS (Minimal Data Set) dated 2/14/23 had a BIMS score of 3, this indicated a significant impairment of cognitive status. Section D for mood indicated Resident 48 felt down or depressed 2-6 days in the 2 weeks of the observation period. Section E for Behavior indicated other behavior symptoms not directed at others such as verbal/vocal symptoms like screaming, disruptive sounds 1 to 3 days of the week prior to assessment. Resident 48's current care plan included the focus of episodes of loud, explosive laughter not appropriate to the environment. Interventions included receive medication as ordered, monitor for side effects, and to offer conversation when distressed. A review of Resident 48's social services note dated 2/13/23 late entried for 2/8/23 indicated Resident 48 had an episode of laughing loudly when not appropriate. A progress note dated 2/25/23 at 3:45 PM indicated Resident 48 slept well with no unwanted behaviors. An observation of Resident 48 and an interview with LPN 2 on 03/16/23 at 10:31 AM indicated she was involved in activity sitting quietly. During the interview LPN 2 indicated Resident 48 had a diagnosis related to loud outbursts. She indicated Resident 48 was unable to help it; therefore, it was not considered a behavior. LPN 2 indicated she had been disruptive and upsetting to other residents a couple times. She had been removed from peers. LPN 2 indicated Resident 48 took medication for the condition, the loud outbursts were expected to happen and therefore were not documented. An interview on 3/16/23 at 10:36 AM, Activities 6 indicated Resident 48 does upset peers at times and requires direct 1 to 1 care to calm down. A current policy and procedure titled, Behavior Management Plan revised 04/2022, was provided by the executive director on 3/16/23 at 12:12PM. The policy indicated; .quality of life through the management of problematic behaviors that are distressing or harmful . 1. Staff will document behavior in the EMR (electronic medical record) .Residents enrolled in Behavioral Management will be reviewed monthly by Social Services to ensure Behavior Care Plan accuracy 3.1-43(a)(1)

Based on record review and interview the facility failed to ensure monitoring of psychotropic medications for 3 of 4 residents reviewed (Resident 3, Resident 38, and Resident 201). Findings include: Resident 201's record review began on 03/15/23 at 9:21 AM. Diagnoses include traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, muscle weakness, type 2 diabetes mellitus with diabetic neuropathy, and major depressive disorder. A Minimum Data Set (MDS) assessment dated [DATE] indicated Resident 201 had a BIMS (brief interview for mental status) score of 14 (cognitively intact). A physician's order, dated 2/23/23, indicated to give Sertraline HCL (hydrochloride) oral tablet 25mg 1 tablet by mouth one time a day for depression was administered daily starting 2/23/23 to 3/14/23. A physician's orders dated 3/13/23 included to monitor antidepressant medication - monitor for headache, nausea and vomiting, diarrhea, fatigue, drowsiness, lethargy, dizziness, agitation, irritability. If any signs and symptoms observed, note findings in a progress note every shift. A review of progress notes between 2/23/23 and 3/13/23 did not indicate side effects of Steraline had been monitored. There were no orders prior to 03/13/23 to monitor for side effects of antidepressant medication. 2) Resident 38's record review began on 03/14/23 at 12:17 PM. Diagnosis included dementia, anxiety, depression, vitamin deficiency, arthritis, and non-displaced fracture. Resident 38's current annual MDS (Minimal Data Set) dated 2/1/23 indicated BIMS (Brief Interview for Mental Status) score was a 6. A score of 6 indicated significant cognitive decline. Section N for Medications of MDS indicated Resident 38 took antianxiety medication for 7 of the last 7 days of the assessment period. Resident 38's physician orders included to monitor for side effects of the following medications; antidepressant, antipsychotic, and diuretics. There were no orders to monitor for side effects of antianxiety medication side effects. Resident 38 had the following order for Buspirone 5mg 1 tablet three times a day started on 12/23/22. In the medication administration record for Buspirone 5mg tablet for February and March 2023 up to the 13th documented administered three times a day. There was no indication the side effects of Buspar had been monitored. 45930 3. Resident 3's record was reviewed on 3/14/23 at 1:56 PM. Diagnoses included unspecified diastolic (congestive) heart failure, anxiety disorder, unspecified, major depressive disorder, single episode, unspecified, chronic pain syndrome, primary osteoarthritis, unspecified site, scoliosis, unspecified, rheumatoid arthritis, unspecified. A Minimum Data Set (MSD) assessment, dated 1/23/2023, indicated Resident 3 had a brief interview for mental status (BIMS) score of 13 (cognitively intact). A physician's order, dated 3/6/23, indicated to give Ativan (Lorazepam) oral tablet 0.5 milligram (mg.) (medication used to treat anxiety), 1 tablet by mouth every 6 hours prn (as needed) for anxiety/agitation for 14 days. A physician's order, dated 3/7/23, indicated to give Ativan (Lorazepam) oral tablet 0.5 mg. by mouth at bedtime related to anxiety disorder, unspecified. A physician's order, dated 3/15/23, indicated Resident 3 received anti-anxiety medication, to monitor for drowsiness, slurred speech, dizziness, nausea, aggressive/impulsive behavior. If any signs or symptoms observed, note findings in a progress note every shift. There was no order to monitor Resident 3 for side effects of anti-anxiety medication prior to 3/15/23. A current care plan, titled Behavior Management Program, dated 2/17/23, indicated Resident 3 had episodes of verbal aggression (talk in a threatening manner) and would yell at, curse, belittle (make feel unimportant) staff when upset or during care. Resident 3 would refuse care at times, refuse to take medication, refuse to wear a gait belt (belt used to aid in safe movement when transferring or walking) for walking or transfers, refuse to change positions in bed, refuse to change his clothes, would threaten to be on his call light all day if things weren't done correctly. Resident 3 has episodes of smacking at and hitting at staff during care when agitated and/or anxious. Resident 3 had a diagnosis of anxiety and was taking an anti-anxiety medication. The goal indicated Resident 3 would accept care from staff and would refrain from negative, aggressive and/or demeaning (negative) remarks toward staff when he was upset. The interventions included: educate Resident 3 on the purpose and safety risks for using the gait belt verses not using the gait belt, encourage Resident 3 to participate in activities of daily living (ADLs) (dressing, bathing, etc.) as much as he was able to, explain the behavior was inappropriate and ask calmly for Resident 3 to stop, explain the care you would like to provide prior to giving the care , engage in conversation with Resident 3 during and prior to the care being given, and Resident 3 would receive his medication as ordered. This care plan did not indicate to monitor Resident 3 for adverse side effects of anti-anxiety medication. A current care plan, dated 2/8/23, indicated Resident 3 used anti-anxiety medication. The goals indicated Resident 3 would be free from discomfort or adverse (harmful) reactions related to anti-anxiety therapy through the review. The interventions included: administer anti-anxiety medications as ordered by the physician, monitor for side effects and effectiveness every shift. Monitor, document, and report as needed any adverse reactions to anti-anxiety therapy: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision, unexpected side effects: mania (extremely elevated and excitable mood), hostility (unfriendly behavior), rage (uncontrollable anger), aggressive (ready or likely to attack) or impulsive ( done without thought) behavior, and hallucinations (where you hear, see, smell, taste, or feel things that appear to be real but are not). A progress note, dated 3/5/23 at 7:38 PM, indicated Resident 3's prn Ativan remained effective with no adverse drug reactions indicated. A progress note, dated 3/6/23 at 4:08 PM, indicated Resident 3 was very drowsy and unable to perform normal tasks such as drinking his own Boost. Resident 3's Ativan order was decreased to 0.5mg every 6 hours as needed per hospice and the Nurse Practitioner due to confusion and drowsiness. A progress note, dated 3/13/23 at 3:30 PM, indicated Resident 3 did have drowsiness after taking Ativan. No other adverse drug reactions were noted from the medication. There were no other progress notes to indicate Resident 3 was monitored for adverse side effects of the anti-anxiety medication he was receiving. Resident 3's Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated March 2023, indicated Resident 3 was given the medication, Ativan (Lorazepam) oral tablet 0.5mg, 1 tablet by mouth every 6 hours as needed (prn) for anxiety/agitation for 14 days (start date 2/27/23 at 10:30 AM, discontinued on 3/4/23 at 5:27 PM) on 3/2/23 at 12:57 AM and 3/4/23 at 10:15 AM. Resident 3's MAR and TAR, dated March 2023, indicated Resident 3 was given the medication, Ativan (Lorazepam) oral tablet 0.5mg, 2 tablet by mouth every 6 hours as needed (prn) for anxiety/agitation for 14 days (start date 3/4/23 at 5:30PM, discontinued on 3/6/23 at 12:14 PM) on 3/4/23 5:34 PM and 3/5/23 at 8:03 PM. Resident 3's MAR and TAR, dated March 2023, indicated Resident 3 was given the medication, Ativan (Lorazepam) oral tablet 0.5mg, 1 tablet by mouth every 6 hours as needed (prn) for anxiety/agitation for 14 days (start date 3/6/23 at 12:15 PM) on 3/7/23 at 12:30 AM, 3/9/23 at 10:48 AM, 3/12/23 at 9:53 AM and 6:39 PM, and 3/13/23 at 6:58 AM. Resident 3's MAR and TAR, dated March 2023, indicated Resident 3 was given the medication, Ativan (Lorazepam) 0.5mg oral tablet, 0.5mg by mouth at bedtime related to anxiety disorder, unspecified (start date 3/7/23 at 9:00 PM) on 3/7/23, 3/8/23. 3/9/23, 3/10/23, 3/11/23, 3/12/23, 3/13/23, and 3/14/23. Resident 3's MAR and TAR, dated March 2023, indicated Resident 3 received an anti-anxiety medication. Resident 3 was to be monitored for drowsiness, slurred speech, dizziness, nausea, or aggressive/impulsive behavior. If any signs or symptoms were observed, findings were to be noted in a progress note every shift. The start date was 3/15/23. There was no documentation on this date. There was no other documentation on the MAR or TAR to indicate Resident 3 was monitored for adverse side effects of anti-anxiety medication. In an interview on 3/16/23 at 10:20 AM, RN 9 indicated she monitored for adverse side effects when a resident received blood pressure medication, any new medication, and any behavior medication. RN 9 indicated an order or alert note would indicate a resident needed monitored for side effects of a medication. RN 9 indicated residents were monitored for adverse side effects every shift. Documentation of the monitoring for adverse side effects was done on the MAR and TAR and any specific observations of adverse side effects were documented in a health status progress note. In an interview on 3/16/23 at 11:00 AM, LPN 3 indicated residents were monitored for adverse side effects if they received antianxiety medication (relieve/control anxiousness), antipsychotic medication (relieve/control symptoms of hallucinations-thinking something is present when it's not, paranoia- unjustified suspicion or mistrust , hearing voices, delusion-false beliefs, anxiety) , an anticoagulant (blood thinner), a sedative (cause sleepiness), a hypnotic (cause sleepiness), an antidepressant (control anxiety and feeling severe sadness), a diuretic (used to get rid of excess fluid in the body, water pill), or insulin (used to treat high blood sugar). LPN 3 indicated there were templates on the computer program to indicate a resident needed to be monitored for adverse side effects of a medication. These templates needed to be added to the orders by the nurse when the order for the medication was entered. LPN 3 indicated there was a reference guide in the narcotic books listing the medications that required a resident to be monitored for adverse side effects. Documentation was done on the MAR and TAR to indicate the resident was being monitored for adverse side effects of the medication. Documentation of the observed adverse side effects was done in a progress note and the doctor or Nurse Practitioner (NP) would be notified. A current policy, titled Antipsychotic Medications, dated 1/2020, was provided by the Executive Director on 3/16/23 at 11:10 AM. The policy indicated .Antipsychotic medication must be used with great caution in residents as they can cause adverse effects .Prior to use of Antipsychotics .Must evaluate the effectiveness of the medication and monitor for adverse consequences (i.e., Increased confusion or over sedation) .Monitoring and Follow-up-up: 2. The Behavior Management Team will .Detect emergence or presence of adverse consequences: a. Anticholinergic effects (dry mouth, constipation, urinary retention (urine remaining in the bladder), bowel obstruction (blockage), dilated pupils (pupils looking large), blurred vision, increased heart rate and decreased sweating), b. signs and symptoms of Cardiac Arrythmias (abnormal heart rhythm) c. Metabolic Effects (increased blood pressure, high blood sugar, excess fat around the waist, and abnormal cholesterol or triglyceride levels), d. Neurological effects (paralysis, muscle weakness, poor coordination, loss of sensation, seizures, confusion, pain and altered levels of consciousness), e. Individualized monitoring parameters, 3. Concerns that are identified related to the effectiveness or potential and/or actual adverse consequences of a resident's medical regimen must be relayed to the physician and must respond with changes as necessary. 4. If the physician does not provide a timely and appropriate response to the notification, staff must contact the medical director and the Director of Nursing for further review and intervention .Monitoring for Continued Use at Least Quarterly: Document rationale for continuing medication, including evidence the following was evaluated .c. whether the resident experienced any medication-related adverse consequences during the previous quarter This policy did not indicate specific guidelines for monitoring a resident receiving an anti-anxiety or anti-depresant medication for adverse side effects. A current policy, titled Antipsychotic Medications in Residents with Dementia, dated 1/2020, was provided by the Executive Director on 3/16/23 at 11:10 AM. The policy indicated .Antipsychotic medication must be used with great caution in residents with dementia as they can cause adverse effects . Prior to use of Antipsychotics .3. Must evaluate the effectiveness of the medication and monitor for adverse consequences (i.e., Increased confusion or over sedation) . Monitoring and Follow-up: 2. The Behavior Management Team will .Detect emergence or presence of adverse consequences: a. Anticholinergic effects (dry mouth, constipation, urinary retention, bowel obstruction, dilated pupils, blurred vision, increased heart rate and decreased sweating), b. signs and symptoms of Cardiac Arrythmias (abnormal heart rhythm) c. Metabolic Effects (increased blood pressure, high blood sugar, excess fat around the waist, and abnormal cholesterol or triglyceride levels), d. Neurological effects (paralysis, muscle weakness, poor coordination, loss of sensation, seizures, confusion, pain and altered levels of consciousness), e. Individualized monitoring parameters, , 3. Concerns that are identified related to the effectiveness or potential and/or actual adverse consequences of a resident's medical regimen must be relayed to the physician and must respond with changes as necessary. 4. If the physician does not provide a timely and appropriate response to the notification, staff must contact the medical director and the Director of Nursing for further review and intervention . Monitoring for Continued Use at Least Quarterly: Document rationale for continuing medication, including evidence the following was evaluated .c. whether the resident experienced any medication-related adverse consequences during the previous quarter This policy did not indicate specific guidelines for monitoring a resident receiving an anti-anxiety or anti-depressant medication for adverse side effects. 3.1-48(a)(3)

Based on interview and record review, the facility failed to implement care plan interventions to prevent falls for 1 of 5 residents reviewed. (Resident T). Findings include: On 12/28/22 at 12:09 P.M., Resident T's record was reviewed. Diagnoses included hemiplegia and hemiparesis affecting the right non-dominant side. MDS (Minimum Data Set) assessments, dated 9/8/22 and 12/6/22, indicated a BIMS (Brief Interview Mental Status) score of 9-moderately impaired cognition. The resident required extensive assistance from 2 staff members for transfers. Care plans indicated the following: -Resident T had an ADL self-care deficit due to right sided hemiplegia. Interventions included: (initiated on 9/17/21) Hoyer-mechanical lift as needed; provide extensive to total assistance from 1-2 staff members and use of hemiwalker for all transfers. -The resident was at high risk for falls due to weakness and right hemiplegia. Interventions included: place a sign as a reminder to use the hemiwalker for transfers (created 12/28/22). Progress notes indicated: -11/23/22 at 6:53 p.m., the resident had a fall witnessed by the nurse, CNA (Certified Nurse Aid) and resident spouse. He was being assisted from his wheelchair to his recliner, was very unstable, fell back against the chair with his bottom at the edge of the seat, and slid down to the floor. -11/24/22 at 10:28 a.m., a fall follow up was completed. He had a skin tear present from his fall, on the right lateral wrist. -12/1/22 at 3:53 p.m., per the CNA, they had attempted to transfer the resident from his wheelchair to his recliner after lunch. The resident was unable to complete the transfer and was lowered to the floor. He had no obvious injuries. -12/6/22 at 4:45 p.m., the CNA reported the resident was on the floor in front of his recliner. He had no obvious injuries. The CNA indicated she had attempted to transfer him from his recliner to the wheelchair when his leg gave out and she lowered him to the floor. On 12/29/22 at 9:28 A.M., CNA 5 was interviewed. During the interview, she indicated at times, Resident B could be transferred with 1 staff member. She would try to assist him to stand but if he was weak or unable to, she would set him back down and get another staff member to help her. She indicated he was tall which made it more difficult to transfer him. There was no documentation in Resident B's record to indicate care plan interventions were put into place to prevent further falls from occurring. The resident's MDS assessments indicated he required extensive assistance from 2 staff members for transfers. Falls on 11/23, 12/1, and 12/6/22 occurred when the resident was transferred by only 1 staff member. A current facility policy, titled Fall Program, provided by the Administrator on 12/28/22 at 10:30 A.M., stated the following: Purpose: 1. To identify residents who are at risk for falling. 2. Identification of precipitating events leading up to falls that do occur. 3. Identify pattern in falls. 4. Implement interventions to prevent or reduce the incidence of further falls .Procedure .3. Any resident that sustains a fall will be discussed at the the fall IDT committee meeting. Discussion to include all factors noted on the incident report, Fall Scene Investigation, Fall Huddle, and Root Cause Analysis This Federal tag relates to Complaint IN00395994. 3.1-45(a)

Based on interview and record review the facility failed to ensure a resident's narcotic medication was not misappropriated by a facility nurse for 1 of 3 resident medications reviewed for misappropriation. (Resident B) Findings include: The clinical record for Resident B was reviewed on 9/22/2022 at 11:00 A.M. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was to rate the level of pain based on a 1 being low and 10 being severe pain. The order indicated it was discontinued, but was lacking a discontinued date. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order indicated it was discontinued, but was lacking a discontinued date. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order had a discontinued date of 8/18/2022 and indicated it was completed. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order had a discontinued date of 8/18/2022 and indicated it was completed. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order had a discontinued date of 9/2/2022. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order had a discontinued date of 9/2/2022. Review of the August 2022 MAR (Medication Administration Record) and the Pharmacy Controlled Substance Records for Resident B, indicated LPN (Licensed Practical Nurse) 1 documented on 8/18/2022 at 6:00 P.M. 2 half tablets of [MEDICATION(S)] were wasted/dropped. On 8/18/2022 at 6:00 P.M., she documented 2 half tablets were signed out and administrated. On 8/19/2022, at 2:00 A.M., she signed off 2 half tablets of [MEDICATION(S)], but the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's incident report indicated LPN 1 had allegation of missing [MEDICATION(S)] for Resident B. The investigation was completed and found the torn missing [MEDICATION(S)] medication blister card for 10 tablets of [MEDICATION(S)]. The blister card was delivered to the facility on [DATE] and was found in the shred bin in the Nurse's Room on the unit. Review of LPN 2's statement, written on 8/20/2022, indicated she had received a card of whole tablets of [MEDICATION(S)] from the Pharmacy delivery man at the front desk. When she got back to the unit, she immediately went to Resident B's room and told them that they had received 10 whole tablets. The resident would have enough pain medications until her next delivery. LPN 1 had called the Pharmacy to get an authorization code to get the [MEDICATION(S)] from the EDK (Emergency Drug Kit) but the pharmacist indicated the medication was not in the EDK. LPN 2 requested the medication to be delivered stat (immediately). After she had shown Resident B the medication card that was delivered, the medication were put in the narcotic box, the count sheet was placed in the book and she filed the pink delivery status sheet in the filing cabinet. When LPN 1 came into replace her at shift change, she informed LPN 1 the [MEDICATION(S)] for Resident B had come. LPN 1 cosigned the pink controlled substance record by her name and placed the sheet in the narcotic book. On Saturday morning she was in the [NAME] Unit and heard Resident B discussing her pain medications with LPN 3. The resident made a comment about only having half tablets. She asked LPN 3 about the whole [MEDICATION(S)] tablets. LPN 3 indicated there was a card of half tables in the narcotic drawer, no whole tablets. They went to look for the medication. In the unit office in the medical record box was the delivery sheet for [MEDICATION(S)] 10 mg tablets for 2 tablets, which were already administered. When LPN 2 realized the [MEDICATION(S)] card was not accounted for she immediately called the executive director. The written statement was signed by LPN 2 and dated 8/20/2022 Review of LPN 3's statement, written on 8/20/2022, indicated when she had started her shift, she and LPN 1 counted the narcotics. She had signed the narcotic book for 3 count sheets and 3 medication cards. Resident B was requesting pain medications and she gave the resident 2 half tablets of [MEDICATION(S)]. Resident B was upset with her for not giving her a whole tablet. Around 11:00 A.M., she was talking with Resident B about the half tablets verses whole tablet and LPN 2 overheard them. LPN 2 knew Resident B had had whole tablets. When they realized the medication was gone and no paperwork was in the medical records, LPN 2 called the Administrator because she had received a stat delivery of whole tablets yesterday. The written statement as signed by LPN 3. During an interview with the Administrator on 9/22/2022 at 11:00 A.M., he indicated the reported incident occurred and was investigated. They had reviewed the security camera's video on the unit. The video showed LPN 1 open the narcotic box in the medication cart, she took a medication cup and was observed to go into the therapy gym on the unit. No cameras were in the therapy gym, but LPN 1 was in the gym for about 11 minutes and them was observed to go into the Nurses' Room. The shred bin in the Nurse's room was searched and part of the medication card and the delivery receipt from the 1:40 A.M. [MEDICATION(S)] order was found. No medications were found in the shred bin. The LPN had called the facility NP, for a new order for the [MEDICATION(S)] 10 mg half tablets for 14 days on 8/19/2022 around 2:00 AM. The order was written and entered in system at 3:57 AM. During an interview with LPN 2 on 9/22/2022 at 1:15 P.M., she indicated she had received Resident B's [MEDICATION(S)] on Friday afternoon, 8/19/2022. She had stopped by the resident's room to let her know she had received 10 whole tablets. She usually did not inform residents when their medication arrive, but the resident was worried about running out of the medication. She heard LPN 3 and Resident B talking and about the resident not having [MEDICATION(S)] whole tablets. She and LPN 3 searched everywhere for the resident's [MEDICATION(S)] whole tablets medication card and count sheet, they looked for the pink delivery receipt, none of them were found. They called the Administrator when they could not find the medication card. During an interview with LPN 3 on 9/22/2022 at 3:00 P.M.,she indicated she had worked on the [NAME] Unit on Saturday 8/20/2022. She moved to the unit around 6:30 A.M. when an agency staff called off. She had counted the narcotics with Nurse 1 when she came to the unit. The narcotic count was correct with the correct number of cards and count sheets. Resident B asked about getting a whole tablet instead of 2 half tablets and she told her only half tablets were available. LPN 2 overheard us and said she had received whole tables Friday afternoon. Both her and LPN 2 searched everywhere for the medication. When they could not find the medication LPN 2 called the Administrator. During an interview with the DON, on 9/22/2022 at 1:00 P.M., she indicated all Nurses and QMAs were educated on 8-29-2022 on professional conduct, drug diversion, records and variances of narcotic and controlled drugs, including drug security, accurate inventory counts and timely and accurate completion of narcotic registers and policy and procedures on any unresolved inventory or discrepancies was to be reported to the DON immediately and investigated. Staff were also educated to verifying the accuracy of the narcotic counts was completed by 2 licensed nurses or QMA. The DON also provided Quality Assurance Audits for the Narcotic Count Sheets, which began on 9/9/2022 for 3 times a week and was completed 3 times a week and required correction during 2 audits. Review of a current facility policy, provided by the Administrator on 9/22/2022 at 11:00 AM, titled, Drug Diversion, dated 2/9/2018, indicated, .To maintain security of all medication housed and dispensed by .follow all state and federal guideline in the storage and dispensing of all medications that are the responsibility of the facility. In the event a staff member becomes aware that there is medication missing they will contact the DON or House Supervisor immediately .1. Search medication cart, floor, medication room and immediate area for the missing medication .Immediately contact the DON and Administrator if not already done .Drug screen all employee having access to the missing medications during the time frame the medicated is thought to be missing. Employees that refuse testing may be subject to termination .Initiate investigation .Fill out abuse investigation forms [misappropriation of resident property] and send to IDSH Contact local policy .Replace the missing drugs at the facility's expense .Notify dispensing pharmacy .Consider QAPI (Quality Assurance Performance Improvement) to ensure drug diversion does not reoccur Review of a current facility policy, provided by the Administrator, on 9/22/2022 at 5:04 p.m., titled, Abuse, Neglect and Exploitation, revision date 9/2022, indicated, .It is the policy of this facility to provide protections for the health,, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent .Screening .Training .Prevention of Abuse, Neglect and Exploitation .Identification of Abuse, Neglect and Exploitation .Investigation of Alleged Abuse, Neglect and Exploitation .Protection of Resident .Reporting/Response .Coordination with QAPI The deficient practice was corrected by 9/9/22 after the facility implemented a systemic plan that included the following actions: completed investigation; all residents controlled medication records were reviewed; staff were educated; and auditing/monitoring was started prior to the start of the survey. This Federal tag relates to Complaint IN 472. 3.1-28(a)

Based on observation, interview and record review the facility failed to post the nursing staff information daily at the beginning of each shift in a prominent location readily accessible to residents and visitors. There were 69 residents who resided in the facility. Findings include: In an observation on 4/12/22 at 10:40 a.m., the nurse staffing information was not observed to be posted. In an observation on 4-12-22 at 2:30 p.m., the nurse staffing information was not observed to be posted. In an interview with the Administrator on 4/12/22 at 3:25 p.m. indicated he was unable to locate staff posting. He further indicated the staff posting got missed in the transition and the staff scheduler had not been trained to post staffing information. A current policy and procedure titled Posting of Nursing Department Staffing revised 4/22 was reviewed with the Director of Nursing (DON) on 4/19/22 at 12:12 p.m. The policy indicated that the scheduler or designee is to post the daily nursing staffing for each shift as well as actual hours worked. The procedure indicated that the completed nursing staffing form will be posted on the staff bulletin board and at the reception desk, and that weekend staffing will be posted as scheduled by the weekend shift supervisor every Saturday and Sunday.

Based on observation and record review the facility failed to ensure proper temperatures and documentation for 2 of 6 refrigerators reviewed. ([NAME] A and [NAME] B) Findings include: During an observation, on 4/12/22 at 12:16PM, a resident complained their milk was warm. The milk was temped at 42 degrees with a calibrated thermometer. The refrigerator did not have a thermometer. The Dietary Manager obtained a new thermometer. The refrigerator temp was 38 degrees after 30 minutes. The freezer had 2 thermometers. The kitchen staff ensured everything from refrigerator was thrown away for safety. The temperature logs dated March 2022 for [NAME] A had missing entries on the temperature record sheet. [NAME] A had no entries on 3/13, 3/26, and 3/27. The temperature logs for [NAME] B were reviewed on 4/12/22 at 1:06 PM. There was currently no Refrigerator Temperature Record sheet for April 2022. The refrigerator temperature record sheet dated March 2022 had the following dates without entries: 3/14, 3/15, 3/22, 3/23, 3/24, 3/25, 3/26, 3/27, 3/28, 3/29 and 3/30. On 4/18/22 at 10:32 AM April's Refrigerator Temperature Record sheet for [NAME] B was provided. There were no entries on the following dates April 1st through April 11th. A policy titled, Cold Storage Temperatures was revised on 1/20, and was provided by Administrator 4/14/22 at 11:23 AM. The cold storage policy indicated refrigerator storage was to be a maximum of 41 degrees Fahrenheit or below .each refrigerator will have a thermometer . each morning at opening and each night at closing the temperature was to be recorded. 3.1-21 (a)(2)

Based on observation, interview, and record review the facility failed to ensure 1 of 12 residents reviewed was treated with dignity (Resident 11). Findings include: A record review, started on 4/12/22 at 3:53 PM, indicated Resident 11 had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 11's MDS (Minimum Data Set) assessment dated , January 26, 2022 indicated the resident had a BIMS (Brief Interview for Mental Status) score of 3. The score of 3 was an indicator Resident 11 had a significant cognitive impairment. Section D (mood) indicated total severity score of 99, Resident 11 was unable to give a response to questions regarding mood and feelings. Resident 11's care plan dated 1-22 indicated a problem of potential psychosocial well-being. The intervention was to sit down with the resident, sing hymns and read Bible verses to her. This activity was not observed during the survey. The care plan did not indicate a preference for being called any nick names. Many areas in care plan had interventions related to Resident 11's husband calming resident. A progress note from social services on 4/8/22 indicated the resident was checked on due to her husband dying day prior. An observation, on 4/12/22 at 12:15 PM, indicated the DON was speaking about Resident 11 not having any family to speak of therefore she did not understand why Resident 11 repeated a female name. The DON was speaking to LPN 2 and QMA 3 in the dining area where Resident 16 and her family member were within hearing range. Resident 11's husband had passed away just 8 days prior. Resident 11 did not reply to the DON. In an observation, on 4/12/22 at 2:53 PM, CNA 4 referred to Resident 11 as [NAME] Booty. Resident 11 was sitting on side of bed with feet and legs over the side bars. Resident 11 did not acknowledge CNA 4 at the time. In an interview, LPN 2, on 4/12/22 at 3:16 PM, indicated Resident 11 recently lost her husband and that she prefers to be called by her first name. A policy titled; Promoting/Maintaining Resident Dignity, provided by administrator on 4/18/22 at 11:14 AM, indicated .it is the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity 3.1-3(a)(1)

Based on interview and record review the facility failed to ensure choices were honored for 3 of 9 residents reviewed for choices. (Resident 26, Resident X and Resident Y) Findings include: Resident 26's record was reviewed 3-25-2019. [DIAGNOSES REDACTED]. The annual MDS (Minimum Data Set) assessment, dated 3-12-2019, indicated the resident's BIMS (Basic Interview for Mental Status) score was 10 of 15. The assessment also indicated it very important for the resident to be able to choose tub bath, shower or other, and the resident was dependent on others for bathing. On 03-21-2019 at 2:40 PM, in an interview, Resident 26 was oriented to the day of the week, the location, and season of the year. Resident 26 indicated they wanted a whirlpool bath because it soothed her, they received one or less whirlpools per week, otherwise, the only bath given were bed baths. A review of Resident 26's care plan, dated 3-12-2019, indicated the residenet required extensive assistance for bathing, refer to bath/ shower schedule. The care plan did not indicate the resident had any refusals related to bathing/ showering, nor that the resident prefered whirlpool baths. A review of the CNA task schedule did not indicate when to bathe/ shower, nor whether the resident preferred baths, showers, or whirlpools. A review of Resident 26's bath/ shower schedule did not indicate the type of bath/ shower given. The schedule indicated the residnet had recieved a shower or bath twice weekly, did not indicate the resident had refused a bath or shower in the last two week period, and did not indicate the type of bathing the residnet had recieved, whether shower, bath , or whirlpool. A review of the behavior tracking dated 3-2019 did not indicate the resident had refused any services. In an interview on 03-25-19 at 1:28 PM, RN 1 indicated the resident always received bed baths on Tuesday and Friday. In an interview on 03-25-19 at 1:31 PM, LPN 2 indicated the resident enjoyed the whirlpool baths, and was especially attached to the specific staff who would give the whirlpool baths. In an confidential interview, a staff member indicated she worked mostly second shift, she worked closely with the resident to get her to take baths, but staff just gave the resident a bed bath. In an interview on 03-25-19 at 2:36 PM, the Executive Director indicated the resident refused baths and showers consistently. In interviews conducted during a resident meeting on 3-25-2019 at 1:10 PM, Resident X and Resident Y indicated the facility did not give them choices regarding bedtime and bathing preference. 3.1-3(u)

Based on interview and record review the facility failed to ensure Physician's orders were followed for an as needed gastro-[MEDICAL CONDITION] reflux disease (GERD) medication. This deficiency affected 1 of 5 residents reviewed for unnecessary medications (Resident 22). Findings include: The clinical record for Resident 22 was reviewed on 3/25/19 at 10:29 A.M. [DIAGNOSES REDACTED]. A Pharmacy Consultation Report signed by the Physician on 12/5/18 indicated Resident 22's [MEDICATION NAME] was to be changed from 20 milligrams daily to 20 milligrams daily as needed (PRN) for dyspepsia [MEDICAL CONDITION] and was to be discontinued if it was not used in 30 days. A Physician's order started on 12/5/2018, indicated Resident 22 was to receive 20 milligrams of [MEDICATION NAME] daily PRN for dyspepsia [MEDICAL CONDITION] and was to be discontinued if it was not used in 30 days. Medication Administration Records (MAR) provided by the Director of Nursing Services (DNS) on 3/27/19 at 2:40 P.M., indicated Resident 22 had not used the 20 milligrams of PRN [MEDICATION NAME] in (MONTH) (YEAR), January, February, or (MONTH) 2019. The DNS was interviewed on 3/27/19 at 11:45 A.M. During the interview the DNS indicated the [MEDICATION NAME] should have been discontinued after it had not been used for 30 days and it had not been. 3.1-35(g)(1)

Based on interview and record review, the facility failed to ensure safety for 1 of 3 cognitively impaired residents, reviewed for elopement (Resident B) Findings include: On 12/28/18 at 10:21 A.M., The Administrator provided an Indiana State Department of Health incident report form, filed on 12/13/18, regarding Resident B. The report included: Incident Date: 12/13/18, Incident Time: 11:08 a.m., and the following: At 5:01 a.m., Resident B walked to the Assisted Living hall where she used to live and continued to walk down to the end of the hall where she exited the building .another resident in the community saw the resident and brought her back into the facility The facility's investigation indicated the resident had been seen in her room at 4:00 a.m. by staff but when checked on at 4:55 a.m., Resident B was not in her room and her whereabouts were unknown. At 5:25 a.m., the front door bell rang and Resident B was found accompanied by a community resident who found her walking outside by the clubhouse and stating she was trying to get to (city). She had no injuries. The report indicated her whereabouts had been unknown for 26 minutes. On 12/28/18 at 10:21 A.M., Resident B's record was reviewed. [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 12/7/18, indicated a BIMS (Brief Interview Mental Status) score of 3 which signified Resident B had significantly impaired cognition. She required supervision of one staff member when ambulating in her room and corridor and for locomotion on and off the unit. The MDS indicated the resident experienced hallucinations and delusions during the assessment period. A Care Plan, dated 9/17/18, indicated Resident B wandered around at times and could become easily agitated when wandering. She does not always recall where she is at or why she is here. The goal was the resident's safety would be maintained, she would accept redirection when wandering, and would remain safe when wandering. Interventions (all dated 9/17/18) included, but were not limited to, distract resident from wandering by offering pleasant diversions, monitor her whereabouts when wandering, offer redirection when wandering, and use electronic non-audible monitoring device-audible only to staff. A Wandering Risk Assessment, dated 11/30/18 at 1:24 p.m., indicated the resident was at moderate risk for wandering due to forgetfulness, short attention span, disturbed by environmental noise levels, independent with aide for mobility, dementia, and a known history of wandering. Nurse Progress Notes indicated the following: On 9/16/18 at 9:12 a.m., the resident was extremely confused. She was let out into the courtyard where she attempted to unlock the gate. She was immediately escorted back into the building. Half hour checks were initiated and a motion sensor was placed in her room. On 9/17/18 at 1:13 a.m., the resident was agitated and wanted to go home. On 9/18/18 at 9:27 p.m., The NP (Nurse Practitioner) visited Resident B. Staff reported she had been severely confused, agitated, and had hallucinations. Hallucinations and delusions had been observed and the resident was noted to be slightly anxious when she realized her misperceptions. The plan was to continue to monitor for safety, moods, sleep, and behaviors. On 9/20/18 at 11:26 a.m., Half hour checks were discontinued. The resident was rounded on and had made no further attempts to exit. On 10/10/18 at 9:41 a.m., Resident B was confused and asked if she could get on the bus with the staff. She wanted to be let out of the unit door onto the unsecured patio area. The note indicated she took redirection poorly. On 10/24/18 at 2:41 a.m., The resident wandered around her room. She indicated she had some things to do and then was going home. On 11/26/18 at 6:22 a.m., Resident B was very tearful at bedtime and wanted to go home. Staff sat with her and reassured her with, her family knew she was here and that she should stay due to the late hour and cold temperaturse. She accepted this and was easily re-directed. On 11/26/18 at 11:45 a.m., The resident was confused at lunch time. She stated another resident was licking the table at breakfast time. An attempt was made to reorient her without success. On 11/28/18 at 1:22 p.m., The NP visited the resident due to increased confusion and hallucinations. The plan was to initiate UTI (Urinary Tract Infection) protocol and push fluids. On 12/2/18 at 10:01 a.m., Resident B still had delusions and/or hallucinations. She was confused to time, place, and situation but was easily redirected. On 12/2/18 at 11:49 p.m., The resident got up out of bed and dressed; she thought it was time to get up. Staff were unable to redirect her back to bed. On 12/3/18 at 1:23 p.m., Resident B showed slight confusion after breakfast and did not know where her room was. The note indicated this was resident's normal. On 12/7/2018 at 12:39 p.m., a care plan meeting was held with the resident's family. Her family had noticed a decline in the resident's cognition and an increase in hallucinations since moving from the AL (Assisted Living). the possibility of a move to memory care was mentioned to famiily. The facility indicated it might be beneficial for the resident as she tended to sundown in the evenings and was not sure where she was going or where her room was. The family member indicated perhaps the resident would fit in better on memory care. the note indicated staff took the resident's family member around the memory care unit. The family member indicated it would be a good move for her when a room is available. The note indicated the facility would keep in touch with the family member in regards to the room move. On 12/12/18 at 10:15 a.m., The NP visited the resident for routine follow up visit. The note indicated she had periods of confusion and at times, had hallucinations and delusions. The note also indicated the resident required the provision of a safe environment. On 12/13/18 at 5:30 a.m., the CNA (Certified Nurse Aid) went in to check on the resident. Resident B was noted not to be in her room. Staff immediately searched the unit. While staff searched the facility, a facility resident returned Resident B to the facility. The resident indicated she wanted to go to (city) and continued to ask if she could go. She was redirected to the secured memory care unit. A (MONTH) (YEAR) TAR (Treatment Administration Record) indicated the resident had an order to utilize a motion detector in her room for elopement prevention. The TAR indicated, per staff initials, the alarm was on every shift from 12/1-12/10/18 when it was discontinued. On 12/28/18 at 1:20 P.M., the DON (Director of Nursing) was interviewed. During the interview, she indicated motion alarms were used for residents at risk for elopement. The alarm was inaudible to the resident but sounded an alarm on the nurse's cart when activated. She indicated Resident B's motion alarm had been discontinued on 12/10/18 because staff believed she was no longer at risk for elopement due to her limited mobility. The DON was not able to provide documentation or assessments to indicate the resident was no longer at risk for elopement or that she had limited mobility. This Federal tag related to Complaint IN 725. 3.1-45(a)(2)

Based on record review, and interview the facility failed to ensure 1 resident (B) in a sample of 3 resident records reviewed received pain medication as ordered. This resulted in prolonged severe pain for Resident B. Findings include: Review of the clinical record for resident B on 10/1/17 at 10:00 a.m. indicated he was admitted with [DIAGNOSES REDACTED]. The resident admitted to the facility from the hospital after having a knee replacement. Interview with the resident B's wife on 10/1/17 at 9:45 a.m. indicated the resident was discharged from the hospital and arrived at the facility at approximately 6:45 p.m. She indicated the resident had been medicated for pain at the hospital at 4:00 p.m. and did not receive any pain medication at the facility until the next day at approximately 8:20 a.m. Resident B's wife indicated the resident had called her at 12:20 a.m. on 9/3/17 and she had not heard her phone. She indicated when she saw the call on her phone at 5:00 a.m. on 9/3/17. She called the facility and the nurse told her the resident was calm, resting and had been medicated. The resident then called his wife at 8:00 a.m. and stated he was going to call 911 to go to the hospital because he had not gotten any pain medication, had dropped his call light, and had been yelling for help through the night. Resident B's wife indicated she came into the facility at approximately 8:20 a.m. on 9/3/17 and the day shift nurse had given her husband his pain medication. She asked the nurse if she had given him any of his morning medications and she stated she needed to order them from the pharmacy as the night nurse had not ordered the medications. The day shift nurse had gotten the pain medication out of the facility emergency drug kit. A review of Resident B's Medication Administration Record [REDACTED]. On 10/1/17 at 1:15 p.m. interview with the facility Administrator indicated she had investigated and reported the incident of the resident not getting his medications. She indicated the day shift nurse on 9/3/17 had retrieved pain medication for the resident and medicated him for pain. She further indicated the night shift nurse on 9/2/17 had not medicated the resident for pain and had not ordered his medications from the pharmacy. She indicated the night nurse had access to retrieve the pain medication from the emergency drug kit in the facility but had not done so. A review of the Emergncy Drug Kit medication sign out indicated niether pain medication ordered for Resident B had been signed out of the kit for him. On 10/2/17 at 1:30 p.m. review of Resident B's MEDICATION ORDERS FOR [REDACTED] [MEDICATION NAME] 5-325 milligrams, give 2 tablets by mouth every 6 hours as needed for pain on a scale of 6-10. [MEDICATION NAME] 5-325 milligrams, give 1 tablet by mouth every 6 hours as needed for pain on a scale of 1-5. [MEDICATION NAME] 50 milligrams, give 1 tablet by mouth every 6 hours as needed for pain on a scale of 1-5. Untram 50 milligrams, give 2 tablets by mouth every 6 hours as needed for pain on a scale of 6-10. This federal tag is related to complaint IN 773 3.1-37(a)

Based on interview and record review, the facility failed to ensure one of three resident's (#66) reviewed for accidents, had adequate interventions to prevent a fall resulting in a fracture. Findings include: An interview with LPN #1 on 3/10/16 at 1:53 P.M.,indicated Resident #66 had a fall on 2/15/16 at the facility which resulted in a femur fracture. Review of Resident #66's record on 3/11/16 at 9:15 A.M. indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/12/16, a Morse Fall Scale Assessment was completed and indicated a score of 55, which is a high risk for falling. The instructions section indicated Fall Risk is based upon Fall Risk Factors and is more than a Total Score. Determine Fall Risk Factors and Target Interventions to Reduce Risks. Complete on admission, quarterly, at change of condition, and after a fall. The assessment indicated the resident had: a history of falling; gait was normal/bedrest/wheelchair; ambulatory aid was none/bedrest/wheelchair/nurse assist; mental status was overestimates or forgets limits. Resident #66 had a physician progress notes [REDACTED].M., which indicated Resident #66 had been sleeping when staff went into her room to check on her. Staff were in the next room when they heard yelling and ran back and found the resident on the floor. The left leg was shortened and externally rotate. The resident did not recall if she got dizzy, and couldn't tell much about the fall. Resident #66 was noted to have facial pain, swelling and redness over the left cheek. Complaints of leg, hip and knee pain. The resident was transported to a local emergency room for evaluation and treatment. The NP assessment indicated a left hip fracture. An interview with RN #2, on 3/11/16, at 10:11 A.M., indicated the resident was admitted to the facility on [DATE] which was a Friday, and the facility should have started an interim care plan upon admission. RN #2 did not believe an interim care plan was implemented before 2/15/16. RN #2 indicated fall interventions should have been added for Resident #66 based on being a high fall risk as indicated by the Morse Fall Assessment of 2/12/16. An interview with the Administrator (Admin), on 3/11/16, at 10:15 A.M. indicated Resident #66 did not have an interim care plan upon admission. The Admin indicated Resident #66 should have had an interim care plan upon admission on 2/12/16. An interview with the Director of Nursing Services (DNS) and the Admin was conducted on 3/11/16, at 10:38 A.M The DNS and Admin indicated the investigation of Resident #66's fall with a fractured femur on 2/15/16 occurred 30 seconds after a Certified Nursing Assistant (CNA) left the room. The CNA heard a noise and went back in the room and found the resident had fallen. The DNS and Admin indicated they believed Resident #66 had tried to transfer herself out of bed and fell . They indicated the resident was not to transfer herself and was to be assisted from bed to the wheelchair. The DNS and Admin indicated the resident was somewhat confused when she was admitted on [DATE] and indicated Resident #66 had been using the call light to call staff. The DNS and Admin indicated Resident #66 was readmitted from the hospital on [DATE] and an intervention of a bed alarm was added. On 3/14/16 at 1:59 P.M. an interview with Resident #66's spouse indicated the resident was not totally alert when she was admitted and had dementia, which was the reason for admission to a nursing home. On 3/14/16 at 2:03 P.M., the DNS provided a Fall Assessment Policy dated 2/15/16. The policy indicated all residents admitted to the facility were to be assessed upon admission to the facility for falls by nursing staff. The policy further indicated what actions were to be taken after a fall. On 3/14/16 at 2:03 P.M., the DNS provided a current undated policy for Resident Care Plans. Under General Guidelines: An initial nursing care plan for the resident will be written and implemented upon admission. 3.1-45(a)(1)

Based on record review and interview, the facility failed to ensure the physician was informed of a resident's low oral fluid intake, which resulted in the resident requiring intravenous fluids, for 1 of 1 residents reviewed for hydration (Resident #59). Findings include: The record for Resident #59 was reviewed on 3/14/2016 at 9:30 A.M. [DIAGNOSES REDACTED]. Physician orders [REDACTED]. An admission progress note by the facility Registered Dietitian (RD), dated 2/4/2016 at 1:37 P.M., indicated Resident #59's intakes were poor, with averages of 0-25% of meals consumed. The note also indicated the resident reported no issues with chewing or swallowing. The note further indicated Resident #59 was assessed as requiring 1380 cc (cubic centimeters) of fluids daily. The note indicated (Resident's name) dx (diagnoses) of intestinal obstruction and poor intakes increase her risk for weight loss and dehydration. A Nutritional Risk Assessment-Alternate completed by the RD, dated 2/4/2016, indicated Resident #59 consumed less than 1000 cc of oral fluids daily. Fluid consumption intake records for Resident #59 for February 2016 were provided by the facility Director of Nursing Services (DNS) on 3/14/2016 at 1:30 P.M. The intake record indicated the resident had received 720 cc of fluid on 2/4/2016, 960 cc of fluid on 2/8/2016, and 300 cc of fluid on 2/13/2016. There was no other documentation of amount of fluids consumed on the resident's fluid intake record. A Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Nurse's notes indicated the Resident was seen by the physician on 2/9/16 and on 2/10/16 by a Nurse Practitioner. A progress note by the physician, dated 2/18/2016 at 5:41 P.M., indicated Pt (patient) with confusion. Appears to be coughing. Can't provide much history. HX (history) is limited. The progress note indicated the plan was to obtain laboratory tests (complete blood count and comprehensive metabolic profile), a chest x-ray, and a urinalysis and to start intravenous fluids. The note further indicated Based on labs and x ray results, further steps will be initiated. The note also indicated the resident's prognosis was guarded. A nursing progress note, dated 2/18/2016 at 6:24 P.M., indicated orders had been received from the physician to start intravenous fluids of normal saline (fluid used to treat dehydration). A physician progress notes [REDACTED].M., indicated Resident #59 was seen by the physician for a follow up visit. The note indicated the resident was still very weak. The note further indicated the resident's family had declined aggressive treatment in the past, but the physician had been informed the resident's family was considering hospice. The note indicated the antihypertensive medications were to be held and the physician was waiting for the results of the comprehensive metabolic profile. A laboratory report, with a collection date of 2/19/2016 at 10:35 A.M. and reported date of 2/19/2016 at 11:23 A.M., indicated a blood urea nitrogen (an indicator of hydration status and kidney function) level of 79 mg/dL (milligrams per deciliter) with a normal reference range of 7-18 mg/dL and a Creatinine (an indicator of kidney function) level of 5.83 mg/dL with a normal reference range of 0.61-1.10 mg/dL. The report also indicated a potassium level of 9.0 mmol/L (millimole per liter, used in medicine to measure concentrations of substances in blood) with a normal reference range of 3.6 - 5.1 mmol/L. A nursing progress note, dated 2/19/2016 at 11:08 A.M., indicated the nurse had texted the nurse practitioner (NP) to advise her that the resident had pulled the IV. A progress note dated 2/19/2016 at 11:10 A.M. indicated the NP texted back to the nurse asking if the lab results were available. A progress note dated 2/19/2016 at 11:24 A.M. indicated the nurse texted back to the NP regarding the elevated potassium level. A note dated 2/19/2016 at 11:30 A.M. indicated the NP texted back to the requesting the nurse to call her as soon as possible. A nursing progress note, dated 2/19/2016 at 12:05 P.M., indicated the nurse called the NP with the results from the comprehensive metabolic profile and orders were received to continue the IV fluids. The note also indicated the resident was refusing to eat or drink and the family declined sending the resident to the hospital. The facility DNS was interviewed on 3/16/2016 at 10:00 A.M. During the interview, the DNS indicated the nursing staff had been routinely monitoring the resident for signs and symptoms of dehydration, but there was no further documentation to show fluid consumption for Resident #59. The DNS indicated meal consumption records only indicated the percentage of meals consumed, but did not indicate how much fluids the resident consumed at meals. The DNS indicated the facility staff did not routinely document the amount of fluids consumed by residents unless intakes were ordered to be monitored by the physician. The DNS indicated Resident #59 had been resistant to consuming fluids. CNA #5 was interviewed on 3/16/2016 at 11:20 A.M. During the interview, CNA #5 indicated Resident #59 had often refused fluids, except for coffee, but she would chew ice chips at times. The DNS was interviewed on 3/16/2016 at 11:15 A.M. During the interview the DNS indicated there was no documentation in Resident #59's clinical record to indicate the physician or nurse practitioner had been notified of the resident's decreased oral fluid intake between 2/10/16 and 2/18/2016. An undated facility policy entitled Change in Resident Condition or Status was provided by the DNS on 3/16/2016 at 11:40 A.M. The policy indicated The charge nurse will notify the resident's attending physician when There is a significant need to alter the resident's treatment. 3.1-5(a)(3)

Based on interview and record review, the facility failed to initiate a care plan to reduce the risk of falls for one of three resident's (#66) reviewed for falls. Findings include: An interview with LPN #1 on 3/10/16 at 1:53 P.M.,indicated Resident #66 had a fall on 2/16/16 at the facility which resulted in a femur fracture. Review of Resident #66's record on 3/11/16 at 9:15 A.M. indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/12/16, a Morse Fall Scale Assessment was completed and indicated a score of 55, which is a high risk for falling. The instructions section indicated Fall Risk is based upon Fall Risk Factors and is more than a Total Score. Determine Fall Risk Factors and Target Interventions to Reduce Risks. Complete on admission, quarterly, at change of condition, and after a fall. The assessment indicated the resident had: a history of falling; gait was normal/bedrest/wheelchair; ambulatory aid was none/bedrest/wheelchair/nurse assist; mental status was overestimates or forgets limits. An interview with RN #2, on 3/11/16, at 10:11 A.M., indicated the resident was admitted to the facility on [DATE] which was a Friday, and the facility should have started an interim care plan upon admission. RN #2 did not believe an interim care plan was implemented before 2/15/16. RN #2 indicated fall interventions should have been added for Resident #66 based on being a high fall risk as indicated by the Morse Fall Assessment of 2/12/16. An interview with the Administrator (Admin), on 3/11/16, at 10:15 A.M. indicated Resident #66 did not have an interim care plan upon admission. The Admin indicated Resident #66 should have had an interim care plan upon admission on 2/12/16. On 3/14/16 at 2:03 P.M., the DNS provided an undated policy for Resident Care Plans. Under General Guidelines: An initial nursing care plan for the resident will be written and implemented upon admission. 3.1-35(a)