Every finding on record at Hillcrest Village

Based on observation, interview and record review, the facility failed to ensure a resident's (Resident B) physician's order was followed for 2 of 3 residents reviewed for quality of care. Findings include:During an interview, on 8/12/26 at 2:05 p.m., with the Director of Nursing present, Resident B indicated he kept his vaping pen (electronic cigarette) in the 2nd drawer of his dresser. Resident C came in his room, without his knowledge, and took his vaping pens out of his room.During an interview, on 8/12/26 at 11:40 a.m., the Director of Nursing indicated that Resident C had taken Resident B's vaping pens out of his room and took them to her room without Resident B's knowledge. When she retrieved the vaping pens from Resident C, the cartridges were empty and looked like they had been empty for quite some time. The clinical record for Resident C was reviewed on 8/12/26 at 12:20 p.m. The resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (progressive long-term lung disease that blocks airflow and makes breathing difficult), psychosis (mental health symptom where a person loses touch with reality), persistent affective mood disorder (a low, dark, or sad mood), schizoaffective disorder (a chronic mental health condition that combines symptoms of schizophrenia, such as hallucinations or delusions, with a major mood disorder, like depression or bipolar mania) and metabolic encephalopathy (a brain function loss caused by a chemical imbalance, toxin buildup, or lack of energy). The annual MDS assessment, dated 3/11/26, indicated Resident C had moderately impaired cognition. A progress note, dated 4/14/26 at 11:30 p.m., indicated Resident C was found with three vaping pens in her room. The clinical record for Resident B was reviewed on 8/12/26 at 11:55 a.m. The resident's diagnoses included, but were not limited to, cerebral palsy (a group of permanent movement disorders that affect muscle tone, balance and posture), conversion disorder with seizures or convulsions (a functional neurological disorder that involves sudden, real physical shaking or seizure like attacks) and cognitive communication deficit (trouble with communication caused by disrupted thinking skills like memory, focus and planning). The annual Minimum Data Set (MDS) assessment, dated 6/19/26, indicated Resident B had moderately impaired cognition. The physician's order, dated 11/22/24 at 2:33 p.m., indicated Resident B may smoke electronic cigarette/cigarettes per the facility policy. The electronic cigarette was to be kept in the medication cart. The order was discontinued on 6/2/26. The physician's order, dated 6/2/26 at 11:22 a.m., indicated Resident B may smoke his electronic cigarette per the facility policy. The electronic cigarette was to be kept in the medication cart. The physician's order was discontinued on 8/12/26 at 3:25 p.m. During an observation, on 8/12/26 at 2:05 p.m., Resident B was observed in his room with his white electronic cigarette (vaping pen). During the survey period, between 8/12/26 and 8/13/26, Licensed Practical Nurse (LPN) 11 indicated all physician orders should be followed. On 8/13/26 at 12:15 p.m., the Executive Director provided a current copy of the document titled MatrixCare Physician Orders Policy dated 9/2025. It included, but was not limited to, All.orders will be entered into MatrixCare Physician Orders.The MatrixCare Physician Order is to be considered the official order.

Based on interview and record review, the facility failed to ensure medication administration records reflected the administration of narcotic pain medication (Residents C, D, E and F) for 4 of 5 residents reviewed for medical records. Findings include: 1. The clinical record for Resident C was reviewed on 4/13/26 at 11:06 a.m. The resident's diagnoses included, but were not limited to, osteomyelitis (bone infection) of the vertebra and necrotizing fasciitis (rapidly progressing bacteria infection). The physician's order, dated 3/24/26, indicated the resident was to receive Oxycodone-Acetaminophen (narcotic pain medication) 5-325 mg (milligrams) every 4 hours as needed for pain. Review of the March 2026 and April 2026 controlled substance record indicated the medication was administered on the following dates and times:-3/25/26 at 10:00 p.m.-3/27/26 at 7:00 a.m.-3/27/26 at 4:50 p.m.-3/28/26 at 11:00 a.m. and 4:00 p.m.-3/29/26 at 9:15 a.m. and 3:00 p.m.-3/31/26 at 1:00 a.m.-4/02/26 at 8:00 a.m.-4/3/26 at 8:00 a.m., 12:00 p.m. and 6:00 p.m. The March 2026 and April 2026 medication administration record (MAR) lacked documentation of the administration of the narcotic pain medication. During an interview, on 4/14/26 at 11:39 a.m., Licensed Practical Nurse (LPN) 12 indicated any narcotic medication should be signed off on the controlled substance record and the MAR. 2. The clinical record for Resident D was reviewed on 4/13/26 at 1:55 p.m. The resident's diagnoses included, but were not limited to, rheumatoid arthritis (autoimmune disease where the immune system mistakenly attacks the joints and lining, causing painful inflammation) and chronic pain syndrome (a condition where pain lasts for more than 3 to 6 months). The physician's order, dated 2/24/26, indicated the resident was to receive Oxycodone (narcotic pain medication), 5 mg, every 4 hours as needed for pain. Review of the March 2026 controlled substance record indicated the resident received the Oxycodone medication on the following dates and times:-3/14/26 at 9:00 p.m.-3/18/26 at 8:00 p.m.-3/19/26 at 8:29 a.m. and 8:00 p.m.-3/20/26 at 1:00 a.m., 8:00 a.m. and 8:00 p.m. The March 2026 MAR lacked documentation of the administration of the above listed Oxycodone medication. 3. The clinical record for Resident E was reviewed on 4/14/26 at 10:42 a.m. The resident's diagnosis included, but was not limited to, multiple sclerosis (autoimmune disease of the central nervous system where the immune system attacks the protective sheath surrounding nerves) and generalized anxiety. The physician's order, dated 7/1/25, indicated the resident was to receive Oxycodone-Acetaminophen, 10-325 mg, every 4 hours at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m. The March 2026 MAR lacked documentation of the administration of the narcotic pain medication on 3/16/26 at 8:00 a.m., 3/18/26 at 8:00 a.m. and 3/19/26 at 8:00 p.m. The physician's order, dated 7/13/25, indicated the resident was to receive Lorazepam (narcotic anti-anxiety medication), 0.5 mg, twice daily at 5:00 a.m. and 5:00 p.m. The March 2026 MAR lacked documentation of the administration of the Lorazepam medication on 3/9/26 at 5:00 p.m. and 3/18/26 at 5:00 a.m. 4. The clinical record for Resident F was reviewed on 4/14/26 at 11:18 a.m. The resident's diagnoses included, but was not limited to, diabetes, depression and peripheral vascular disease (progressive circulation disorder involving narrowing, blockage, or spasms of blood vessels, most commonly affecting the legs and feet). The physician's order, dated 3/27/26, indicated the resident was to receive Hydrocodone-Acetaminophen (narcotic pain medication), 5-325 mg, every 8 hours as needed for pain. The April 2026 controlled substance record indicated the resident received the Hydrocodone-Acetaminophen medication on the following dates and times:-4/01/26 at 9:00 p.m.-4/02/26 at 8:30 p.m.-4/03/26 at 9:00 p.m.-4/06/26 at 2:10 a.m.-4/08/26 at 1:00 a.m. and 9:00 p.m.-4/09/26 at 3:15 a.m. and 9:00 p.m.-4/10/26 at 8:15 p.m.-4/11/26 at 11:55 p.m. The April 2026 MAR lacked documentation of the administration of the Hydrocodone-Acetaminophen medication. On 4/14/26 at 1:01 p.m., the Executive Director provided a current copy of the document titled Medication Administration dated 4/25. It included, but was not limited to, Procedure Steps.Medication Administration will be recorded on the EMAR after given. This Citation relates to Intake 2974549 410 IAC (Indiana Authorization Code) 16.2-3.1-50(a)(2)

Based on interview and record review, the facility failed to ensure wound treatments were completed, as ordered by the physician (Resident C and Resident D) and failed to ensure the treatment administration record reflected the completion of wound treatments (Resident C, Resident D and Resident E) for 3 of 4 residents reviewed for pressure ulcers. Findings include:1. The clinical record for Resident C was reviewed on 4/13/26 at 11:06 a.m. The resident's diagnosis included, but was not limited to, Stage 4 pressure ulcer (severe, full-thickness wound with exposed muscle, tendon or bone, often accompanied by necrotic tissue, black, dead skin and deep tissue destruction) of the sacral region. The physician's order, dated 3/30/26, indicated staff were to cleanse the resident's sacral wound with normal saline, pat dry, apply bacitracin, pack the wound with Dakin's (debridement solution) moistened gauze, skin prep the peri wound and cover with a bordered dressing (multi-layered sterile, and absorbent dressing) every shift. The anonymous complaint, during the survey process, indicated Resident C had requested multiple times on night shift to have his treatment completed by Registered Nurse (RN) 8. RN 8 never completed Resident C's treatment. Review of the April 2026 treatment administration record (TAR) indicated the resident's wound treatment had been completed on 4/2/26 by the night shift staff (RN 8). During an interview, on 4/13/26 at 12:12 p.m., Certified Nursing Assistant (CNA) 5 indicated on or around 4/3/26, Resident C reported that his wound care was not completed the night before. The CNA indicated the resident was very upset. CNA 5 reported Resident C's concern to Registered Nurse (RN) 4. During an interview, on 4/13/26 at 1:46 p.m., RN 4 indicated it was reported to her that Resident C's treatment had not been completed on the night shift as prescribed. RN 4 spoke with Resident C who was visibly upset. When RN 4 went to complete the treatment for day shift, on 4/3/26, she removed the treatment that had been completed on day shift (4/2/26) the previous day. RN 8 had signed that she had completed the treatment on the TAR for night shift, but had not because the dressing RN 4 had removed was initialed from the day shift nurse on 4/2/26. During an interview, on 4/14/26 at 11:39 a.m., Licensed Practical Nurse (LPN) 12 indicated that when the nurse's completed a resident's wound treatment, it was to be signed off by the nurse that completed the treatment. 2. The clinical record for Resident D was reviewed on 4/13/26 at 1:55 p.m. The resident's diagnoses included, but were not limited to, chronic non-pressure ulcer of the left heel and mid-foot and a Stage 4 pressure ulcer to the left buttock. The physician's order, dated 2/26/26, indicated staff were to paint the resident's left heel wound with betadine, allow to dry and cover with heel Optifoam (absorbent, polyurethane foam wound dressing designed to manage drainage, maintain a moist wound environment) every shift. Review of the March 2026 TAR lacked documentation the resident's wound treatment was completed on night shift, 3/5/26 and on day shift, 3/18/26. The physician's order, dated 4/8/26, indicated staff were to cleanse the resident's wound to the left buttock with wound cleanse, pat the wound dry, pack the wound with normal saline moistened gauze, skin prep the peri wound and cover with bordered dressing every shift. During an interview, on 4/13/26 at 9:44 a.m., Resident D indicated his wound treatment on his bottom was not completed on night shift, 4/12/26. During an interview, on 4/13/26 at 12:10 p.m., CNA 6 indicated Resident D reported that his wound treatment was not completed last night, 4/12/26. She reported the concern to RN 4. During an interview, on 4/13/26 at 1:46 p.m., RN 4 indicated it was reported to her that Resident D's treatments were not completed on night shift, 4/12/26. Resident D and his family member reported the wound treatments were not completed. When RN 4 went to complete the resident's wound treatment and she removed the treatment completed by the day shift nurse on 4/12/26 and not a wound dressing initialed by the night shift nurse (RN 8). Review of the April 2026 TAR indicated the resident's wound treatment had been completed on night shift, 4/12/26, by RN 8. 3. The clinical record for Resident E was reviewed on 4/14/26 at 10:42 a.m. The resident's diagnosis included, but was not limited to, Stage 4 pressure ulcer to the coccyx/sacral region. The physician's order, dated 12/3/25, indicated staff were to cleanse the resident's coccyx wound with normal saline, skin prep the peri wound, pack with wound with Dakin's (a diluted solution used as a topical antiseptic to clean and treat infected skin wounds) soaked and fluffed 4 by 4 gauze, cover with an abdominal pad (ABD) and secure with tape every shift. Review of the March 2026 and April 2026 TAR lacked documentation of the completion of the resident's wound treatment on the follow dates and shifts: 3/17/26 on night shift; 3/25/26 on night shift; 4/09/26 on day shift; and 4/10/26 on night shift This Citation relates to Intake 2974549 410 IAC (Indiana Authorization Code) 16.2-3/1-40(a)(2)

Based on interview and record review, the facility failed to ensure a resident's (Resident D) blood pressure medication was held when the blood pressure was out of parameter for 1 of 5 residents reviewed for quality of care. Findings include:The clinical record for Resident D was reviewed on 4/13/26 at 1:55 p.m. The resident's diagnosis included, but was not limited to, hypotension (low blood pressure).The physician's order, dated 3/3/26, indicated the resident was to receive Midodrine (medication used to raise blood pressure) 5 mg (milligrams) three times a day at 7:00 a.m., 11:00 a.m. and 4:00 p.m. The medication was to be held with a systolic blood pressure (maximum pressure in your arteries when the heart contracts and pumps blood) greater than 140. The March 2026 medication administration record indicated the resident received the Midodrine medication on the following dates and times:-On 3/05/26 at 11:00 a.m., the resident received the Midodrine with a systolic blood pressure of 157.-On 3/11/26 at 11:00 a.m., the resident received the Midodrine with a systolic blood pressure of 150. During an interview, on 4/14/26 at 11:39 a.m., Licensed Practical Nurse 12 indicated blood pressure medications should not be administered if not within the parameters ordered by the physician. On 4/14/26 at 2:34 p.m., the Director of Nursing indicated the facility did not have a policy related to medication parameters. This Citation relates to Intake 2974549 410 IAC (Indiana Authorization Code) 16.2-3.1-37

Based on interview and record review, the facility failed to ensure qualified medications aides practiced within the scope of practice for 3 of 4 residents reviewed for qualified personnel. (Residents D, E and F) Findings include: 1.The clinical record for Resident D was reviewed on 4/13/26 at 1:55 p.m. The resident's diagnoses included, but were not limited to, rheumatoid arthritis (autoimmune disease where the immune system mistakenly attacks the lining of joints causing painful inflammation, swelling and potential joint deformity); chronic pain and osteoarthritis (joint disease, characterized by the progressive breakdown of articular cartilage). The physician's order, dated 2/24/26, indicated the resident was to received Oxycodone (narcotic pain medication) 5 mg (milligrams) every 4 hours as needed (PRN) for pain. The March 2026 controlled substance record and the March 2026 medication administration record, indicated on 3/18/26 at 9:16 a.m., Qualified Medication Aide (QMA) 9 administered the prn narcotic pain medication to the resident. The clinical record lacked documentation of a licensed nurse initials on the controlled substance record, a documented assessment of the resident by the licensed nurse and permission granted prior to administration of the narcotic pain medication. On 4/14/26 at 11:39 a.m., during an interview with Licensed Practical Nurse (LPN) 12, she indicated when the QMA's reports requested as needed pain medication, the licensed nurse assesses the resident prior to the administration and documents the assessment on the medication administration record and signs off on the controlled substance record with the QMA. 2. The clinical record for Resident E was reviewed on 4/14/26 at 10:42 a.m. The resident's diagnosis included, but was not limited to, a sacrum stage 4 pressure ulcer (a severe, full-thickness wound with exposed muscle, tendon, or bone, often accompanied by necrotic tissue, black dead skin, and deep tissue destruction). The physician's order, dated 12/3/25, indicated staff were to cleanse the resident's sacrum/coccyx wound with normal saline, pack the wound with Dakin's (used for debridement) soaked/fluffed 4 by 4 gauze, cover with an abdominal pain (ADB) and secure with tape twice a day on each shift. Review of the April 2026 treatment administration record (TAR) indicated the following:-On 4/03/26, night shift, from 7:00 p.m. - 7:00 a.m., QMA 10 signed off the TAR as completing the stage 4 treatment to the sacrum The physician's order, dated 8/14/25, indicated nursing staff were to monitor the resident's sacrum wound for signs and symptoms of infection and/or decline. Review of the April 2026 TAR indicated the following:-On 4/09/26, day shift, from 7:00 a.m. to 7:00 p.m., QMA 11 signed off the TAR as completing the monitoring of the resident's Stage 4 wound on the sacrum. 3. The clinical record for Resident F was reviewed on 4/14/26 at 11:18 a.m. The resident's diagnoses included, but were not limited to, diabetes and major depression. The physician's order, dated 3/27/26, indicated the resident was to receive Hydrocodone-Acetaminophen (narcotic pain medication) 5-325 mg every 8 hours as needed for pain. The April 2026 controlled substance record and April 2026 medication administration record indicated on 4/3/26 at 2:27 p.m., the resident was administered the as needed narcotic pain medication by QMA 9. The clinical record lacked documentation of a licensed nurse initials on the controlled substance record, a documented assessment of the resident by the licensed nurse and permission granted prior to administration of the narcotic pain medication. During an interview, on 4/14/26 at 12:46 p.m., QMA 9 indicated licensed nurses assesses the residents prior to the administration of any as needed medication. The licensed nurse then gives permission to the QMA's to administer. The QMA's could not sign off on the treatment administration record for any wound/pressure ulcer higher than a stage 1 (early, reversible injury characterized by intact, non-blanchable redness which is not an open wound). The QMA Scope of Practice that indicated .Administer previously ordered .(PRN) medication only if authorization is obtained from the facility's licensed nurse on duty or on call. If authorization is obtained, the QMA must do the following: .Document in the resident resident record that the facility's licensed nurse was contacted, symptoms were described, and permission was granted to administer the medication, including the time of contact .Ensure that the resident's record is cosigned by the licensed nurse who gave permission by the end of the nurse's shift, or if the nurse was on call, by the end of the nurse's next tour of duty .Apply topical medication to minor skin conditions .stage one decubitus ulcer On 4/14/26 at 12:40 p.m., the Director of Nursing provided a current copy of the document titled QMA Parameters and Scope of Practice dated 11/2025. It included, but was not limited to, Can QMA perform? .Yes/No.Assess a resident's condition.No.Administer previously ordered PRN medication, only if authorization is obtained from the licensed nurse on duty or on call. If authorization is obtained, the QMA must perform the following.Document in the resident record that the licensed nurse was contacted, symptoms were described, and permission was granted to administer the medication, including the time of contact.Ensure the resident's record is co-signed by the licensed nurse who gave permission by the end of the nurse's shift, or if the nurse was on call, by the end of the nurse's next tour of duty.Yes.Administer a treatment that involves advanced skin conditions, including Stage II, III and IV pressure ulcers.No. 410 IAC (Indiana Authorization Code) 16.2-3.1-35(a)(2)

Based on record review, observation, and interview, the facility failed to ensure fall prevention was maintained for residents with muscle weakness during 1 of 5 residents reviewed for accident hazards. (Resident 53) Findings include: The nurse's note by RN 3, dated 12/1/25 at 10:45 a.m., indicated the resident was receiving a bed bath with the assistance of two staff members, Resident 53 was turned to the right side/stomach with the resident's feet crossed, when his feet slipped off the side of the bed and pulled the resident to the floor. The resident received a bruise to the back of the right arm, a long skin tear down his left shin, skin abrasions to the bilateral knees, and scratch like marks to the resident's abdomen. The interdisciplinary team (IDT) note, dated 12/3/25 at 9:36 a.m., indicated a review of the fall on 12/1/25 at 10:45 a.m., indicated during the incident, two staff were giving a bed bath to the resident, when he was turned onto his right side, his legs were crossed and slid off the side of the bed. Upon full body assessment, a bruise was observed to the back of the resident's right arm, bilateral abrasions to his knees, scratch marks to the abdomen and a skin tear down the left shin. The Nurse Practitioner (NP) was informed with new orders to monitor and x-ray the left hip with negative results. The record for Resident 53 was reviewed on 2/25/26 at 9:23 a.m. The resident's diagnoses included, but were not limited to, type 2 diabetes mellitus with diabetic neuropathy (nerve damage that manifests as tingling, numbness, pain, and muscle weakness), bilateral hearing loss, chronic pain, and repeated falls. The care plan, dated 1/7/25, indicated the resident was at risk for falls due to, but not limited to, repeated falls, bilateral hearing loss, chronic pain, unsteady gait, requires assistance with transfer via mechanical lift, lacks understanding of cognitive and physical limitations, and decreased mobility and weakness. The nurse's note, dated 10/11/25 at 2:05 p.m., indicated the resident voiced an inability to move well, with maximum assistance of two staff for proper positioning in a motorized chair. The resident denied any pain, but indicated, My body just won't move. During an interview, on 2/26/26 at 9:40 a.m., RN 3 indicated the resident had a fall from his bed in early December 2025. Two CNAs (CNA 4 and CNA 5) were giving a bed bath to the resident. One CNA turned to obtain bath supplies and the other was by the bed. The resident was turned onto his side and fell from the bed. The CNA at the bedside should have been there to catch the resident. He could not move well on his own. The new intervention was for a bariatric mattress. During an observation of the resident's care, on 2/26/26 at 9:54 a.m., RN 3 placed the resident's left leg over the right leg onto the mattress. She then pulled the resident toward her and rolled him onto his right side. The resident was unable to assist staff with his mobility/roll. During an interview, on 2/26/26 at 11:20 a.m., the Director of Nursing (DON) indicated Resident 53's care was being provided, the resident already had his legs crossed when the staff turned the resident over, there was a momentum (quantity of motion) and the resident rolled out of bed. The Fall Management Policy, last revised June 2025, included, but was not limited to, Policy: It is the policy of the [corporation name] to ensure residents residing within the community have adequate assistance to prevent injury related to falls. 410 IAC (Indiana Administrative Code) 16.2-3.1-45(a)(1)410 IAC (Indiana Administrative Code) 16.2-3.1-45(a)(2)

Based on observation and interview, the facility failed to ensure nursing staff primed the insulin pen's needle prior to dialing the ordered dose during 1 of 4 insulin administrations. (Resident 53) Findings include:During an observation and interview, on 2/24/26 at 11:41 a.m., Resident 53's blood sugar was obtained by Licensed Practical Nurse (LPN) 9 with a reading of 135 milligrams per deciliter (mg/dL). The LPN dialed the Fiasp (fast acting insulin) FlexTouch pen to 25 units without applying a needle. The LPN indicated she had to obtain a second nurse's check on the amount. RN 3 verified the 25 units and checked under the cap. The RN did not say anything and nodded to the LPN it was correct. The needle was then added to the insulin pen by LPN 9. The LPN failed to prime the needle after applying it to the insulin pen. The LPN was stopped from injecting the insulin to the resident. At 11:46 a.m., the LPN 9 indicated she had not primed the needle after she placed it on the insulin pen. The LPN dialed the insulin pen back to zero, then up to 3 units, after priming the needle by expressing the 3 units, the LPN dialed the pen to 25 units and administered the insulin to the resident. The record for Resident 52 was reviewed on 2/25/26 at 9:30 a.m. The resident's diagnoses included, but were not limited to, type 2 diabetes mellitus (inability to produce or properly use insulin) with hyperglycemia (high blood sugar). The care plan, dated 4/9/12 and revised 12/23/25, indicated the resident was at risk for adverse effects of hyperglycemia or hypoglycemia (low blood sugar) related to the use of glucose lowering medication and/or diagnosis of diabetes mellitus. The interventions, dated 4/9/12, included, but were not limited to, administer medications as ordered. The physician's order, dated 5/30/25, indicated staff were to administer 25 unit of Fiasp FlexTouch insulin subcutaneously, three times daily, per sliding scale (a diabetes management method where the dose of rapid acting insulin is adjusted based on a person's current blood glucose level). During an interview on 2/25/26 at 10:46 a.m., the DON indicated the only policy she could locate for priming of the insulin needle was the Administration of Medications, dated 11/15/24, included, but was not limited to, . Subcutaneous (SC) Injections. 9. Draw up medication dose. The online corporate policy for Priming Insulin Needles included, but was not limited to, . Key aspects of insulin pen priming policies in this setting include: Mandatory Before Every Injection: Insulin pens must be primed before every injection to remove air bubbles and ensure the pen is working correctly. The dose knob should be turned to 2 units. 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure glucometers were cleaned per guidelines for infection control when obtaining blood sugar readings for 2 of 5 residents observed. (Residents 26 and 103) Findings include:1. During an observation, on 2/24/26 8:23 a.m., Qualified Medication Aide (QMA) 6 obtained Resident 59's Accu (blood sugar) check. The QMA left the resident's room, laid the glucometer on the medication cart, and did not clean the glucometer. During an observation, on 2/24/26 at 8:45 a.m., QMA 6 was about to obtain Resident 26's blood sugar. She was stopped due to not having cleaned the glucometer. She obtained a 1 inch by 2-inch alcohol wipe and rubbed the glucometer for 20 seconds. The Staff Development Coordinator 7 reminded the QMA that she had the instructions on her medication cart and laid them on top of the narcotic folder. QMA 6 obtained the resident blood sugar at a reading of 107 milligrams per deciliter (mg/dL). During an interview, on 2/24/26 at 8:55 a.m., QMA 6 indicated she should have cleaned the glucometer after every room. She should have rubbed the glucometer for 1 minute and left dry for 30 seconds. QMA 6 then began reading the instructions, she had used an alcohol wipe to clean the glucometer and should have used the bleach wipe instead. After cleaning the glucometer with the bleach wipe, she should have wrapped it for 3 minutes. 2. During an observation, on 2/24/25 at 11:58 a.m., Licensed Practical Nurse (LPN) 8 obtained the resident's blood sugar and administered insulin to Resident 5. During an interview and observation, on 2/24/26 at 12:03 p.m., LPN 8 indicated she had cleaned the glucometer with an alcohol wipe for a minute to a minute and a half after obtaining the blood sugar for Resident 5. The time observed was 30 seconds of rubbing the glucometer with an alcohol wipe. During an observation, on 2/24/26 at 12:12 p.m., LPN 8 obtained the blood sugar of Resident 103. During an interview, on 2/24/26 at 12:20 p.m., LPN 8 indicated she used an alcohol wipe to clean the glucometer by rubbing it for 1 to 2 minutes. Nurses were not allowed to have Clorox wipes in the medication carts anymore. She asked, Aren't the alcohol wipes just as good? The LPN then indicated she felt the alcohol was just as good. She then cleaned the glucometer for 30 seconds with the Clorox wipe and laid it on the cart to dry. During an interview on 2/24/26 at 12:25 p.m., the Director of Nursing (DON) indicated she felt that the nursing staff could use an alcohol wipe or a bleach wipe to clean the glucometers. They should rub or wrap the glucometer in the wipe for 1 minute and then let it dry for 3 minutes. The glucometer should be cleaned after each resident use. It would be ideal for the medication carts to have two glucometers, so that the glucometer could be cleaned and set to dry while the other glucometer was being used. The Bleach Germicidal Wipes Environmental Protection Agency (EPA) number was EPA 67619-12 (industrial-strength, unscented wipes) cleans and disinfects with efficacy: kills 58 microorganisms in three minutes or less. The Blood Glucose Meter Cleaning/Disinfecting and Testing Skills Competency, last revised May 2021, included, but was not limited to, . Obtain germicidal wipe approved for the glucometer approved for use on glucometer. DO NOT use alcohol preps to clean glucometer, as they are not effective in killing bloodborne pathogens. For .glucometers the cleaning and disinfecting wipe is .Bleach Germicidal Wipes. Wipe entire surface of the blood glucose meter with wipes for 3 minutes. When using .Bleach Germicidal Wipes in the individual packet, it is best to squeeze out excess solution into a trash container or plastic cup to be disposed of. Place cleaned meter on paper towel, in plastic cup, or on clean barrier. Allow meter to completely dry. 410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)(2)

Based on observation, interview and record review, the facility failed to ensure staff to resident abuse did not occur for 1 of 3 residents reviewed for abuse. (Resident B) Findings include:The clinical record for Resident B was reviewed on 2/5/26 at 11:50 a.m. The resident's diagnoses included, but were not limited to, traumatic brain injury (brain injury that was caused by an outside force), anoxic brain damage (loss of oxygen supply, causing brain cells to die within minutes, leading to severe cognitive, physical, and emotional impairments), schizophrenia (a chronic, severe brain disorder that affects how a person thinks, feels, and acts) and quadriplegia (paralysis affecting all four limbs).During an observation, on 2/5/26 at 11:02 a.m., the resident was observed resting in his reclining high back wheelchair. He was well groomed with no visible injuries to the facial area. The incident report, dated 12/23/25, indicated it was reported to the Executive Director (ED) that Certified Nursing Assistant (CNA) 6 made contact with Resident B while providing care.The Wound Management Detail Report, dated 12/23/25, indicated the following assessments for Resident B:-Right forehead scratch that measured 2 cm (centimeters) in length with a width of 0.1 cm and no depth-Right eyebrow scratch that measured 0.1 cm in length with a width of 0.5 cm and no depth-Swollen area of the right top lip that measured 0.3 cm in length with a width of 1.8 cm and no depthDuring a telephone interview, on 2/5/26 at 11:29 a.m., CNA 6 indicated on 12/23/25 she was sitting at the desk charting when Resident B was brought out of the dining room. CNA 6 asked CNA 7 to assist her with lying Resident B down. During the process, Resident B punched her in the face. Resident B spit on her 4 times and the spit went in her mouth. CNA 6 then smacked Resident B on the right side of the face. After that, she (CNA 6) exited the room and self-reported the incident to the ED. CNA 6 was just mad at Resident B for hitting and spitting on them and hit the resident.During a telephone interview, on 2/5/26 at 12:00 p.m., CNA 7 indicated on 12/23/25 she assisted CNA 6 with transferring Resident B to his bed. Resident B cursed CNA 6, called her a h*e and a dirty h*e. That must have triggered CNA 6. CNA 6 went up to Resident B and smacked him multiple times with an open hand on the right side of his face. Before CNA 7 could get around the bed to intervene, Resident B spit on CNA 6, at which time, CNA 6 hit the resident again, in the mouth, with an open hand. It all happened within seconds. After that, CNA 6 left the room.During a telephone interview, on 2/5/26 at 2:25 p.m., the Unit Manager indicated she assessed Resident B after the incident. The resident had a scratch to his forehead, a scratch by his right brown and his upper lip was swollen and discolored.On 2/5/26 at 10:46 a.m., the ED provided a current copy of the document titled Abuse Prohibition, Reporting, and Investigation dated June 2023. It included, but was not limited to, Policy.It is the policy.to provide each resident with an environment that is free from abuse.This includes.physical abuse.Definitions.Willful.means the individual must have acted deliberately.Abuse.Physical Abuse.A willful act against a resident by another.staff member.Examples may include but not be limited to.hitting, slapping.The Past noncompliance began on 12/23/25. The deficient practice was corrected by 12/24/25 after the facility implemented a systemic plan that included the following actions: Resident interviews were completed with no other allegations of abuse (12/24/25); Staff interviews were completed with no other allegations of abuse (12/24/25); All staff were educated on the abuse policy and care of dementia residents with behaviors which is ongoing (12/24/25); Skin sweeps were completed for residents unable to be interview with no abnormal findings (12/24/25); All employee files were reviewed to ensure abuse in service was provided upon hire (12/24/25); Emergency Resident Council Meeting held to identify concerns and educate on abuse and reporting (12/24/25); All staff were educated related to working with residents with behaviors which is ongoing (12/24/25); Staff were educated on working with residents who had experienced a traumatic brain injury (12/24/25).This Citation relates to Intake 27008753.1-27(a)(1)

Based on interview and record review, the facility failed to ensure residents' (Resident C, Resident D and Resident E) medication administration records accurately reflected the administration of narcotic medications for 3 of 4 residents reviewed for documentation. Findings include: 1. The clinical record for Resident C was reviewed on 5/1/25 at 2:52 p.m. The resident's diagnoses included, but were not limited to, anxiety, diabetes and chronic pancreatitis. The April 2025 medication administration record (MAR) indicated the resident was to receive Xanax (narcotic anti-anxiety medication) 0.25 mg (milligrams) twice daily at 8:00 a.m. and 8:00 p.m. and oxycodone 10 mg every 4 hours as needed for severe pain. The April 2025 controlled substance record indicated the resident received the Xanax on the following dates and times: - 4/14/25 at 8:00 a.m. - 4/16/25 at 8:00 a.m. - 4/18/25 at 8:00 a.m. - 4/23/25 at 8:00 a.m. The April 2025 controlled substance record indicated the resident received the oxycodone on the following dates and times: - 4/05/25 at 4:40 p.m. - 4/07/25 at 11:20 a.m. and 3:20 p.m. - 4/10/25 at 3:00 p.m. - 4/12/25 at 4:12 p.m. - 4/13/25 at 1:00 a.m., 6:00 a.m. and 8:18 p.m. - 4/15/25 at 4:00 p.m. - 4/16/25 at 4:00 p.m. - 4/19/25 at 8:00 a.m. and 7:33 p.m. - 4/23/25 at 8:00 a.m. and 6:00 p.m. - 4/25/25 at 9:00 a.m. and 2:00 p.m. The April 2025 MAR lacked documentation of the administration of the medications. During an interview on 5/2/25 at 12:55 p.m., Licensed Practical Nurse (LPN) 6 indicated the medication administration record should be signed out when a narcotic medication was administered. 2. The clinical record for Resident D was reviewed on 5/1/25 at 3:05 a.m. The resident's diagnoses included, but were not limited to, depression and rheumatoid arthritis. The March 2025 and April 2025 medication administration record indicated the resident was to receive Tramadol (narcotic pain medication) 50 mg ever 8 hours as needed for pain. Review of the March 2025 and April 2025 controlled substance record indicated the resident received Tramadol (narcotic pain medication) on the following dates and times. - 3/12/25 at 6:00 p.m. - 3/24/25 at 5:00 a.m. - 4/24/25 at 8:00 a.m. - 4/30/25 at 4:40 p.m. The March 2025 and April 2025 medication administration record lacked documentation of the administration of the medication. 3. The clinical record for Resident E was reviewed on 5/2/25 at 9:35 a.m. The resident's diagnoses included, but were not limited to, left femur fracture and osteoarthritis. The April 2025 medication administration record indicated the resident was to receive hydrocodone-acetaminiphen (narcotic pain medication) 5-325 mg every 6 hours as needed for pain. The April 2025 controlled substance record indicated the resident received the medication on the following dates and times: - 4/15/25 at 4:52 p.m. - 4/16/25 at 7:00 p.m. - 4/17/25 at 3:30 a.m. - 4/20/25 at 12:00 p.m. The April 2025 medication administration record lacked documentation of the administration of the medication. On 5/2/25 at 2:16 p.m., the Director of Nursing provided a current copy of the document titled Controlled Substances: Storage, Documentation, Inventory and Destruction (Includes Fentanyl Patch Removal and Destruction) dated 11/2024. It included, but was not limited to, Procedure .Documentation .When a controlled substance is administered to a resident, it must be recorded in the resident's Medication Administration Record .as well as in the resident's Controlled Substances Inventory Record at the time of administration 3.1-50(a)(2)

Based on interview and record review, the facility failed to ensure blood pressure medications were held for out-of-parameter readings for 2 of 3 residents reviewed for medication administration. (Resident B and Resident D) Findings include: 1. The clinical record for Resident B was reviewed on 5/1/25 at 12:40 p.m. The resident's diagnosis included, but was not limited to, hypotension (low blood pressure). The admission order, dated 3/19/25, indicated the resident was to receive midodrine (medication for low blood pressure) 5 mg (milligrams) three times a day at 8:00 a.m., 2:00 p.m. and 8:00 p.m. The medication was to be held if the SBP (systolic blood pressure) was greater than 135 and/or DBP (diastolic blood pressure) was greater that 85. Review of the March 2025 medication administration record indicated, on 4/22/25 at 8:00 p.m., the resident's midodrine was administered when the resident's SBP was 142. During an interview, on 5/2/25 at 12:55 p.m., Licensed Practical Nurse (LPN) 6 indicated blood pressure medications should not be administered with out-of-range parameters. 2. The clinical record for Resident D was reviewed on 5/1/25 ay 3:05 p.m. The resident's diagnosis included, but was not limited to, hypotension. The physician's order, dated 4/7/25, indicated the resident was to receive midodrine 2.5 mg three times a day at 5:00 a.m., 11:00 a.m. and 4:00 p.m. The medication was to be held if the resident's SBP was greater that 140. Review of the April 2025 medication administration record indicated the medication was administered on the following dates and times: - On 4/17/25 at 5:00 a.m., the resident's midodrine was administered when the resident's SBP was 145. - On 4/18/25 at 5:00 a.m., the resident's midodrine was administered when the resident's SBP was 150 - On 4/18/25 at 11:00 a.m., the resident's midodrine was administered when the resident's SBP was 145 - On 4/24/25 at 5:00 a.m., the resident's midodrine was administered when the resident's SBP was 149 - On 4/24/25 at 4:00 p.m., the resident's midodrine was administered when the resident's SBP was 146 - On 4/25/25 at 5:00 a.m., the resident's midodrine was administered when the resident's SBP was 151 - On 4/25/25 at 4:00 p.m., the resident's midodrine was administered when the resident's SBP was 144 - On 4/29/25 at 5:00 a.m., the resident's midodrine was administered when the resident's SBP was 149 This Citation relates to Complaint IN00456231 3.1-37

Based on record review and interview, the facility failed to ensure showers were provided consistently for 1 of 3 residents reviewed for Activities of Daily Living care. (Resident 84) Findings include: The record for Resident 84 was reviewed on 1/27/25 at 11:30 a.m. The resident's diagnoses included, but were not limited to, Parkinson's disease, spinal stenosis, type 2 diabetes mellitus, panic disorder, Meniere's disease, tremor, repeated falls, displaced longitudinal fracture of left patella, subsequent encounter for closed fracture with routine healing, reduced mobility, and muscle weakness. The care plan, dated 9/6/24, indicated the resident required staff assistance to complete activities of daily living (ADL) tasks completely. The interventions included, but were not limited to, the resident had a desire to improve current functional status, assist the resident with ambulation using a walker or wheelchair, physical therapy for mobility, assistance with transfers as needed, assistance with bathing as needed per resident preference. Offer showers two times per week, partial bath in between, assistance with dressing/grooming/hygiene as needed and encourage the resident to do as much for self as possible. The Quarterly Minimum Data Set (MDS) assessment, dated 10/24/24, indicated the resident was cognitively intact. The resident required partial to moderate staff physicial assistance with bathing. The review of the resident's scheduled Shower Report record indicated the following: - On 12/2/24 the shower sheet lacked documentation indicating the resident received a shower. - On 12/9/24 the shower sheet lacked documentation indicating the resident received a shower. - On 12/16/24 the shower sheet lacked documentation indicating the resident received a shower. - On 12/19/24 the shower sheet lacked documentation indicating the resident received a shower. - On 12/21/24 the shower sheet lacked documentation indicating the resident received a shower. - On 12/30/24 the shower sheet lacked documentation indicating the resident received a shower. During an interview, on 1/27/25 at 11:27 a.m., the resident indicated she did not get showers like she was supposed to. She was supposed to get two showers a week, but she was lucky to get one a week. During an interview, on 1/30/25 at 8:50 a.m., Certified Nursing Aide (CNA) 4 indicated the CNAs were supposed to check off what they did for the resident when they provided assistance with giving a shower. During an interview, on 1/30/25 at 8:52 a.m., CNA 5 indicated the staff had been in serviced on checking the boxes on the shower sheet and not leaving them blank. The CNA indicated if the boxes were not checked off, the resident did not get a shower. During an interview, on 1/30/25 at 9:00 a.m., Licensed Practical Nurse (LPN) 3 indicated if the shower sheets were blank then the shower was not given. If staff did not document, then the shower wasn't done. The LPN indicated she would not sign a blank shower record. During an interview, on 1/30/25 at 9:15 a.m., the DON indicated the staff should document on the shower report sheet when the resident had a shower and what care was provided. 3.1-38(2)(A)

Based on record review and interview, the facility failed to ensure a resident received medications as ordered and administered in a timely manner for 2 of 3 resident reviewed for pharmacy services. (Residents 62 and 64) Findings include: 1. The record for Resident 62 was reviewed on 1/27/25 at 12:29 p.m. The resident's diagnoses included, but were not limited to, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, asthma and chronic pain. The physician's order, dated 1/28/25, indicated the resident was to receive Percocet (oxycodone-acetaminophen) 5-325 mg (milligram) every 8 hours orally, and not to exceed 3 gm (gram) of Acetaminophen from all sources within 24 hours. The Quarterly Minimum Data Set (MDS) assessment, dated 12/22/24, indicated the resident was cognitively intact. The care plan, dated 10/14/20 and revised 1/28/25, indicated the resident was at risk for pain related to the absence of the right leg below the knee. The interventions include, but were not limited to, the resident would be free from adverse effects of pain, administer pain medications as ordered, assistance with positioning to comfort, document effectiveness of prn (as needed) pain medications, notify the physician if pain was unrelieved and/or worsening, observe for adverse side effects of pain, observe for nonverbal signs of pain and offer nonpharmacological interventions. The nurse's note, dated 7/15/24 at 6:09 a.m., indicated the resident missed the 6:00 a.m. dose of Oxycodone (Percocet) 5 mg. The medication was not available in Emergency Drug Kit (EDK) and the pharmacy was notified that it needed to be refilled. The pharmacy indicated that the EDK would be changed out on Wednesdays. The nurse's note, dated 7/23/24 at 3:20 p.m., indicated the required form faxed back to pharmacy was for Percocet and the facility requested the medication to be sent STAT (urgent). The nurse's note, dated 8/17/24 at 12:17 a.m., indicated the Nurse Practitioner (NP) was notified that the resident needed a new prescription for Oxycodone 5 mg. The prescription was sent to the pharmacy, and an gave a code to pull three tablets from the EDK. The nurse's note, dated 8/20/24 at 6:02 a.m., indicated the Percocet 5/325 mg awaited prior approval from the physician per the pharmacy spokesperson. The nurse's note, dated 8/21/24 at 9:39 a.m., indicated the Percocet 5/325 mg awaited prior approval from the physician per the pharmacy spokesperson. The nurse's note, dated 10/29/24 at 3:38 p.m., indicated the resident was out of Percocet. A call was placed to the pharmacy to request an authentication code. The pharmacist indicated the EDK was out of her dose, and they would get a refill sent out STAT. The nurse's note, dated 1/14/25 at 3:36 a.m., indicated pharmacy was notified about the absent Norco. The pharmacy indicated they were waiting on the prescription. The nurse's note, dated 1/15/25 at 9:52 a.m., indicated the resident was still out of pain medications, and needed prior approval. The nurse's note, dated 1/22/25 at 12:39 p.m., indicated the resident was still out of pain medications, and waiting for prior approval, but was able to get a code to get it out of the EDK. During an interview on 1/30/25 at 10:45 a.m., the DON indicated the prior approvals for certain medications were getting more difficult. If a resident's medication was not in the medication cart, staff could get the medication from the EDK. It shouldn't take more than a few hours to a day to get the medication from the pharmacy. They did have a backup pharmacy, but they would use them for emergency medications only. The pharmacy would refill the EDK once a week. 2. The record for Resident 64 was reviewed on 1/27/25 at 11:11 a.m. The resident's diagnoses included, but were not limited to, acute respiratory failure with hypoxia, atrial fibrillation, cardiomegaly, type 2 diabetes mellitus, hypertension, and chronic pain. The Annual MDS assessment, dated 12/10/24, indicated the resident was cognitively intact. The nurse's note, dated 12/29/23 at 3:28 p.m., indicated resident's vascular access was replaced with a midline in the resident's left upper extremity. The nurse indicated the residents scheduled antibiotic meropenem-0.9% sodium chloride, that was due at 10:00 a.m., was given at 3:00 p.m. The Infection Prevention nurse was informed regarding the missed dose at 10:00 a.m. The nurse's note, dated 1/2/24 at 2:15 p.m., indicated three doses of the resident's intravenous (IV) antibiotics were missed. The NP was notified, and it was okay to extend the antibiotics to ensure the complete ordered dose was administered. The nurse's note, dated 1/3/24 at 7:21 p.m., indicated the resident was out of IV medication. The pharmacy was notified, and the pharmacy indicated the resident's order had been completed, and all the doses were sent out. The pharmacy was informed that the order was extended due to the missed doses. The pharmacist requested an order be faxed over to him so he could STAT the medication. He indicated the facility had the medication in the EDK. The facility's EDK did not have the right dose available, and the reconstitution was out of stock in the EDK. During an interview, on 1/30/25 at 9:00 a.m., Licensed Practical Nurse (LPN) 3 indicated if a resident's medication wasn't delivered, she would call the pharmacy and notify the provider. Medication should not take days to get to the facility. It should only take a couple of hours at the most to receive STAT medications from the pharmacy. Medications could be pulled from the EDK. If the medication was a narcotic, they would need a code from the pharmacy to retrieve the medication. The facility had a backup pharmacy they could use. The facility had access to the pharmacy, and they provided services 24 hours a day. Medications could be delayed but not missed. 3.1-25(G)(3)

Based on interview and record review, the facility failed to ensure the physician was notified when a resident's (Resident B) blood pressure was not within set parameters for 1 of 3 residents reviewed for notification of change in condition. Findings include: The clinical record for Resident B was reviewed on 11/6/24 at 10:34 a.m. The resident's diagnoses included, but were not limited to, hypertension and left sided hemiparesis (a condition that causes paralysis or weakness on one side of the body)/hemiplegia (one-sided muscle paralysis or weakness) secondary to cardiovascular accident. Review of the resident's vital signs report on 11/7/24 at 2:40 p.m. indicated the acceptable range for the resident's systolic blood pressure (maximum blood pressure during contraction of the ventricles) was between 90 to 180 mmhg (a unit of pressure used to measure blood pressure). The acceptable diastolic range (minimum pressure recorded just prior to next contraction) was 50 to 95. The August 2024 vital signs report indicated the resident had the following out of parameter blood pressures (B/P) - 8/2/24 at 11:38 a.m. - B/P was 157/99 - 8/7/24 at 10:35 p.m. - B/P was 190/106 - 8/10/24 at 7:17 p.m. - B/P was 192/111 - 8/11/24 at 8:25 a.m. - B/P was 178/106 - 8/11/24 at 1:00 p.m. - B/P was 178/103 - 8/17/24 at 8:48 a.m. - B/P was 188/99 - 8/18/24 at 8:52 a.m. - B/P was 198/107 - 8/18/24 at 9:20 p.m. - B/P was 179/115 - 8/22/24 at 2:23 p.m. - B/P was 169/99 - 8/22/24 at 9:52 p.m. - B/P was 172/96 - 8/23/24 at 8:57 a.m. - B/P was 160/98 - 8/24/24 at 10:15 p.m. - B/P was 185/99 - 8/25/24 at 10:27 a.m. - B/P was 197/101 - 8/26/24 at 9:27 p.m. - B/P was 173/100 - 8/29/24 at 9:35 a.m. - B/P was 143/96 - 8/30/24 at 11:22 p.m. - B/P was 180/114 Review of the September 2024 vital signs report indicated Resident B had the following out of parameter B/P's: - 9/6/24 at 10:31 a.m. - B/P was 186/86 - 9/10/24 at 10:05 a.m. - B/P was 196/116 - 9/13/24 at 9:47 p.m. - B/P was 188/98 - 9/14/24 at 8:29 a.m. - B/P was 170/110 - 9/14/24 at 9:18 p.m. - B/P was 186/107 - 9/15/24 at 9:24 p.m. - B/P was 165/101 - 9/17/24 at 10:09 p.m. - B/P was 183/107 - 9/18/24 at 8:31 p.m. - B/P was 200/128 - 9/21/24 at 11:49 a.m. - B/P was 183/111 - 9/21/24 at 9:45 p.m. - B/P was 189/101 - 9/24/24 at 9:41 p.m. - B/P was 161/104 - 9/26/24 at 9:51 p.m. - B/P was 160/104 - 9/27/24 at 9:10 p.m. - B/P was 198/84 - 9/28/24 at 8:12 a.m. - B/P was 187/105 Review of the October 2024 vital signs report indicated Resident B had the following out of parameter B/P's: - 10/4/24 at 9:07 p.m. - B/P was 172/99 - 10/5/24 at 9:25 a.m. - B/P was 148/98 - 10/5/24 at 10:04 p.m. - B/P was 146/99 - 10/12/24 at 9:58 a.m. - B/P was 181/95 - 10/12/24 at 9:15 p.m. - B/P was 148/96 - 10/18/24 at 10:14 a.m. - B/P was 159/99 - 10/19/24 at 8:50 p.m. - B/P was 188/90 - 10/26/24 at 9:18 a.m. - B/P was 179/115 - 10/27/24 at 9:05 a.m. - B/P was 179/99 - 10/27/24 at 8:43 p.m. - B/P was 134/44 - 10/29/24 at 1:29 p.m. - B/P was 168/99 - 10/31/24 at 8:14 a.m. - B/P was 189/106 Review of the November 2024 vital signs report indicated Resident B had the following out of parameter B/P's: - 11/4/24 at 8:20 a.m. - B/P was 156/99 - 11/6/24 at 9:47 p.m. - B/P was 160/97 - 11/7/24 at 8:36 a.m. - B/P was 189/104 The clinical record lacked the physician's notification for the resident's out of parameter blood pressures. During an interview on 11/7/24 at 2:24 p.m., Nurse Practitioner 12 indicated extremely high or low blood pressures would be a change of condition and the expectation would be that facility staff would have notified her at the time of occurrence. On 11/8/24 at 11:31 a.m., the Director of Nursing provided a current copy of the document titled Resident Change of Condition Policy: dated 11/2018. It included, but was not limited to, It is the policy of this facility that all changes in resident condition will be communicated to the physician .and that appropriate, timely, and effective intervention takes place This Citation relates to Complaint IN00444619 3.1-5(a)(2)

Based on observation, interview, and record review, the facility failed to ensure medications for a resident, without a self-administration assessment, were not left at bedside for 1 of 3 residents reviewed for medication self-administration. (Resident B) Findings include: The clinical record for Resident B was reviewed on 11/6/24 at 10:34 a.m. The resident's diagnoses included, but were not limited to, hypertension, left sided hemiparesis (a condition that causes paralysis or weakness on one side of the body) and hemiplegia (one-sided muscle paralysis or weakness) secondary to CVA (cerebral vascular accident) and diabetes. On 11/6/24 at 9:18 a.m., the resident was observed sitting up in her bed eating her breakfast alone in her room. A medication cup with six medication tablets/capsules were observed on her bedside table. Review of the November 2024 Medication Administration Record indicated the resident's following morning medications were to be administered between 7:00 a.m. and 11:00 a.m. - Amlodipine 10 mg (milligrams) for hypertension - Aspirin 81 mg for CVA - Clopidogrel 75 mg for CVA - Metformin 500 mg for diabetes - Metoprolol 25 mg for hypertension - Hydralazine 25 mg for hypertension The clinical record lacked documentation of the resident having a self-administration medication assessment and a physician's order to self-administer medications. During an interview on 11/6/24, Licensed Practical Nurse (LPN) 4 indicated the resident did not self-administer medications. The medications in the resident's room was her morning medications. The resident was taking her medications when she left the room. During an interview on 11/8/24 at 11:42 a.m., the Director of Nursing indicated the resident did not have a medication self-administration assessment. On 11/8/24 at 11:31 a.m., the Director of Nursing provided a current copy of the document titled Self Administration of Medications dated 1/2015. It included, but was to limited to, Procedure .If a resident desires to participate in self-administration, the Interdisciplinary Team will assess the competence of the resident to participate by completing the Self-Administration of Medication Assessment observation .A physician order will be obtained specifying the resident's ability to self-administer medications This Citation relates to Complaint IN00444619 3.1-11(a)

Based on interview and record review, the facility failed to ensure increased monitoring and interventions were in place for a resident (Resident B) with consistent high blood pressures and a history of a cardiovascular accident for 1 of 3 residents reviewed for quality of care. Findings include: The clinical record for Resident B was reviewed on 11/6/24 at 10:34 a.m. The resident's diagnoses included, but were not limited to, hypertension and CVA (cardiovascular accident) with left sided hemiparesis (a condition that causes paralysis or weakness on one side of the body). The current care plan, dated 4/23/24, indicated the resident was at risk for ineffective tissue perfusion related to hypertension, diabetes, anemia and CVA with left sided hemiparesis. The interventions included, but were not limited to: administer medications as ordered; administer oxygen as ordered; elevate lower extremities as needed; labs as ordered; monitor vital signs; observe for and document signs and symptoms of changes in mental status, disorientation, increased confusion, anxiety and notify the physician; observe for and document any decreased urinary output and notify physician; offer rest periods as needed; and observe for and document pallor, cyanosis, dizziness, syncope, shortness of breath, bounding/thready pulse, headache, variations in B/P, abnormal lung sounds, abnormal oxygen saturation, poor capillary refill, abnormal skin color, edema and to notify the physician. The physician's order, dated 7/30/24, indicated the resident was to receive hydralazine (blood pressure medication) 50 mg (milligrams) three times a day (TID) at 8:00 a.m., 2:00 p.m. and 8:00 p.m. The physician's order, dated 6/10/24, indicated the resident was to receive clonidine 0.1 mg twice daily in the morning between 7:00 a.m. and 11:00 a.m. and the evening between 7:00 p.m. and 11:00 p.m. The progress note, dated 8/6/24 at 6:35 p.m., indicated the resident refused the hydralazine 50 mg because the resident believed the medication was too strong. The nurse practitioner was made aware. The progress note, dated 8/9/24 at 1:55 p.m., indicated the resident continued to refuse the hydralazine 50 mg. The nurse practitioner was notified with a new order to discontinue the hydralazine 50 mg TID and to start hydralazine 25 mg TID at 8:00 a.m., 2:00 p.m. and 8:00 p.m. The progress note, dated 8/11/24 at 11:35 p.m., indicated the resident called 911 due to she did not feel good and was light headed. The resident called 911 before speaking to the nurse. The progress note, dated 8/13/24 at 4:10 p.m., indicated the resident's blood pressure (BP) was 164/98 (systolic blood pressure [top number] maximum blood pressure during contraction of the ventricles and diastolic [bottom number] minimum pressure recorded just prior to next contraction). The nurse practitioner was notified with a new order to administer clonidine 0.1 mg now. Review of the resident's vital signs report on 11/7/24 at 2:40 p.m. indicated the acceptable range for systolic blood pressure (top number) was between 90 to 180 mmhg (a unit of pressure used to measure blood pressure). The acceptable diastolic range (bottom number) was 50 to 95). The August 2024 vital signs report indicated the resident had the following out of parameter blood pressures. On 8/2/24 at 11:38 a.m., the resident's B/P was 157/99 with no follow up or documented recheck of the blood pressure. On 8/7/24 at 10:35 p.m., the resident's B/P was 190/106 with no follow up or documented recheck of the blood pressure. On 8/10/24 at 7:17 p.m., the resident's B/P was 192/111 with no follow up or documented recheck of the blood pressure. On 8/11/24 at 8:25 a.m., the resident's B/P was 178/106 with no follow up or documented recheck of the blood pressure. On 8/11/24 at 1:00 p.m., the resident's B/P was 178/103 with no follow up or documented recheck of the blood pressure. On 8/17/24 at 8:48 a.m., the resident's B/P was 188/99 with no follow up or documented recheck of the blood pressure. On 8/18/24 at 8:52 a.m., the resident's B/P was 198/107 with no follow up or documented recheck of the blood pressure. On 8/18/24 at 9:20 p.m., the resident's B/P was 179/115 with no follow up or documented recheck of the blood pressure. On 8/22/24 at 2:23 p.m., the resident's B/P was 169/99 with no follow up or documented recheck of the blood pressure. On 8/22/24 at 9:52 p.m., the resident's B/P was 172/96 with no follow up or documented recheck of the blood pressure. On 8/23/24 at 8:57 a.m., the resident's B/P was 160/98 with no follow up or documented recheck of the blood pressure. On 8/25/24 at 10:27 a.m., the resident's B/P was 197/101 with no follow up or documented recheck of the blood pressure. On 8/26/24 at 9:27 p.m., the resident's B/P was 173/100 with no follow up or documented recheck of the blood pressure. On 8/29/24 at 9:35 a.m., the resident's B/P was 143/96 with no follow up or documented recheck of the blood pressure. On 8/30/24 at 11:22 p.m., the resident's B/P was 180/114 with no follow up or documented recheck of the blood pressure. The progress note, dated 9/7/24, indicated the resident called 911 from her personal cell phone. The resident's blood pressure at 4:00 p.m. was 166/99 and she would not allow a recheck of her blood pressure, and called emergency medical services (EMS) instead. The progress note, dated 9/10/24 at 3:35 a.m., indicated the resident call 911 with claims of not feeling well related to her blood pressure. The resident's vital signs were assessed twice prior to 911 call and the vitals were within normal limits. The resident wanted the nurse to give her clonidine but the resident did not have an as needed order. The progress note, dated 9/10/24 at 5:59 a.m., indicated the hospital called and informed the facility that the resident was to be discharged . The resident was given clonidine in the emergency department. The progress note, dated 9/10/24 at 11:55 a.m., indicated the resident had returned from the hospital with a high blood pressure of 196/116. The nurse practitioner was notified and the resident's morning medications were administered. The resident's blood pressure stabilized at 158/80. The progress note, dated 9/18/24 at 1:33 p.m., indicated the Director of Nursing Services provided the nurse practitioner with a vital signs report to review from 9/1/24 through 9/18/24. Upon review, on 9/6/24, 9/10/24, 9/13/24, 9/14/24, 9/15/24, 9/17/24 and today, the resident had out of range blood pressure results. The nurse practitioner indicated the resident refused to comply with the medication regimen and the facility was to continue with the current orders. The progress note, dated 9/18/24 at 6:08 p.m., indicated the resident continued to complain of not feeling well, very anxious and upset at this time. The resident stated her family never visits her and that she did not like her roommate. One on one attempted but the resident continued to be argumentative and defensive. Current blood pressure reading was 165/96. The nurse practitioner was notified with a new order for an electrocardiogram (EKG). The progress note, dated 9/19/24 at 12:02 a.m., indicated the resident had called 911 for an ambulance to come pick her up and take her to the hospital due to her elevated blood pressure. The progress note, dated 9/19/24 at 2:30 a.m., indicated the resident returned from the hospital with a blood pressure of 156/90. The progress note, dated 9/20/24 at 4:16 p.m., indicated the EKG results were reviewed by the nurse practitioner with a new order to schedule an appointment with the cardiologist. The progress note, dated 9/20/24 at 11:55 p.m., indicated the resident requested a blood pressure check with a reading of 164/94. The resident received her night time medications at 10:30 p.m. with a blood pressure of 172/82 prior to administration. The resident stated her blood pressure had not gone down. The resident called 911 for transport to the hospital. The progress note, dated 9/21/24 at 11:09 a.m., indicated the resident returned from the hospital in stable condition and no new orders were requested. The resident refused vital signs at that time. The progress note, dated 9/29/24 at 11:27 p.m., indicated the resident refused all of her night medications except for her blood pressure medications. Review of the September 2024 vital signs report indicated the resident had the following out of parameter B/P's: On 9/6/24 at 10:31 a.m., the resident's B/P was 186/86 with no follow up or documented recheck of the blood pressure. On 9/10/24 at 10:05 a.m., the resident's B/P was 196/116 with no follow up or documented recheck of the blood pressure. On 9/13/24 at 9:47 p.m., the resident's B/P was 188/98 with no follow up or documented recheck of the blood pressure. On 9/14/24 at 8:29 a.m., the resident's B/P was 170/110 with no follow up or documented recheck of the blood pressure. On 9/15/24 at 9:24 p.m., the resident's B/P was 165/101 with no follow up or documented recheck of the blood pressure. On 9/17/24 at 10:09 p.m., the resident's B/P was 183/107 with no follow up or documented recheck of the blood pressure. On 9/18/24 at 8:31 p.m., the resident's B/P was 200/128; the follow up blood pressure was on 9/19/24 at 12:01 a.m. with 190/116. On 9/21/24 at 11:49 a.m., the resident's B/P was 183/111 with no follow up or documented recheck of the blood pressure. On 9/21/24 at 9:45 p.m., the resident's B/P was 189/101 with no follow up or documented recheck of the blood pressure. On 9/24/24 at 9:41 p.m., the resident's B/P was 161/104 with no follow up or documented recheck of the blood pressure. On 9/26/24 at 9:51 p.m., the resident's B/P was 160/104 with no follow up or documented recheck of the blood pressure. On 9/27/24 at 9:10 p.m., the resident's B/P was 198/84 with no follow up or documented recheck of the blood pressure. On 9/28/24 at 8:12 a.m., the resident's B/P was 187/105 with no follow up or documented recheck of the blood pressure. The progress note, dated 10/15/24 at 3:13 p.m., indicated the nurse practitioner was notified of the resident's abnormal vital signs and the resident's refusal of medications. No new orders were received. The progress note, dated 10/24/24 at 5:42 p.m., indicated the physician was in for a routine visit. The resident's clonidine 0.1 mg was discontinued. New orders were obtained for a clonidine patch 0.1 mg/24 hour to be applied weekly and to start metoprolol 25 mg twice daily with vital signs monitoring and parameters. The progress note, dated 10/31/24 at 11:44 p.m., indicated the resident had an elevated blood pressure. The nurse practitioner was made aware and an as needed clonidine 0.1 mg was given. The blood pressure was rechecked after 30 minutes with a reading of 189/87. Review of the October 2024 vital signs report indicated the resident had the following out of parameter B/P's: On 10/4/24 at 9:07 p.m., the resident's B/P was 172/99 with no follow up or documented recheck of the blood pressure. On 10/5/24 at 9:25 a.m., the resident's B/P was 148/98 with no follow up or documented recheck of the blood pressure. On 10/5/24 at 10:04 p.m., the resident's B/P was 146/99 with no follow up or documented recheck of the blood pressure. On 10/12/24 at 9:58 a.m., the resident's B/P was 181/95 with no follow up or documented recheck of the blood pressure. On 10/12/24 at 9:15 p.m., the resident's B/P was 148/96 with no follow up or documented recheck of the blood pressure. On 10/18/24 at 10:14 a.m., the resident's B/P was 159/99 with no follow up or documented recheck of the blood pressure. On 10/19/24 at 8:50 p.m., the resident's B/P was 188/90 with no follow up or documented recheck of the blood pressure. On 10/26/24 at 9:18 a.m., the resident's B/P was 179/115 with no follow up or documented recheck of the blood pressure. On 10/27/24 at 9:05 a.m., the resident's B/P was 179/99 with no follow up or documented recheck of the blood pressure. On 10/27/24 at 8:43 p.m., the resident's B/P was 134/44 with no follow up or documented recheck of the blood pressure. On 10/29/24 at 1:29 p.m., the resident's B/P was 168/99 with no follow up or documented recheck of the blood pressure. On 10/31/24 at 8:14 a.m., the resident's B/P was 189/106 with no follow up or documented recheck of the blood pressure. Review of the November 2024 vital signs report indicated the resident had the following out of parameter B/P's: On 11/4/24 at 8:20 a.m., the resident's B/P was 156/99 with no follow up or documented recheck of the blood pressure On 11/6/24 at 9:47 p.m., the resident's B/P was 160/97 with no follow up or documented recheck of the blood pressure On 11/7/24 at 8:36 a.m., the resident's B/P was 189/104 with no follow up or documented recheck of the blood pressure Review of the September 1, 2024 and October 29, 2024, the clinical record lacked documentation of the resident's refusals of blood pressure medications. During an interview on 11/6/24 at 2:32 p.m., Licensed Practical Nurse (LPN) 4 indicated the resident had refused her medications a lot except for her blood pressure and diabetes medication. Her blood pressure was consistently high and new blood pressure medications were started. During an interview on 11/7/24 at 2:24 p.m., Nurse Practitioner (NP) 22 indicated she did not make changes to the residents blood pressure medications due to the resident being very noncompliant, in a consecutive manner. She would order something and the resident would not want it and she would say it did not work. She refused medications at times and would then call 911 because her blood pressure was high. She tried to increase the resident's hydralazine, but the resident did not want the 50 mg, but wanted the 25 mg of hydralazine. She did not think the resident was alert and oriented, however, the resident's BIMS (brief interview of mental status) on 10/11/24 was intact. When the resident refused suggested changes, she considered that non-compliance on her part. The staff reported to her that the resident had refused her medications. Her plan for a hypertensive crisis would include a cardiology consult, neurology consult, increase her clonidine patch, add as needed clonidine with parameters, notify her of refusals, and an emergency transfer with blood pressure parameters. The physician's order, dated 11/7/24, indicated the resident was to have a Clonidine patch weekly, 0.1 mg transdermal once a day on Thursdays. The physician's orders, dated 11/8/24, indicated the resident was to have Hydralazine 25 mg every 8 hours as needed for hypertension; contact provider if SBP greater than 180 and send to the ER for systolic blood pressure greater than 180 or diastolic blood pressure greater than 120 with any of the following: chest pain, SOA, back pain, numbness and back pain, numbness or change in vision; and staff were to monitor for increased symptoms of chest pain, shortness of air, back pain, numbness and change in vision every shift. During an interview on 11/8/24 at 12:16, NP 22 indicated she had not made any changes in the resident's medications prior to 11/7/24 since the resident had just been seen by the MD on 10/24/24. This Citation relates to Complaint IN00444619 3/1-37

Based on interview and record review, the facility failed to ensure a resident's record accurately reflected the administration of medications for 1 of 3 residents reviewed for medical records. (Resident B) Findings include: The clinical record for Resident B was reviewed on 11/6/24 at 10:34 a.m. The resident's diagnoses included, but was not limited to, hypertension and diabetes. The care plan, dated 4/23/24, indicated the resident had ineffective tissue perfusion related to hypertension and diabetes with an intervention to administer medications as ordered. The physician's order, dated 6/10/24, indicated the resident was to receive metformin (diabetes medication) 500 mg (milligrams) twice a day at 8:00 a.m. and 8:00 p.m. Review of the October 2024 Medication Administration Record lacked documentation of the administration of the medication on 10/11/24 at 8:00 a.m. and 10/31/24 at 8:00 a.m. The physician's order, dated 8/16/24, indicated the resident was to receive hydralazine (blood pressure medication) 25 mg three times a day at 8:00 a.m., 2:00 p.m. and 8:00 p.m. Review of the October 2024 Medication Administration Record lacked documentation of the administration of the medication on 10/08/24 at 8:00 p.m., 10/09/24 at 8:00 p.m., 10/11/24 at 8:00 a.m., 10/14/24 at 8:00 p.m., 10/21/24 at 8:00 p.m., 10/28/24 at 8:00 p.m., 10/29/24 at 8:00 p.m., and 10/31/24 at 8:00 p.m. The physician's order, dated 10/31/24 was created on 11/8/24 at 11:03 a.m., indicated the resident was to receive a one-time dose of clonidine (blood pressure medication) 0.1 mg for elevated blood pressure. The October 2024 Medication Administration Record lacked documentation for the administration of the one-time medication. During an interview on 11/8/24 at 9:06 a.m., Licensed Practical Nurse (LPN) 5 indicated when medications were administered, they should be signed out on the medication administration record. For a one-time order staff were to enter the one-time order in the electronic medical record and sign it off on the medication administration record once the medication was administered. On 11/8/24 at 11:31 a.m., the Director of Nursing provided a current copy of the document titled Medication Administration (Medication Pass Procedure) dated 07/2023. It included, but was not limited to, Procedure Steps .Medication administration will be recorded on the MAR/EMAR .after given This Citation relates to Complaint IN00444619 3.1-50(a)(2)

Based on interview and record review, the facility management failed to report an incident to the Indiana Department of Health when a resident (Resident B ) reported an allegation of abuse for 1 of 3 residents reviewed for verbal abuse. Findings include: The clinical record for Resident B was reviewed on 7/22/24 at 9:33 a.m. The diagnoses included, but were not limited to, right fibula/tibia fracture and peripheral autonomic neuropathy. The Admission MDS (minimum data set) assessment, dated 5/7/24, indicated the resident's cognition was alert and oriented. During a telephone interview on 7/22/24 at 9:59 a.m., Resident B indicated she had multiple bad interactions with LPN (Licensed Practical Nurse) 7. During one incident, she had requested her pain medication from LPN 7, at which point, LPN 7 became aggressive and told Resident B she had a problem. Resident B asked LPN 7 why she had to be such a smart a** and LPN 7 responded because you are acting like a smart a**. She reported the incident to LPN 6. Review of the facility reported incidents for June 2024 lacked documentation of an allegation of verbal abuse for Resident B. During an interview on 7/23/24 at 11:16 a.m., LPN 6 indicated Resident B did report that LPN 7 called her a smart a**. She reported the incident to the ED (Executive Director). During an interview on 7/23/24 at 11:32 a.m., the ED indicated no staff member had reported anything of that nature to him. The facility provided no other information related to the incident. On 7/23/24 at 1:06 p.m., the Director of Nursing provided a current copy of the document titled Abuse Prohibition, Reporting, and Investigation dated 6/2023. It included, but was not limited to, Reporting/Response .All abuse allegations must be reported to the Executive Director immediately .it must be reported immediately but no later than 2 hours to the Long-Term Care Division of the Indiana Department of Health via the Gateway Portal This Citation relates to Complaint IN00436365. 3-1.28(c)

Based on interview and record review, the facility failed to ensure a resident's blood pressure was obtained prior to medication administration (Resident D) for 1 of 3 residents reviewed for quality of care. Findings include: The clinical record for Resident D was reviewed on 7/22/24 at 12:40 p.m. The diagnoses included, but were not limited to, cardiovascular disease and hypertension (high blood pressure). The physician's order, dated 5/22/24, indicated the resident was to receive Clonidine HCl (hydrochloride) 0.1 mg (milligrams) every 6 hours at 12:00 a.m., 6:00 a.m., 12:00 p.m. and 6:00 p.m. for hypertension. The medication was to be held for a systolic blood pressure less than 100. The care plan, dated 5/5/2021, indicated the resident was at risk for ineffective tissue perfusion due to hypertension and to administer medications as ordered by the physician. Review of the June and July 2024 MAR (medication administration record) indicated the following related to the administration of Resident D's Clonidine: - On 6/02/24 at 6:00 a.m., the resident's Clonidine was administered. The resident's blood pressure was not documented. - On 6/02/24 at 12:00 p.m., the resident's Clonidine was administered. The resident's blood pressure was not documented. - On 6/02/24 at 6:00 p.m., the resident's Clonidine was administered. The resident's blood pressure was not documented. - On 6/08/24 at 12:00 a.m., the resident's Cloniidine was not administered as it was on hold. There was no documentation as to why the medication was on hold. During an interview on 7/23/24 at 1:43 p.m., LPN (Licensed Practical Nurse) 8 indicated if there were blood pressure parameters in place for a resident, the resident's blood pressure should have been documented and obtained prior to the administration of the medication. On 7/23/24 at 1:06 p.m., the Director of Nursing provided a current copy of the document titled Medication Administration (Medication Pass Procedure) dated 7/23. It included, but was not limited to, Vital signs obtained, if necessary .Medication administration will be recorded on the MAR .after given This Citation relates to Complaint IN00436365. 3.1-37

Based on observation, record review, and interview, the facility failed to ensure appropriate oversight of medication administration during 5 of 25 random observations. (Residents 104, 12, 98, 134, and 97) Findings include: 1. During an observation on 12/11/23 at 9:05 a.m., Resident 104 was resting abed, finishing her breakfast. There was a medication cup containing 1 clear yellow capsule, 1 red oblong capsule, 1 small green oblong tablet, 1 white round scored tablet, 1 white round unscored tablet, 1 large white oblong tablet, and 1 small pink oval tablet. The nurse was not within sight. During an interview on 12/111/23 at 9:06 a.m., Resident 104 indicated the pills in the cup were her morning medications. Staff typically left her medication on the table. She was going to take them in a little while. They'd been brought to her about 5 to 10 minutes prior. During an interview on 12/11/23 at 9:14 a.m., RN 20 indicated she didn't know if the resident typically kept her medications at bedside. She usually watched the residents take them. She entered the room and observed the medication cup. She asked Resident 104 if they were her medications and the resident indicated they were. The nurse indicated she guessed they were from that morning. She was not certain if the resident had been assessed to take medication by herself or have medications left at the bedside. She did not typically leave medications at the bedside, but Resident 104 was usually with it. The medications in the cup were the resident's vitamin C, Eliquis, garlic, potassium, sertraline, Thera M plus, and zinc. The record for Resident 104 was reviewed on 12/11/23 at 10:00 a.m. The diagnoses included, but were not limited to, depression, vitamin D deficiency, and saddle embolus of pulmonary artery with acute cor pulmonale. The Quarterly MDS (Minimum Data Set) assessment, dated 10/24/23, indicated the resident was moderately cognitively impaired. The physician's current orders indicated the resident was receiving garlic 1000 milligrams (mg) daily, sertraline 25 mg daily, Eliquis 5 mg twice daily, potassium chloride 20 meq daily, vitamin C 500 mg daily, and Thera M plus multivitamin 1 tablet daily. The MAR indicated the medications were last documented as administered on 12/11/23 between 7:00 a.m. and 11:00 a.m., by RN 20. The resident's record lacked documentation of any orders, care plan, or assessments for the resident to self-administer medications, or any orders for the resident's medications to be left at her bedside. 2. During an observation on 12/11/23 at 10:38 a.m., Resident 12 was resting abed self-administering a nebulizer treatment. The nebulizer machine was running, the resident had the mouthpiece in her mouth and was inhaling the vapor, which could be seen exiting the end of the mouthpiece upon the resident's exhalation. There was an albuterol sulfate HFA 90 mcg/act (micrograms per actuation) inhaler lying on her bedside table. The nurse was not in sight. During an interview on 12/11/23 at 10:39 a.m., Resident 12 indicated the nurses brought her breathing treatments to her but did not stay in the room with her while she administered it. The record for Resident 12 was reviewed on 12/11/23 at 12:30 p.m. The resident's diagnoses included, but were not limited to, COPD and chronic respiratory failure. The Significant Change MDS assessment, dated 11/6/23, indicated the resident was cognitively intact. The physician's current orders indicated the resident was receiving albuterol sulfate HFA 90 mcg/act (micrograms per actuation) 2 puffs inhaled every 6 hours as needed, budesonide 0.5 mg per 2 mL 1 vial twice daily, and ipratropium-albuterol 0.5 mg per 3 mL 1 vial every 6 hours. The December MAR indicated the following: - There were no administrations of the resident's albuterol sulfate HFA 90 mcg/act documented in the month of December. - The resident's budesonide 0.5 mg per 2 mL was last documented as administered between 7:00 a.m. and 11:00 a.m. on 12/11/23. - The resident's ipratropium-albuterol 0.5mg per 3 mL was last documented as administered at 10:00 a.m. The resident's record lacked documentation of any orders, care plan, or assessments for self-administration of medications, or any orders for the resident's medications to be left at her bedside. 3. During an observation on 12/13/23 at 12:45 p.m., Resident 98 was resting abed with her eyes closed. There was a medication cup on the table with 2 white tablets imprinted TCL 340. The nurse was not in sight of the room or the medication. The nurse was down the hall preparing another resident's medication. During an interview on 12/13/23 at 12:47 p.m., LPN 21 indicated she would have sworn the resident took the medication when she gave it to her. She had taken the medication in about 10 minutes prior, it was the resident's Tylenol. The resident's diagnoses included, but were not limited to, cognitive communication deficit, lack of coordination, muscle weakness, and personal history of transient ischemic attack. The Quarterly MDS assessment, dated 10/6/23, indicated the resident was moderately cognitively impaired. The physician's current orders indicated the resident was receiving Tylenol 325 mg 2 tablets 4 times daily for pain. The MAR indicated the medication was last documented as administered by LPN 21 on 12/11/23 at 12:00 p.m. The resident's record lacked documentation of any orders, care plan, or assessments for the resident to self-administer medications, or any orders for the resident's medications to be left at her bedside. 34309 4. During an observation on 12/11/23 at 9:29 a.m., a liquid medication in a medication cup and two tablets in another medication cup were observed on the bedside table of Resident 134. On 12/11/23 at 10:42 a.m., LPN 14 was asked to return to Resident 134's room to identify the medications at her bedside. LPN 14 asked the resident to take her medications. The LPN indicated the tablets were metformin and Buspar and the liquid medication was a protein. The record for Resident 134 was reviewed on 12/12/23. The diagnoses included, but were not limited to, type 2 diabetes mellitus, generalized anxiety disorder, and depression. The care plan, dated 11/17/23, indicated the resident was at risk for adverse side effects related to the use of psychotropic medication related to antianxiety, antidepressant and hypnotic medications. The interventions, dated 11/17/23, included, but were not limited to, administer medications as ordered, observe for effectiveness, document side effects as observed and notify the MD. The care plan, dated 11/17/23, indicated the resident was at risk for adverse effects of hyperglycemia or hypoglycemia related to use of glucose lowering medication and/or diagnoses of diabetes mellitus. The interventions, dated 11/17/23, included, but was not limited to, administer medications as ordered. The physician's current order, dated 11/17/23, indicated to administer metformin 1000 mg twice daily at 8:00 a.m. and 5:00 p.m., given with meals for the diagnoses of type 2 diabetes mellitus. The MDS (Minimum Data Set) Admission assessment, dated 11/23/23, indicated the resident was cognitively intact. The physician's order, dated 11/27/23, indicated to administer buspirone 10 mg (milligrams) three times daily for generalized anxiety disorder. The physician's order, dated 11/27/23, indicated to administer ProSource liquid 10-100 grams-kcal/30 mL (milliliters) daily to promote wound healing. During an interview on 12/12/23 at 8:52 a.m., LPN 14 indicated when administering a resident's medication she should make sure the resident took the medication in front of her. 5. During an observation on 12/12/23 at 8:27 a.m., Resident 97 walked out of her room to LPN 15 in the hallway, by the medication cart, and indicated her pills were on her bedside table from the night shift. She had missed her 4:00 a.m. levothyroxine and it was not in her medications. On 12/12/23 at 8:33 a.m., Unit Manager 16 and LPN 15 entered the resident's room and obtained the medications. The resident indicated she had not received her levothyroxine a lot of times. The resident indicated if the levothyroxine was there, it was lost. On 12/12/23 at 8:42 a.m., Unit Manager 16 indicated the identity of the 4 tablets in the cup. The medications were; gas relief 80 mg, 2 tablets and Acetaminophen 325 mg, 2 tablets. The resident's diagnoses included, but were not limited to, type 2 Diabetes Mellitus and rheumatoid arthritis. The Quarterly MDS assessment, dated 9/18/23, indicated the resident was cognitively intact. She required extensive assistance for ambulation and transfers. The care plan, dated 1/19/23, indicated the resident was at risk for pain related to decreased mobility and fibromyalgia. The interventions included, but were not limited to, administer medications as ordered, document effectiveness of p.m. medications, and notify the MD if pain was unrelieved and/or worsening. The December MAR (Medication Administration Record) for 12/12/23, lacked documentation of the administration of 2 tablets of acetaminophen 325 mg. The physician's orders lacked documentation of an order for the resident to receive Gas Relief or levothyroxine. The physician's orders, dated 1/18/23, indicated the administer acetaminophen 325 mg 2 chewable tablets every 4 hours as needed. On 12/12/23 at 8:46 a.m., Unit Manager 16 indicated when medications were found at a resident's bedside, the Unit Manager should be notified. The nurse should have let the resident know they had their medication and watched the resident take their medication. The night shift nurse was LPN 17 and she had left the medication on the bedside table for Resident 97. During an interview on 12/12/23 at 9:18 a.m., Unit Manager 16 indicated Resident 97 was not on levothyroxine, and did not have an order for it. During an interview on 12/12/23 at 10:00 a.m. the DON indicated the facility did not have Self Administrations of Medication Assessments for residents. Cross Reference F565. 3.1-11(a)

Based on observation, interview and record review, the facility failed to ensure a resident (Resident C) was provided adequate supervision and assistance of two staff members with bed mobility in accordance with the resident's assessment and care plan, which resulted in a right distal femur supracondylar (break of the bone at the knee) fracture after a fall out of bed, for 1 of 3 residents reviewed for accident hazards. Findings include: The clinical record for Resident C was reviewed on 1/21/21 at 12:54 p.m. [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 10/6/20, indicated intact cognition and required assistance of two staff members with bed mobility. The current care plan, dated 1/29/19, indicated the resident was a fall risk, on 2/3/19, the facility implemented the intervention for the resident to have the physical assistance of 2 staff members when turning or repositioning. The incident report, dated 10/19/20 at 6:04 p.m., indicated CNA (Certified Nurse Aide) 6 was changing the resident when the resident threw her right leg over her left leg, to turn over, and proceeded to roll out of bed. The IDT (Interdisciplinary Team) note, dated 10/20/20 at 10:23 a.m., indicated the resident had rolled out of bed during care and was admitted to the hospital with [REDACTED]. Current interventions included non-skid footwear and an assistance of 2 persons with turning and repositioning. The hospital discharge summary, dated 10/26/20 at 11:30 a.m., indicated the resident had a fall out of bed on 10/19/20 which resulted in a right distal femur supracondylar fracture with an ORIF (open reduction and fixation which was a surgery to repair a broken bone) completed on 10/20/20. During an interview on 1/13/21 at 10:25 a.m., the Director of Nursing indicated CNA 6 had provided care to the resident without the assistance of another staff member. On 1/13/21 at 1:05 p.m., the resident was observed with a scar to the right knee which measured 9 cm (centimeters) in length. Resident C indicated CNA 6 was by herself at the time of the incident. She had asked the aide to get someone to assist her at which time CNA 6 responded that she was the only one. On 1/13/21 at 1:35 p.m., the Director of Nursing provided a current copy of the document titled IDT Comprehensive Care Plan Policy dated 10/2019. It included, but was not limited to, Policy .It is the policy of this facility that each resident will have a comprehensive person-centered care plan .The care plan will include .resident specific interventions based on resident needs This Federal tag relates to Complaint IN 809 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a significant medication error did not occur when a nursing student was not supervised by a staff nurse during medication administration and a resident (Resident B) was given another residents medication. This deficient practice resulted in the hospitalization and intubation (insertion of a tube to assist with breathing) of Resident B due to compromised ventilation for 1 of 3 residents reviewed for medication errors. The Immediate Jeopardy began on 7/18/19 when a resident was given another resident's medication which resulted in the hospitalization and intubation of the resident secondary to the significant medication error. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 8/2/19 at 3:25 p.m. The Immediate Jeopardy that began on 7/18/19 was removed and the deficient practice was corrected, on 7/25/19, prior to the start of the survey and was therefore past non-Compliance. Findings include: The clinical record for Resident B was reviewed on 8/1/19 at 1:51 p.m. [DIAGNOSES REDACTED]. The resident had intact cognition. The incident report, dated 7/18/19 at 11:04 a.m., indicated Resident B was given the wrong medication by a nursing student. The resident was sent to the hospital for precautionary measures and in stable condition. The (MONTH) 2019 Medication Administration Record [REDACTED] - Carvedilol (medication for heart failure) 3.125 mg (milligrams) - [MEDICATION NAME] (medication for heart failure) 2.5 mg - Thera M Plus (multivitamin) - [MEDICATION NAME] (diuretic) 2 mg - Potassium Chloride (supplement) 40 meq (milliequivalents) The facility investigation indicated Resident B also received the following medications that were prescribed to another resident (Resident E) on the morning of 7/18/19 without a physician's orders [REDACTED].>- Aspirin 81 mg - [MEDICATION NAME]-[MEDICATION NAME] (medication for restless leg syndrome) 10-100 mg - [MEDICATION NAME] Sodium (medication for constipation) 100 mg - [MEDICATION NAME] (diuretic) 20 mg - [MEDICATION NAME] (hypertensive medication) 25 mg - Potassium Chloride 10 meq - Thera M Plus - [MEDICATION NAME] (antianxiety medication) 1 mg - [MEDICATION NAME] (antipsychotic medication) 250 mg - Juven (wound healing supplement) 1 packet - [MEDICATION NAME] (muscle relaxer) 10 mg - [MEDICATION NAME] (narcotic pain medication) 15 mg The SBAR (Situation, Background, Assessment, Recommendation) event, dated 7/18/19 at 10:29 a.m., indicated the following vital signs for Resident B: - Blood Pressure - 98/45 - Pulse - 30 - Oxygenation - 80% The progress note, dated 7/18/19 at 10:30 a.m., indicated the resident was observed with an altered mental status possible caused by medication regimen. The physician was notified and the resident was sent to the emergency room for evaluation. The written statement from LPN (Licensed Practical Nurse) 7, dated 7/18/19 and untimed, indicated Resident B's medications were pulled by LPN 7 at 9:02 a.m. and given to Nursing Student 8 to deliver to Resident B's room. The medications were then pulled by LPN 7 for Resident [NAME] and given to Nursing Student 8 with instructions to remind the resident his pain pill and muscle relaxer were in the medication cup. Nursing Student 8 was told the residents name and room number by LPN 7 and reminded a second time to let the resident know his pain pill and muscle relaxer were in the medication cup. Time passed and Resident [NAME] reported he did not get his medicine. LPN 7 called Nursing Student 8 and asked her which resident she gave the medications to with pain pill and muscle relaxer. Nursing Student 8 told LPN 7 the medications were given to the resident that got sent out (Resident B) The written statement from Nursing Student 8, undated and untimed, indicated Nursing Student 8 was passing medications with LPN 7 and they had previously given Resident B his medications. Nursing Student 8 was standing at the medication cart as LPN 7 was pulling medications for two people. LPN 7 handed Nursing Student 8 one of the cups with the medications and was instructed to give them to Resident B. Nursing Student 8 asked what the room number was again to clarify since Resident B was already given medications. LPN 7 told Nursing Student 8 to let the resident know his muscle relaxer and pain medication were in the cup. When I told him this he responded OK and took the medications. The emergency provider note, dated 7/18/19 at 11:15 a.m., indicated the patient was sent to the ER (emergency department) from the nursing home for altered mental status. The nursing home called and stated the patient had accidentally received another patients medications in the morning, which included [MEDICATION NAME] and [MEDICATION NAME]. [MEDICATION NAME] was given initially when he arrived and there was no change in response. The hospital [MEDICAL CONDITION] consultation report, dated 7/18/19 at 3:18 p.m., indicated Resident B came to the ER (emergency room ) from nursing home, who per report through ED, had received not only his medications in the morning, but medications from another resident as well. The additional medications included a beta blocker as well as other sedating medications. [MEDICATION NAME] was given with no improvement. He was unable to respond to his name, does not follow any commands, and was seen on a [MEDICAL CONDITION] (positive pressure ventilator). The patient has not responded to noninvasive positive pressure ventilation. Impression .chronic hypoxic [MEDICAL CONDITION] .acute [MEDICAL CONDITION], suspected toxic metabolic from polypharmacy at outlying facility, as well as hypercapnia [MEDICAL CONDITION] .suspected health-care associated pneumonia. The anesthesia progress note, dated 7/18/19 at 4:08 p.m., indicated the resident was intubated and placed on a ventilator. During an interview on 8/2/19 at 11:45 a.m., the Director of Nursing indicated a facility licensed nurse should have been with the nursing student when the medications were administered. During an interview on 8/2/19 at 12:24 p.m., LPN 4 indicated from her understanding, LPN 7 and Nursing Student 8 were pulling medications together. LPN 7 was going to go with Nursing Student 8 to administer the medication but got distracted. Nursing Student 8 took the medications and administered them without LPN 7. On 8/1/19 at 2:38 p.m., the Administrator provided a current copy of the document titled Affiliation and Preceptorship Agreement. It included, but was not limited to, This Affiliation and Preceptorship Agreement .by and between (name of corporation) .(hereinafter referred to as Sub-Acute/Long Term Care Facility and (name of nursing school) (hereinafter referred to as School) .Clinical Learning Experiences .Upon mutual consent of Sub-Acute/Long Term Care Facility and School, the clinical learning experiences offered at Sub-Acute/Long Term Care Facility may include preceptor arrangements, Sub-Acute Care/Long Term Care Facility will assign one or more qualified staff members to serve as preceptors to supervise and facilitate students' clinical learning experiences The current policy titled Medication Errors, dated (MONTH) (YEAR), included, but was not limited to, Policy .It is the policy of this provider to ensure residents residing in the facility are free of medication errors and the facility maintains a medication error rate of less than 5% The past noncompliance Immediate Jeopardy that began on 7/18/19 was removed and the deficient practice corrected on 7/25/19 after the facility implemented a systemic plan that included the following actions: all student nurse training and skills check off on medication pass procedures was completed; all facility nurses were educated on medication administration, skills check off, medications administration with student nurses completed; and student nurses were assigned to one area only with a nurse and student instructor to supervise. This Federal tag relates to Complaint IN 438 3.1-48(c)(2) 3.1-25(d)

A. Based on record review and interview, the facility failed to ensure a resident at risk for elopement was assessed, care was planned, and the resident was supervised to prevent elopement for 1 of 5 residents reviewed related to risk for elopement in a sample of 5. (Resident C) Resident C eloped from the facility and was found non-responsive on public transportation in an adjoining city across a river. The resident required emergency medical services and was hospitalized with [DIAGNOSES REDACTED]. The resident required ventilator support during hospitalization . B. Based on observation, record review, and interview, the facility failed to ensure door alarms used to alert staff to residents exiting the facility without supervision were functioning. The deficient practice had the potential to affect 16 of 16 residents identified by the facility at risk for elopement. Findings include: A. An interview was completed on 1/11/11 at 12:45 p.m. with the facility's Nurse Consultant #1 and Nurse Consultant #2, the Administrator, and the Director of Nursing. During the interview, Nurse Consultant #1 provided a binder containing documentation related to the elopement of Resident C on 1/8/11. Information in the binder indicated on 1/8/11, Resident C participated in the facility's 6:00 a.m. smoke break, and at 10:00 a.m., Resident C could not be located to receive medications. Facility staff implemented the facility elopement procedure. Also included in the binder was a plastic bag containing a Wanderguard bracelet with the wristband cut, and also a nail clipper. During the interview, Nurse Consultant #1 indicated the items were found in the resident's drawer in his room during investigation into the elopement. She indicated the resident had apparently cut the wristband with the nail clippers. She also indicated it was unknown which door the resident used to leave the facility. Written statements by staff on duty before and after the elopement indicated the following: RN #4, "On the night of 1/7/11, I performed 15 minute checks on (name of Resident C)....He was given his a.m. (morning) meds (medications) at around 6:00 a.m., and at this time I noted a Wanderguard on his wrist. While taking his meds (medications) he did state that he did not 'like it here.'" LPN #5, "...I went to his room @ 10 AM (a.m.) and attempted to give him his medication as ordered. He wasn't there, so I went to the smokers lounge and he wasn't there. I spoke (symbol for with) week-end supervisor and let her know his breakfast tray was there and he hadn't touched it. I was attempting to locate him and he wasn't anywhere so far that I had looked. As the events unfolded he had cut his safety band off and left the facility...." During telephone interview completed on 1/11/11 at 10:45 p.m., RN #4 indicated she checked the resident every 15 minutes (on the night of 1/7/11 -1/8/11) since he had been out to the behavior center. She indicated this wasn't part of the plan for Resident C, but she always watched residents closely if they had a problem with behaviors. She indicated she had not seen the behavior but heard that Resident C obtained money from other residents. She indicated the resident had slept until about 2:30 a.m. and then was up sitting at the door to the smoking area or in the lounge the remainder of the night. She indicated she saw the resident about 6:45 a.m. after he went out to smoke and then returned to his room. Documentation failed to indicate the every 15 minute checks or that the resident was seen between 6:45 a.m. and 10:00 a.m. on 1/8/11. Emergency medical services records in the binder indicated assessment of the resident was initiated on 1/8/11 (earliest legible time 9:39 a.m.), and the resident was received by the emergency room nurse on 1/8/11 at 10:37 a.m. Narrative information on the emergency medical services report indicated, "Crew called for unresponsive. Arrived to find (age) on (name of local public transportation company) bus unresponsive. Bystanders stated that pt (patient) had been drinking and suddenly became unresponsive. Pupils dilated and non reactive...." The report indicated further assessment of the resident, an intravenous line was placed, Narcan was administered, and the resident was started on oxygen at 15 liters per minute by rebreather mask and transported to the hospital emergency room . Hospital records in the binder indicated the resident was transferred from the emergency room to a hospital intensive care unit on 1/11/11 at 12:15 p.m. The history and physical note dated 1/8/11 at 9:40 p.m., indicated, "...in the ER (emergency room )...He was nasally intubated....Despite not being sedated, he remained nonresponsive more than 3 hours after intubation, so we called for vent (ventilator) management." The assessment and plan indicated, "...Will admit and treat....CNS (central nervous system): alcohol intoxication: no sedation. CPAP (continuous positive airway pressure) trial when he wakes up, followed by spontaneous breathing trial with weaning parameters. Expect will be able to extubate him tonight or tomorrow morning...." The clinical record for Resident C was provided and reviewed on 1/11/11 at 2:00 p.m. The record indicated the resident was admitted to the facility on [DATE] from another long term care facility. An Elopement Risk assessment dated [DATE] indicated "Yes" answers to the following questions: "Is the resident cognitively impaired with poor decision making skills?, Does the resident have a [DIAGNOSES REDACTED].?, Does the resident ambulate independently, with or without the use of an assistive device?", and "Does the resident wander aimlessly?". Next to the question, "Is the wandering behavior a pattern or routine tied to resident's past? was written: "Possibly." Next to the question, "Has the resident been recently admitted or readmitted (within past 30 days) and not accepting of the situation?" was written: "New admit." On the reverse side of the assessment in the section for "Summary of Assessment" was marked with a checkmark: "Resident at risk for elopement, as evidenced by: dementia, depression, hx (history) of wandering aimlessly, ambulates independently. Next to "Appropriate interventions have been:" was a checkmark next to "Initiated." Interventions selected for initiation were: "1. Personal safety alarm devices, 2. Exit and stairwell alarms, and 4. Frequent monitoring. Check every (handwritten in blank space was the word) hour." The assessment was signed by a nurse. admission orders Wanderguard (Departure Alert System) rt. (right) wrist - check placement q (every) shift." The nurse signed "Above orders verified per telephone with physician" with the date written is as: "12/(blank space)/10." An Elopement Risk assessment dated [DATE] indicated a check mark next to "Yes" answers to the following questions: "Is the resident cognitively impaired with poor decision making skills?, Does the resident have a [DIAGNOSES REDACTED].?, Does the resident ambulate independently, with or without the use of an assistive device?", and "Does the resident wander aimlessly?". Next to the question, "Is the wandering behavior a pattern or routine tied to resident's past?" where "Possibly" was written was a checkmark. Next to the question, "Has the resident been recently admitted or readmitted (within past 30 days) and not accepting of the situation?" where "New admit" was written was a checkmark. On the reverse side of the assessment in the section for "Summary of Assessment" was marked with a checkmark: "Resident at risk for elopement, as evidenced by: wanders/pacing, (arrow pointing down) cognition, ambulates independently." dementia, depression, hx (history) of wandering aimlessly, ambulates independently. Next to "Appropriate interventions have been:" was a checkmark next to "reviewed." Interventions selected for review were: "4. Frequent monitoring. Check every (handwritten) hour. 5. Keep behavior logs, 8. Recreational activities, 9. Music, 13. Staff aware of wander risk, 14. Other: (handwritten) Wanderguard." The assessment was signed by the social worker. Documentation in the record failed to indicate the hourly monitoring of the resident was completed. During interview on 1/11/11 at 3:05 p.m., the Social Worker and Social Services/Activities Consultant discussed how the decision was made to use the Wanderguard system for this resident on 12/8/10. The Social Services/Activities Consultant indicated that on the day the resident moved into the facility, she was the Administrator at the facility and saw from her office window that the resident went out to his brother's truck as the brother was unloading the resident's belongings to bring into the facility. She indicated she felt the resident needed a Wanderguard at that time and requested it be used, and that the resident would be monitored for a quarter. She indicated she did not document the information. The admission Minimum Data Set assessment dated [DATE] indicated the resident did not have wandering behaviors during the assessment period. A Care Plan Worksheet indicated a problem dated 12/8/10 for "Resident has been found to be at risk for elopement d/t (due to) depression, dementia, aimlessly wandering." The goal was, "Resident will not leave the facility unattended thru (through) the next review." Interventions included, "Complete elopement risk assessment. Use Redirection, distraction and re-orientation when resident attempts to exit bldg (building). Follow facility policy and procedures. Encourage participation in activities of choice and interest. Ensure all basic needs have been met. Observe for s/s (signs and symptoms) of depression. Mental health services as needed or ordered." Documentation failed to indicate the care plan was updated after 12/8/10. A Behavioral Contract signed by the resident and Social Worker dated 12/16/10, included, but was not limited to, related to behaviors, "Wandering/Intrusive/Elopement," and "I have agreed to "...2. Not to leave facility without signing out with my responsible party. 3. Not to enter other's rooms, office...." The document indicated, "I am willing to work with the staff to improve on them (behaviors). The staff will provide me with 1. Problem solving techniques, 2. Solutions to resolve these issues, 3. Praise, 4. Support, 5. Verbal reminders, 6. Reassurance as needed, 7. Resident teaching/education on safety concerns." A Care Plan Worksheet for "Problem: Mood and Behavior Care Plan" indicated dates of 12/10/10, 12/14/10 and 1/6/11 with "Problem: Resident presents with primary [DIAGNOSES REDACTED]." The list of behaviors included, but was not limited to, "...Wandering/Pacing within facility...Intruding into other's space." The Goal was "Episodes of moods and behaviors will be redirected and/or diffused daily thru (through) next review." Interventions included, but were not limited to, "...Bx (behavior contract) in place. Wanderguard bracelet - check placement & functioning q (every) shift." The Behavior Monthly Flow Record for December 2010 indicated the resident had behaviors including, but not limited to, continuous wandering on day shift on 12/18/10 and intruding into others' rooms and offices on day shift on 12/14, 12/18/10, 12/25/10, and 12/30/10. A psychiatric visit consult note dated 12/20/10 indicated, "Nsg (nursing) reports R (resident) having difficulty (symbol for with) adjustment - (symbol for not) sleeping at noc (night) - staying in lobby areas...." On 12/30/10 a physician's orders [REDACTED]." The History and Physical at the behavior center, dated 12/31/10 indicated, "History of Present Illness: ...More recently, he has been seen to be increasingly agitated and has been having behavioral problems. He has been stealing money and he has been intrusive and med (medication) seeking, and has been difficult to be redirected. He also smokes cigarettes and drinks diet coke constantly...." The resident was readmitted to the facility on [DATE]. Documentation failed to indicate an Elopement Risk Assessment was completed upon the resident's return from the behavior center. admission orders Treatments: Wanderguard to rt. wrist (checkmark) placement q shift" and "Activity level: Amb (ambulatory)." During interview on 1/11/11 at 3:05 p.m., the Director of Nursing (DoN) indicated she would need to check policy to see if a reassessment of Elopement Risk was required upon readmission from the behavior unit. During interview at this same time, the Social Worker and Social Services/Activities Consultant looked at each other and shook their heads "No" when the hourly monitoring of the resident indicated on the Elopement Risk Assessments dated 12/8 and 12/10/10 were discussed. On 1/12/11 at 2:55 p.m., documentation was provided by Nurse Consultant #1 related to the hourly monitoring. During interview at this time, she indicated the documentation was found in the Administrator's office. The documents were entitled, "Specialized Monitoring Every Hour Observation for Wandering Residents and Sexually Inappropriate Residents" The documents indicated Resident C was monitored hourly from 12/8/10 at 5:00 p.m. until 12/13 at 11:00 p.m. An unsigned and undated notation on the document dated 12/13/10 indicated, "Interdisciplinary team deemed no longer necessary for 1 (symbol for hour) checks d/t (due to) no exit leaving behavior." On 1/12/11 at 3:45 p.m. Nurse Consultant #1 provided copy of "Unit Manager Morning Meeting Summary" dated 12/13/10 which indicated, "(name of Resident C) - continuous questions, not sleeping well...up for IDT (interdisciplinary team) review hourly (checkmark)s, (name of Resident C) (symbol for no) attempts @ departure elopement d/c (discontinue) please." Documentation failed to indicate the Elopement Risk Assessment and care plan were updated when the decision was made to discontinue the hourly monitoring. The Behavior Monthly Flow Record for January 2011 indicated on 1/5/11 one episode of "Non-compliance (symbol for with) smoking/smoking R/T Bx" on evening shift. On 1/6/11 indicated one episode each of "Intruding into other's rooms/offices" and "Rep (repetitive) questions" on day shift. The record included no nurse's notes after 1/6/11 at 3:00 p.m., which indicated, "...Resident up ambulating per self...No s/s (signs and symptoms) of distress noted." Social services notes for 1/6/11 indicated, "Spoke with resident's brother/POA about res's continued behavior even after returning from behavior unit. Brother stated res knows better, I'll come talk to him. I don't know what else to do with him. Discussed options including the locked down men's unit in (name of another town) that would possibly be more appropriate setting for resident. Brother stated he wanted to talk to resident, and see if he could get behaviors under control, and if not he would pursue considering another facility." Documentation failed to indicate care plans were updated at this time. On 1/12/11 at 3:25 p.m., the facility's Elopement Risk Assessment Policy was provided by the Social Worker. Review of the policy indicated, "Policy: Assess residents for potential elopement. To assure that all residents are free from harm at all times. Procedures: 1. Identify residents at risk for elopement by completing the elopement risk assessment upon admission, quarterly and with significant changes in mental/psychosocial status. 2. Residents who are identified for possible elopement will immediately have interventions placed to prevent elopement...." B. During Initial Tour of the facility on 1/11/11 between 9:50 a.m. and 11:45 a.m., various facility door alarms were observed. The Maintenance Supervisor and Nurse Consultant #2 were present intermittently during the tour and described various alarms. The facility has three floors: the ground floor, leading to a back parking lot; the first floor, with exit to the alley; and a second floor with exit through the facility lounge and front door to the street. The first floor has two exit doors into the facility's enclosed outdoor courtyard. The second floor also has an exit door from the 2-East and 2-West hallways, an exit door to the outdoor smoking patio, and a delivery door. The door alarming systems included a Wanderguard (Departure Alert System) at the facility's second floor front entrance, at elevator doors, at stairwell doors, and at the ground floor back entrance. When the doors with Wanderguards are approached by a resident wearing a Wanderguard alarm, the alarm sounded. The doors which were not connected to the Wanderguard system had battery-operated alarms or hardwire alarms and coded keypads. During observation on 1/11/11 at 10:15 a.m., the patio gate alarm leading to the street was checked for functioning by the Maintenance Supervisor. The alarm did not sound when the Maintenance Supervisor opened the gate. During interview at this time, the Maintenance Supervisor indicated, "Someone has reset this alarm." He indicated he "had to get back to the beginning of the cycle" to set the alarm to function. The Maintenance Supervisor indicated the door alarm was not battery operated but hardwired into the electrical circuit. During review of the Elopement Binder on the facility's Transitional Care Unit on 1/11/11 at 10:50 a.m., 16 residents from the facility were listed as "Residents at Risk for Elopement." During interview at this time, Nurse Consultant #2 indicated the Elopement Binder had been updated since a resident's elopement on 1/8/11, and all residents at risk for elopement were being checked every 15 minutes. During observation on 1/11/11 at 10:40 a.m., the door alarm from the facility's secured unit, leading from the nurse's station into the facility's courtyard used by residents for supervised smoking, failed to alarm when opened by the Maintenance Supervisor. During interview at this time, the Maintenance Supervisor indicated the alarm needed a new battery. He indicated he had been busy with snow removal during the morning and had not done alarm safety checks. During observation on 1/11/11 at 12:45 p.m., the door alarm at the end of the 2-West hall was checked by Nurse Consultant #2. The door failed to alarm when the Consultant opened it. The Consultant closed the door and opened it a second time, and the alarm did not sound. The Consultant opened the door a third time, and the alarm sounded. The Maintenance Supervisor approached, and the Consultant indicated to him that the door had a "glitch" in its function. During interview on 1/11/11 at 1:30 p.m., the Consultant for Social Services/Activities indicated after a resident's elopement, on 1/10/11, the facility had ordered new door alarms for all facility doors not connected to the Wanderguard system. She indicated the facility had concerns with the current alarms. She indicated the alarms would be installed immediately upon arrival at the facility This federal tag relates to Complaint IN 571. 3.1-45(a)(1) 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure residents were safely transferred, related to the failure of staff to use a gait belt when transferring a resident who fell and received a head laceration requiring sutures, for 1 of 3 residents reviewed for falls in a sample of 16. (Resident #50) Findings include: The clinical record for resident #50 was reviewed on 11/16/10 at 8:25 a.m. The resident [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set, dated dated [DATE], included, but was not limited to: Requires cues/supervision poor decision making, extensive assist of one person for transfers, walk in room requires extensive assist of one person, not able to balance while standing and balance while sitting - position, trunk control unsteady, but able to rebalance self without physical support. The Care Plan Worksheet for ADL (Activities of Daily Living) Assist Required dated 7/6/10, 8/5/10, 8/29/10, and 9/28/10 included but was not limited to: "Problem: The resident requires up to mod (moderate) - max (maximum) assist in performing ADLs due to: impaired transfers, weakness... Risk for Falls dated 7/6/10, 8/5/10, 8/27/10, 9/28/10 Problem: The resident has multiple risk factors for falls, such as: weakness, recent hip fx (fracture) impaired ADLs: Interventions: added 10/29/10 non skid socks, non skid strips beside bed and tape to underside of mattress to prevent sliding." Nursing Progress Notes included, but were not limited to "10/28/10 1355 (1:55 p.m.) CNA (certified nursing assistant) called nurse to room stating resident standing at bed sliding mattress resident lost balance and resident's head (Rt side) hit the arm of the chair and then she hit the floor. Lacerating head to Rt side of head. Pressure applied to area. Family & MD notified orders received to send to (named hospital) ER (emergency room ) for evaluation & treatment...10/28/10 1800 (6 p.m.) "Resident has laceration to back of head with 5 sutures..." 10/28/10 1900 (7 p.m.) "Resident returned from (named hospital) with new orders to clean laceration twice a day with hydrogen peroxide, then apply Bacitracin (antibiotic cream). The sutures are to be removed in 10 days by nursing staff or primary care provider...." Review of the Rehabilitation Screening Form dated 10/28/10, included but was not limited to "Resident fell on [DATE]. CNA got resident up and resident standing on side of bed. CNA didn't apply gait belt and resident started helping CNA fix her mattress and bed. Resident lost footing and fell ." In interview with LPN (Licensed Practical Nurse) #1 on 10/17/10 at 4:35 a.m., she indicated all residents who were not independent walkers, were to use gait belts. On 11/16/10 at 2:45 p.m., LPN #2 provided the facility "Gait Belt Procedure" which included, but was not limited to "Purpose: To insure safety in transfer and ambulation. To provide a point of contact and increased support from the staff and prevent injuries to staff and residents who are unable to transfer or ambulated independently. Procedure: Transfer: 1. Explain use of belt to the resident. 2. Place belt snugly around resident's waist and buckle securely. 3. After properly positioning resident for the transfer, grasp belt on each side of resident waist. 4. Remember proper body mechanics and transfer techniques. 5. After completing transfer, unfasten belt and slowly remove from resident's waist. Ambulating: 6. Apply belt as above. Walk closely beside resident, taking small slow steps as resident is able. 7. Maintain firm grasp on belt at mid back and offer free hand for resident to hold for stability. 8. Remove belt slowly after safely placing resident in chair, wheelchair, or bed." On 11/18/10 at 9:50 a.m., LPN #2 provided the signed and dated 4/29/09 Gait Belt Policy for CNA #1. 3.1-45(a)(2)