Every finding on record at Ignite Medical Resort Dyer LLC

Based on observation, record review, and interview, the facility failed to ensure dependent residents received Activities of Daily (ADL) assistance related to bathing, hair washing, repositioning and eating for 2 of 3 residents reviewed for ADLs. (Residents F and G) Findings include: 1. During a random observation on 6/22/26 at 12:15 p.m., Resident F was observed lying in bed. Her lunch tray was on the over bed table in front of her, however she was not eating it. The resident indicated she had asked the person who brought in the tray to reposition her so she could eat. He told her he was not able to do that, and left the room. The resident indicated there was no way she could eat being so far down in the bed. The resident also indicated she had not had a shower or her hair washed since she had been admitted . During an interview on 6/24/26 at 10:07 a.m., the resident indicated she did not eat breakfast because no one would help her reposition in bed. She told someone, but they never came back to help and her food was cold. During an observation on 6/25/26 at 10:13 a.m., the resident was observed sitting up in a wheelchair by her bed. The resident indicated she was very tired and had asked staff a little bit ago to be put to bed. She indicated they told her she would be back but no one had come back to put her to bed. At 10:15 a.m., LPN 2 was observed across the hall passing medications. She was asked who the CNA was for Resident F. The LPN indicated it was CNA 4, and she was busy with other residents and would get to her when she had a chance. The nurse was asked why she could not help put the resident back to bed, and had no answer for the question. At 10:17 a.m., LPN 2 pushed her medication cart by Resident F's door and prepared and poured her medications. At 10:20 a.m., CNA 5 was observed entering a door from the outside and talking on her cell phone. She walked over to the lounge area and hung up her phone and put it away. At that time, LPN 2 asked CNA 5 to come over to her and help her put Resident F to bed. CNA 5 quickly responded and stated, I have to go get [resident name] up and help her. But there is CNA 4 [name] right now, you can ask her. CNA 5 walked away from LPN 2 and proceeded toward another resident's room. At 10:25 a.m., LPN 2 walked away from Resident F's room and to the nurses' station looking for someone to help her put the resident back to bed. At 10:35 a.m., CNA 4 and LPN 2 entered the resident's room to put her back to bed. At 12:05 p.m., the Dietary Aide delivered the resident's lunch tray to her walked out of the resident's room. At that time, the resident's call light came on. The resident indicated she needed to be repositioned in bed so she could eat. At 12:10 p.m., LPN 2 sat down to feed another resident on the unit and CNA 5 was making sure all the residents received a lunch tray. At 12:17 p.m., CNA 5 entered a resident's room to feed them and Resident F's call light was still on. She had not been repositioned nor had started to eat her lunch. At 12:20 p.m., LPN 2 entered the resident's room to answer the call light and the resident told her she needed to be changed and repositioned in bed so she could eat her lunch. During an interview on 6/25/26 at 3:30 p.m., the resident indicated her hair still had not been washed since she had been in the facility. The record for Resident F was reviewed on 6/25/26 at 11:35 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, heart failure, COPD, acute respiratory failure with hypoxia, history of lung cancer, high blood pressure, heart disease, atrial fibrillation, chronic kidney disease, and pulmonary hypertension. The 6/21/26 admission Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and needed supervision or touching assistance with eating and was dependent on staff for bathing, The resident needed partial to moderate assistance with bed mobility and substantial to max assist with transfers. A Care Plan, dated 6/17/26 indicated the resident had ADL self-care performance deficits and limitations in physical mobility. On 6/25/26 at 12:00 p.m., CNA 4 brought out the shower sheets in a binder for the unit. The shower sheets were reviewed and there was no shower sheet for Resident F in the book. The Unit Manager provided a list of how the showers were determined. The resident was to receive a shower on Wednesday and Saturdays in the evening. A shower sheet for the resident was found in the Unit Manager's office and was not in the book. The shower sheet indicated the resident received a bed bath on 6/20 and 6/24/26, however, her hair was not washed since she had been in the facility. During an interview on 6/25/26 at 11:40 a.m., CNA 4 indicated after a resident had a shower completed, they would fill out the shower sheet for that resident. During an interview on 6/26/26 at 11:15 a.m., the Director of Nursing indicated the resident's hair was just washed on 6/26/26. He indicated there needed to be a better system for tray delivery and helping with meals. He had no other additional information to provide. 2. During a random observation on 6/22/26 at 11:18 a.m., Resident G was in bed with her head elevated. Her uneaten, covered breakfast was on the table in front of her. She was holding a covered cup of juice. She slowly lifted the lidded cup to her mouth, was unable to drink, then put the cup down. After four unsuccessful attempts, the resident fell asleep. On 6/22/26 at 12:56 p.m., the uneaten, covered breakfast remained on the resident's table. At that time, Dietary Aide 1 brought the resident's lunch tray to nurses station. She indicated that was what she did with the trays of all residents who needed to be fed. She had not delivered the breakfast trays that day. During an interview on 6/22/26 at 1:00 p.m., CNA 3 indicated the resident needed to be fed, and she was not there for breakfast that day. The resident's record was reviewed on 6/25/26 at 12:38 p.m. Diagnoses included, but were not limited to, muscle weakness, need for assistance with personal care, and dementia. The Minimum Data Set (MDS) assessment, dated 4/26/26, indicated the resident had severe cognitive impairment, and was dependent in activities of daily living (ADLs). A Care Plan, dated 4/22/26, indicated the resident had an ADL self-care deficit and was dependent in eating. During an interview on 6/25/26 at 3:15 p.m., the Director of Nursing was informed of the finding and had no additional information to provide. This citation relates to Intakes 3051819 and 3051964. 410 IAC (Indiana Administrative Code) 16.2-3.1-38(a)(2)(B) 410 IAC (Indiana Administrative Code) 16.2-3.1-38(a)(2)(D) 410 IAC (Indiana Administrative Code) 16.2-3.1-38(a)(3)(B)

Based on record review and interview, the facility failed to ensure a resident received treatment and care in accordance with professional standards, related to medications not administered timely and as ordered by the Physician, for 1 of 7 residents reviewed for quality of care. (Resident D)Finding includes:Resident D's record was reviewed on 11/18/25 at 11:27 a.m. The diagnoses included, but were not limited to, urine retention, hypertension, osteomyelitis, chronic kidney disease, heart failure, and edema.An admission Minimum Data Set (MDS) assessment, dated 9/22/5, indicated an intact cognitive status, no behaviors, dependent for toileting, incontinent of bowel and bladder, received intravenous (IV) medications, and had a central line.An admission Physician's Order, dated 9/19/25 at 7:24 p.m., indicated carvedilol (heart medication) 3.125 milligrams (mg) was to be given twice a day with meals for hypertension.The Medication Administration Record (MAR), dated 9/2025, indicated the carvedilol was scheduled for 8:00 a.m. and 5:00 p.m. and was received as ordered on 9/20/25 and 9/21/25.The MAR indicated the medication had not been given on at 8:00 a.m. and 5:00 p.m. on 9/22/25 and 9/23/25.The Nurses' Progress Notes, dated 9/23/25 at 9:33 a.m. and 9/23 at 6:08 p.m., indicated the medication was on order.There was no documentation the physician had been notified of the carvedilol not administered as ordered.The Pharmacy Emergency Medication Kit (EDK) medication inventory list, dated 1/5/24 and received from the Director of Nursing (DON) as the Pharmacy used by the facility in September and October, indicated the carvedilol was available in the EDK.A Physician's Order, dated 9/19/25 at 8:33 p.m., indicated Midodrine HCL (medication for hypotension) 10 mg was to be administered three times a day for hypotension.The MAR, dated 9/2025, indicated the Midodrine HCL was scheduled for 9:00 a.m., 1:00 p.m., and 5:00 p.m. The Midodrine HCL had not been administered on 9/23/25 at 9:00 a.m. and 1:00 p.m. and 9/24/25 at 9:00 a.m. and 1:00 p.m.There was no documentation in the Nurses' Progress Notes, nor on the MAR that indicated why the medication had not been administered and the Physician had been notified.A Physician's Order, dated 9/19/25 at 1:39 p.m., indicated vancomycin (antibiotic) 250 mg, was to be administered four times a day.The MAR, dated 9/2025, indicated the medication was scheduled for 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m.The Mar indicated the vancomycin had not been administered on 9/22/25 at 9:00 a.m., 9/22/25 at 5 p.m., and 9/23/25 at 1:00 p.m.There was no documentation in the Nurses' Progress Notes, nor on the MAR, that indicated why the medication had not been administered or that the phad been notified.A Physician's Order, dated 9/19/25 at 10:24 a.m., indicated enoxaparin sodium solution (blood thinner) 40 mg/0.4 milliliter was to be injected one time a day for prevention of blood clots for 30 days.The MAR, dated 9/2025, indicated the medication was scheduled for 9:00 a.m. daily. The medication had not been given at 9:00 a.m. on 9/20/25, 9/22/25, and 9/23/25. The 9:00 a.m. dose on 9/21/25 had been administered.A Nurse's Progress Note, dated 9/20/25 at 5:51 p.m., indicated the medication was on order.A Nurse's Progress Note, dated 9/23/25 at 9:11 a.m., indicated the medication had been re-ordered.The Pharmacy EDK medication inventory list, dated 1/5/24 and received from the Director of Nursing (DON) as the Pharmacy used by the facility in September and October, indicated the medication was available in the EDK.There was no documentation in the Nurses' Progress Note why the medication had not been given on 9/22/25 or that the physician had been notified of the medication not given on 9/20/22, 9/22/25, and 9/23/25.During an interview on 11/19/25 at 9:28 a.m., the DON acknowledged the medications had not been administered as ordered. The facility had a new Pharmacy as of 11/1/25, due to problems with medication delivery. He was not sure if the medications were not available in the EDK or why the EDK had not been used. He had not been notified that the medications were not available.The prior Pharmacy delivery policy, dated 10/2023 and received from the Nurse Consultant as current for September and October 2025, indicated the original physician's order was to be sent to the pharmacy as soon as it was written. The first dose may be available from the EDK. Refill orders were to be sent when there was only a three day supply left of the medication. Delivery Monday through Friday was 2:30 p.m. to 5:30 p.m. if ordered before 8:00 a.m. and 12:30 a.m.-3:30 am., if ordered before 5:00 p.m. Orders before 2:00 p.m. on Saturday and Sunday were delivered between 9:30 p.m. and 12:30 a.m.The Hospital Transfer re-admission Physician's orders, dated 10/4/25, indicated orders of metoprolol succinate ER (extended release) (heart medication) 25 mg daily and empagliflozin (diabetic medication) 10 mg daily.The Physician's Orders and the MAR, dated 10/2025, indicated the orders had not been transcribed until 10/6/25.The MAR, dated 10/2025, indicated the metoprolol succinate ER was first administered on 10/7/25 at 9:00 a.m. and the empagliflozin was first administered on 10/8/25 at 9:00 a.m.There was no documentation that indicated the resident and physician had been notified of the delay in treatment.During an interview on 10/19/25 at 1:48 p.m., the DON indicated the omitted orders were found during an audit on 10/6/25.A Physician's Order, dated 10/6/25 at 6:53 p.m., indicated midodrine HCL, 10 mg was to be administered twice a day for hypotension. The medication was not to be administered if the systolic blood pressure was greater than 90.The MAR, dated 10/2025, indicated the medication was scheduled for 8:00 a.m. and 5:00 p.m.The medication had been administered on October 8-11, 2025 and October 13 - 31, 2025 at 8:00 a.m. There was no blood pressure checked prior to the administration of the medication on October 9, 11, and 13, 2025. The blood pressure on October 8, 14 -31, 2025 at 8:00 had a systolic pressure over 90.The medication had been given at 5:00 p.m. on October 8, 9, 11, 12, 14-31, 2025. There was no blood pressure obtained prior to the administration of the medication on October 8, 9, 11, and 12, 2025. The blood pressure on October 14-31, 2025 had a systolic pressure over 90.The MAR, dated 11/2025, indicated the medication had been administered November 1-17, 2025 at 8:00 a.m. with the systolic blood pressure over 90. The 5:00 p.m. dose was administered November 1-4 and 7-17, 2025 with a systolic blood pressure over 90.During an interview on 11/19/25 at 1:48 p.m. the DON and Nurse Consultant acknowledged the medications had been administered with a systolic blood pressure over 90.This citation relates to Intakes 2656197 and 2664121.3.1-37(a)

Based on record review and interview, the facility failed to ensure residents were provided with laboratory (lab) services, related to lab tests not completed as ordered for 2 of 3 residents reviewed for lab services. (Residents D and E)Findings include:1. Resident D's record was reviewed on 11/18/25 at 11:27 a.m. The diagnoses included, but were not limited to, urine retention, hypertension, osteomyelitis, chronic kidney disease, heart failure, and edema.An admission Minimum Data Set (MDS) assessment, dated 9/22/25, indicated an intact cognitive status, no behaviors, dependent for toileting, incontinent of bowel and bladder, received intravenous (IV) medications, and had a central line.A Physician's Order, dated 9/19/25 indicated a complete blood count (CBC), C-reactive protein (CRP) (measures protein in the blood), comprehensive metabolic panel (CMP) (measures chemical balance, electrolyte levels, kidney and liver function), and erythrocyte sedimentation rate (ESR)(monitor for inflammation) blood tests were to be obtained on 9/29/25. There was no documentation the blood tests were completed, the reason the tests were not completed or that the physician had been notified the tests had not been completed.A Physician's Order, dated 10/16/25, indicated a vitamin B1 level (thiamin level) was to be obtained on 10/27/25. There was no documentation the blood test had been completed, the reason it was not completed or that the physician had been notified the test had not been completed.A Physician's Order, dated 10/22/25, indicated a stool sample was to be obtained to test for occult blood. There was no documentation the test had been completed, the reason it was not completed or that the physician had been notified the test had not been completed.A Physician's Order, dated 11/4/25, indicated a CMP blood test was to be completed on 11/5/25. There was no documentation the test had been completed, the reason it was not completed or that the physician had been notified the test had not been completed.During interviews on 11/19/25 from 2:40 p.m. through 3:11p.m., the Director of Nursing (DON) acknowledged there were orders for the above lab tests and no documentation why they were not completed or that the physician had been notified. He indicated when the Physician's Order is typed into the computer, it goes directly to the Laboratory Company who is contracted to complete the facility labs. 2. Resident E's record was reviewed on 11/20/25 at 8:23 a.m. The diagnoses included, but were not limited to, urinary tract infection, diabetes mellitus, Parkinson's disease, and dementia.An admission MDS assessment, dated 11/2/25, indicated a moderately impaired cognitive status and no behaviors.A Physician's Order, dated 10/31/25, indicated a urinalysis was to be completed. There was no documentation the test had been completed, no results in the record, or that the Physician had been notified the test had not been completed.During an interview on 11/20/25 at 9:12 a.m., the DON indicated it was documented it had been collected but the lab had not picked it up.A facility policy for lab orders, dated 11/2025 and received as current from the DON, indicated the lab was integrated with the facility's electronic medical record and the results would be downloaded to the record.This citation relates to Intake 2656197.3.1-37(a)

Based on record review and interview, the facility failed to ensure residents' records were accurate and complete, related to documentation of the amount of urine found after bladder scans were completed, for 2 of 4 residents reviewed for bladder scans. (Residents D and E)Findings include:1. Resident D's record was reviewed on 11/18/25 at 11:27 a.m. The diagnoses included, but were not limited to, urine retention, hypertension, osteomyelitis, chronic kidney disease, heart failure, and edema.An admission Minimum Data Set (MDS) assessment, dated 9/22/25, indicated an intact cognitive status, no behaviors, dependent for toileting and was incontinent of bowel and bladder.A Physician's Order, dated 9/24/25 at 4:52 p.m., indicated a post void bladder scan was to be completed daily for one week. The results were to be documented and the physician's office was to be notified of the results daily.The Medication Administration Record (MAR), dated 9/2025, indicated by initials and a check mark, the order was completed on day shift on 9/25 through 9/30/25.There was no documentation of the amount of urine found during the scan on the MAR or the Nurses' Progress Notes. There were no Bladder Scan Evaluations completed.During an interview on 11/19/25 at 8:21 a.m., the Unit Manager indicated the bladder scans were completed and she had personally e-faxed (notification per computer) the physician's office. She indicated the bladder scans were to be documented on the Bladder Scan Evaluation form and in the Nurses' Progress Notes.During an interview on 11/19/25 at 8:21 a.m., the Director of Nursing (DON) indicated there was no documentation of the amount of urine found during the scans other than for 9/25/25 at 7:02 p.m., which was 240 cubic centimeters. 2. Resident E's record was reviewed on 11/20/25 at 8:23 a.m. The diagnoses included, but were not limited to, urinary tract infection, diabetes mellitus, Parkinson's disease, and dementia.An admission MDS assessment, dated 11/2/25, indicated a moderately impaired cognitive status and no behaviors.A Physician's Order, dated 10/31/25, indicated a bladder scan was to be completed every eight hours for three days.The MAR, dated 11/1/25, indicated the bladder scan was scheduled for 6:00 a.m., 2:00 p.m., and 10:00 p.m. from 11/1/25 through 11/3/25.On 11/1/25 at 2:00 p.m. and 10:00 p.m. and 11/2/25 at 6:00 a.m. and 2:00 p.m., there were initials and a check mark on the MAR that the scan was completed. The amount of urine found during the scan was not documented.There was no documentation in the Nurses' Progress Notes and there were no Bladder Evaluation forms completed.During an interview on 11/202/5 at 10:54 a.m., the DON indicated there was no documentation of the amount of urine found during the scan.A facility bladder scan policy, dated 11/2025 and received as current from the Nurse Consultant as current, indicated the amount of urine found during the scan would be recorded.This citation relates to Intake 2656197.3.1-50(a)(1)3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by staff members (CNA 1 and CNA 2) when providing care to a residents who were in Enhanced Barrier Precautions (EBP) for 2 of 4 residents reviewed for EBP. (Residents F and J) Findings include:1. During an observation on 11/17/25 at 9:25 a.m., Resident F's outside doorframe had a magnetic sign that indicated EBP was to be utilized during care and there was a PPE bin located below the sign. Upon entering the room, the resident was in bed and CNA 1 was providing incontinence care. The CNA had gloves on but had not donned a gown. The CNA was interviewed after the care was completed. She indicated she should have worn a gown while providing the resident's care. Resident F's record was reviewed on 11/20/25 at 11:19 a.m. The diagnoses included, but were not limited to, gastrostomy tube (feeding tube). A Care Plan, dated 11/5/25, indicated EBP was required. The interventions indicated PPE, specifically gowns and gloves, during high contact resident care were to be worn. A Physician's Order, dated 11/5/25, indicated EBP was required related to the feeding tube. 2. During an observation on 8/19/25 at 8:18 a.m., Resident J's door had a magnetic sign on the outside door frame that indicated EBP was required. Upon entering the room, CNA 2 was in the room and had just transferred the resident from the bed to the wheelchair and was making the bed. She indicated she had just provided care to the resident. She was wearing gloves and a gown was not worn. She indicated she should have wore a gown while providing care to the resident. Resident J's record was reviewed on 11/20/25 at 3:02 p.m. The diagnoses included, but were not limited to, peripheral vascular disease. A Care Plan, dated 10/10/25, indicated EBP was required. The interventions indicated PPE, specifically gowns and gloves, during high contact resident care were to be worn. The Physician's Order Summary (POS) indicated an order on 10/13/25 that EBP was to be utilized. On 11/17/25, the POS indicated the resident received a midline intravenous catheter, and on 11/19/25 an order for a treatment and dressing for an open area on the right toe. A facility EBP policy, dated 3/2025 and received from the Nurse Consultant as current, indicated residents with wounds, indwelling medical devices, and feeding tubes were to have EBP utilized during high contact care. Gowns and gloves were to be worn with care. This citation relates to Intake 2655001. 3.1-18(b)

Based on observation, record review and interview, the facility failed to initiate and update effective resident-specific interventions to prevent the elopement from the facility of a resident with a diagnosis of dementia and history of exit-seeking behaviors for 1 of 5 residents reviewed as elopement risk. The resident had indicators of being an elopement risk and behaviors of wanting to exit the facility. The resident exited the building without supervision, through the main front door entrance, and the facility was unaware of the resident's whereabouts. The resident ambulated approximately 0.15 miles from the facility on a highly traveled four lane road and was returned to the facility by Emergency Services staff. (Resident B)The Immediate Jeopardy began on 7/27/25, when the facility was unaware that the resident had exited the facility without supervision. The resident walked independently and was found across the street from the facility at approximately 9:03 p.m. by Emergency Services staff, who assisted the resident back to the facility. The Administrator, Director of Nursing (DON), and [NAME] President of Clinical Operations were notified of the immediate jeopardy on 7/30/25 at 1:30 p.m. The immediate jeopardy was removed on 7/30/25 and the deficient practice corrected on 7/28/25, prior to the start of the survey and was therefore Past Noncompliance.Finding includes:Resident B's closed record was reviewed on 7/30/25 at 9:06 a.m. Diagnoses included, but were not limited to, dementia and abnormalities of gait and mobility. The resident was admitted to the facility on [DATE]. A Wander/Elopement Risk Evaluation, dated 7/9/25, indicated the resident was not an elopement risk. The Initial/Baseline Care Plan, dated 7/9/25, indicated the resident had cognitive impairment, was at risk for falls, and was not an elopement risk. A Fall Risk Evaluation, dated 7/9/25, indicated the resident was at high risk for falls. A Social Service Note, dated 7/10/25 at 7:10 p.m., indicated the resident was currently exit-seeking. The resident's daughter was notified and informed the resident would need alternate placement. Education was provided on facilities with a memory care unit. The resident's daughter indicated the family was exploring other facilities.There was no documentation to indicate any interventions were implemented by the facility to address the resident's exit-seeking behavior identified by Social Services to the family on 7/10/25. An Initial Psychiatric Evaluation, dated 7/10/25, indicated given acuity of cognitive symptoms, she is not a good candidate for psychotherapy at this time. Will only follow-up in the future if requested by medical team or family. A Physician Note, dated 7/11/25 at 9:04 a.m., indicated the resident had profound dementia. Found to be wandering in the hall on 9 occasions yesterday and set off the door alarms on several occasions. This will be reviewed with psych services to determine if any therapy is needed. There was no documentation to indicate any new interventions were attempted for the wandering behaviors on 7/11/25. A Progress Note, dated 7/12/25 at 7:16 p.m., indicated the resident was actively trying to elope. She had tried to get out the emergency exits on both doors on the unit. She was difficult to redirect. A Behavior Progress Note, dated 7/12/25 at 8:23 p.m., indicated the resident was attempting to leave the unit again and indicated she wanted to go outside. She was redirected multiple times and continued to wander. A Behavior Progress Note, dated 7/12/25 at 9:13 p.m., indicated the resident was attempting to go out the emergency exit door on the unit and asking to go outside. A Behavior Progress Note, dated 7/12/25 at 9:28 p.m., indicated the resident was attempting to exit the building through the emergency exit. A Behavior Progress Note, dated 7/12/25 at 9:41 p.m., indicated the resident was wandering the halls asking to go outside. She was not easily redirected and did not understand why she was at the facility. A Behavior Progress Note, dated 7/12/25 at 9:57 p.m., indicated the resident was exit seeking and the door alarm was sounding as the resident was attempting to leave the building. The resident's daughter was notified and indicated the resident's family had been at the facility visiting most of the day and had taken the resident outside for much of that time. The resident lived on her own prior to being hospitalized and was accustomed to going outside whenever she wanted to. There was no documentation to indicate new resident-specific interventions were implemented to address the continued exit-seeking on 7/12/25 or the resident's previous lifestyle and routine to go outside with supervision. A new Elopement Risk Screening, dated 7/12/25, indicated the resident was at risk for elopement. The admission Minimum Data Set (MDS) assessment, dated 7/13/25, indicated the resident was severely cognitively impaired, had wandering behaviors 1 to 3 days, and wandering placed her at significant risk of getting to a potentially dangerous place. A Progress Note, dated 7/14/25 at 10:50 a.m., indicated the resident was observed ambulating toward the exit and was redirected by staff. There was no documentation to indicate any new interventions were attempted for the wandering/exit-seeking behaviors on 7/14/25. A Care Plan, dated 7/15/25, indicated the resident was at risk for elopement and had a history of attempts to leave the facility unattended. The interventions included frequent monitoring and to distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or a book. A Physician Progress Note, dated 7/15/25 at 11:13 a.m., indicated the resident had advanced dementia and was a wanderer. The resident was not safe to return home, and family was making alternative plans. A Progress Note, dated 7/16/25 at 6:32 p.m., indicated the resident continued to exit-seek and her daughter was notified. There was no documentation to indicate any new interventions were attempted for the exit-seeking behaviors on 7/16/25. There was no documentation assessing the effectiveness of interventions put into place on the 7/15/25 care plan. A Physician's Order, dated 7/17/25, indicated to monitor the placement of wander guard (wearable device that alarms when exiting facility doors) to left ankle every shift for elopement risk. The Medication Administration Record, dated 7/2025, indicated the wander guard was monitored for placement every shift. A Physician Progress Note, dated 7/18/25 at 2:15 p.m., indicated the resident had advanced dementia, was a wanderer, and continued to exit-seek. There was no documentation from 7/18 - 7/27/25 indicating the effectiveness of current interventions for the exit-seeking behaviors or any new interventions implemented. A Progress Note, dated 7/27/25 at 9:00 p.m., indicated at approximately 8:45 p.m. the resident was no longer be sitting at the Nurse's Station where she was previously observed. A code was called, and a search of the entire facility was initiated including all indoor and exterior areas. Emergency Services was called at approximately 9:00 p.m. and the resident was located a few minutes later outside the facility by the local police. The resident was returned to the facility at 9:16 p.m. and placed on 1:1 care. An assessment was completed and there were no injuries noted. The resident's daughter and Physician were notified. An Indiana Department of Health Reportable Incident, dated 7/28/25, indicated on 7/27/25 at 8:35 p.m. Resident B stood up from the Nurse's Station where she had been sitting and walked to the front entrance of the facility and out the door. At 8:46 p.m. staff realized the resident was no longer sitting at the Nurse's Station and began searching for the resident in the immediate area. Staff was unable to find the resident and called a code orange (missing resident) alert. At 8:49 p.m. multiple staff members went outside the facility and searched the property and surrounding area but were unable to find the resident. At 9:00 p.m. staff called the Administrator, the resident's Physician, the resident's daughter, and Emergency Services, to report the resident missing. At 9:03 p.m. the local police department called the facility to notify them that the resident had been located down the street. The resident was returned to the facility at 9:16 p.m. by Emergency Services staff. During an interview on 7/30/25 at 9:55 a.m., LPN 1 indicated she was working the night of 7/27/25. She was passing medications, and the CNAs were doing rounds. The resident was seated at the Nurse's Station and the next time she looked; the resident was gone. Staff were unable to locate the resident and LPN 1 called a code orange. Staff searched the entire building and outside the facility and were unable to find the resident. LPN 1 then called Emergency Services. While on the phone with Emergency Services they indicated the resident had already been found across the street. EMTs (Emergency Medical Technicians) were called to assess the resident and there were no injuries. The Police returned the resident to the facility, and she was put on 1:1 care. The resident had a history of exit seeking and did have a wander guard in place. LPN 1 had not heard the wander guard sound when the resident left the building nor when the Police had brought her back in the building. During an interview on 7/30/25 at 10:15 a.m., the Administrator indicated the resident did have a wander guard in place on 7/27/25 and it was functioning. The wander guard alarm sound was the same sound as a call light going off. Staff would have to look at the call light box at the Nurse's Station to see that the wander guard was alarming. If staff were on the floor doing care they would not have seen the box to know wander guard alarm was going off. The resident was observed on the facility camera walking from the Nurse's Station to the front entrance of the facility and exiting the main entrance at 8:35 p.m. At 8:46 p.m. staff realized the resident was no longer sitting at the Nurse's Station and began searching for the resident. They were unable to locate the resident and called Emergency Services. The resident was found across the street near where the bridge begins to go uphill and was brought back to the facility by Emergency Services. Upon admission to the facility, the resident wanted to go home but she was not exit seeking. She had multiple episodes of exit seeking on 7/12/25 and staff were educated to keep the resident in their view. An elopement drill was completed with the resident on 7/16/25. She had never previously gone out of the facility unattended. The resident was reviewed for exit seeking behaviors in the At Risk Meeting on 7/17/25 and the wander guard was put in place at that time. During an interview on 7/30/25 at 10:32 a.m., LPN 2 indicated she was working the night of 7/27/25. She had received notice of a code orange and assisted with searching for the resident in the facility going room to room. She then searched the back parking lot and grass areas outside the facility but could not locate the resident. During an interview on 7/30/25 at 11:00 a.m., CNA 1 indicated she was working the night of 7/27/25. Around 8:30 p.m. to 8:45 p.m. she was doing rounds, and the resident had been sitting at the table at the Nurse's Station. She came out of a resident room and noticed the resident was no longer sitting there. She immediately started looking for the resident but was unable to find her. She reported this to LPN 1 who called a code orange. On 7/30/25 at 11:30 a.m., the pathway from the front door to the approximate area, across the street, where the resident was found, was walked. Once across the street, there was a sidewalk that led uphill toward an overpass bridge. The distance was measured with a sports watch and registered at 0.15 mile. The road had four lanes and there were multiple cars observed driving on the road. During an interview on 7/30/25 at 11:47 a.m., CNA 2 indicated she was working the night of 7/27/25. She had been doing her rounds and answering call lights. She noticed the resident was no longer sitting at the table where she had been and the CNAs started looking for her. They were unable to locate her and notified the nurse who called a code orange. They searched outside the building but could not find the resident. She got in her car to continue searching and saw an ambulance with its lights on across the street towards the top of the bridge. It was dark outside, and the resident was on the sidewalk. She had already been found by Emergency Services. The facility elopement policy, updated 11/2024 and received from the Administrator as current, indicated The facility wishes to ensure the safety of those residents who have been identified as being at risk for elopement. It is the policy of this facility to identify those residents at risk for elopement and take precautions to ensure their safety and well-being. The past noncompliance immediate jeopardy began on 7/27/25. The immediate jeopardy was removed on 7/30/25 and the deficient practice corrected by 7/28/25 after the facility implemented a systemic plan that included the following: staff members were inserviced on residents at risk for elopement, elopement, and the elopement policy and procedures, further elopement drills were conducted, the exit doors were all tested and the service company changed the exit door alarm sounds. Staff were interviewed and indicated residents who exhibited signs of possible elopement would be reported to the Charge Nurse, DON, and Administrator. Care Plans would be implemented and interventions followed. If a resident was unable to be found, a code orange would be called and an immediate search of the building and surrounding area would be completed. The Administrator would be notified immediately and Emergency Services would be contacted. The facility will continue to inservice all new staff and remaining staff who have not yet been educated prior to working. An audit was initiated for all residents in the facility and elopement risk assessments were updated. Care plans of all residents who were identified as at risk were reviewed and revised as needed. All exit doors were checked for proper functioning. Wander guard bracelets were checked every shift for placement and the wander guard alarm system was updated. This citation relates to Complaint 2573709. 3.1-45 (a)(2)

Based on observation, record review and interview, the facility failed to ensure oxygen was available on the crash cart (mobile unit with life-saving equipment used in medical emergencies) for 1 of 2 crash carts reviewed. (A Wing) Finding includes:On 7/31/25 at 1:25 p.m., the A wing crash cart near Room A160 was observed with the A Wing Unit Manager. The oxygen tank on the cart were empty. During an interview at that time, the A Wing Unit Manager indicated the oxygen tank was empty and she would replace it. She was unsure how often the oxygen tank level was checked but the crash cart supplies were checked daily. During an interview on 7/31/25 at 2:08 p.m., the Director of Nursing (DON) indicated the crash cart oxygen should be checked daily. A facility policy, titled Oxygen Storage and received from the DON as current, indicated, .Check oxygen nightly on crash cart. This citation relates to Complaint 2573709. 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure treatment orders were updated and completed as ordered for 1 of 3 residents reviewed for non-pressure related skin conditions. (Resident H) Finding includes: Resident H's record was reviewed on 7/31/25 at 11:17 a.m. Diagnoses included, but were not limited to, orthopedic aftercare following surgical amputation, chronic osteomyelitis (bone infection) of the right ankle and foot, cellulitis (skin infection) of the left and right lower limb, and type 2 diabetes mellitus. The admission Minimum Data Set (MDS) assessment, dated 6/27/25, indicated the resident was cognitively intact for daily decision making and had 1 unstageable pressure injury. A Care Plan, dated 6/20/25, indicated the resident had actual impairment to the skin integrity. Interventions included, but were not limited to, evaluate and treat per physician order and wound consult as needed. A Physician's Order, dated 6/21/25, indicated cleanse the second toe on the right foot with normal saline, pat dry, apply Xeroform (fine mesh gauze occlusive dressing), wrap with Kerlix (medical gauze), and secure with tape, Monday, Wednesday, Friday, and as needed. A Physician's Order, dated 6/21/25, indicated cleanse the fourth toe on the right foot with normal saline, pat dry, apply Xeroform, wrap with Kerlix, and secure with tape Monday, Wednesday, Friday, and as needed. A Physician's Order, dated 6/20/25, indicated cleanse the right lateral foot with normal saline, apply skin prep and leave open to area every day and as needed. A Physician's Order, dated 6/21/25, indicated cleanse the right medial foot with normal saline, pat dry, apply Xeroform, wrap with Kerlix, and secure with tape Monday, Wednesday, Friday, and as needed. The July 2025 Medication and Treatment Administration Record indicated the orders for wound care were administered as ordered by the physician. An After Visit Summary, dated 7/2/25, indicated, Instructions - Have the facility change dressings to all open wounds. On open wounds apply Iodosorb followed by xeroform, gauze roll, and tap. Apply betadine to deep tissue injuries/eschar. A Progress Note, dated 7/2/25 at 4:34 p.m., indicated the resident returned from a podiatry appointment with new orders for for iodosorb (gel for wound treatment) followed by adaptive dressing and rolled gauze and to apply betadine to deep tissue injury. An After Visit Summary, dated 7/11/25, indicated, Wound Care Discharge Instructions .Dressing Change Instructions: Have nurse at facility change dressings every 2-3 days. Keep clean and dry. Right lateral foot - apply betadine to deep tissue injuries followed by ABD and gauze roll. All other wounds to bilateral feet - apply xeroform, ABD, and gauze roll . A Progress Note, dated 7/11/25 at 12:00 p.m., indicated the resident returned from a wound care appointment with new orders for wound care nurse to change dressing every 2-3 days. The right lateral foot wound care order was to apply betadine to the deep tissue injury followed by abdominal (ABD) gauze pad and gauze roll. All other wounds to the bilateral feet were to apply Xeroform, ABD, and gauze roll. The Physician's Orders and Medication Administration Record for July 2025 indicated the wound care orders were not updated and implemented after the 7/2 and 7/11/25 wound care visits. During an interview on 7/31/25 at 4:10 p.m., the Wound Care Nurse indicated she had put in the progress notes for the order updates and did not update on the Physician Order Summary. This citation relates to Complaint 2573709. 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure G-tube (gastrostomy tube, a tube inserted directly into the stomach) placement and/or residual was checked prior to instilling a bolus feeding as well as flushing the tube after the feeding had infused. The facility also failed to ensure the amount of G-tube residual was documented for 3 of 3 residents reviewed for tube feeding. (Residents D, C and E) Findings include: 1. On 6/5/25 at 1:12 p.m., LPN 2 was observed washing her hands and donning a gown and gloves prior to entering Resident D's room. The LPN was going to administer the resident's bolus (a G-tube feeding given in a short amount of time) tube feeding. The LPN poured 300 milliliters (ml) of Osmolite into a plastic cylinder, explained to the resident what she was going to do, and then connected a plastic syringe to the G-tube port. At that time, the LPN indicated that she had checked the G-tube for placement and residual (the amount of fluid or formula remaining in the stomach after a tube feeding) that morning. The LPN proceeded to instill the feeding via gravity. After the bolus feeding was completed, the LPN removed the syringe from the port and she rinsed the syringe and cylinder with water prior to leaving the room. The LPN did not flush the resident's G-tube with water after the feeding was completed. The record for Resident D was reviewed on 6/5/25 at 1:42 p.m. Diagnoses included, but were not limited to, gastrostomy status, dysphagia (difficulty swallowing), and protein calorie malnutrition. The 5 day Medicare Minimum Data Set (MDS) assessment, dated 5/28/25, indicated the resident was cognitively intact and had a feeding tube. A Care Plan, dated 5/24/25, indicated the resident required enteral (nutrition through a feeding tube) nutrition. Interventions included, but were not limited to, check for tube placement and gastric contents/residual volume per facility protocol and record. Hold per physician's orders. A Physician's Order, dated 4/4/25 and listed as current on the June 2025 Physician's Order Summary (POS), indicated the feeding tube was to be checked for placement and patency every shift for monitoring. Check enteral feeding tube placement and patency prior to each use per guidelines. A Physician's Order, dated 5/27/25, indicated the resident's feeding tube was to be flushed with 225 ml of water every 6 hours at 12:00 a.m., 6:00 a.m., 12:00 p.m., and 6:00 p.m. A Physician's Order, dated 5/29/25, indicated the resident was to receive 300 ml of Osmolite tube feeding four times a day at 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m. During an interview on 6/5/25 at 2:33 p.m., the Director of Nursing (DON) indicated the resident's G-tube should have been checked for placement and/or residual prior to giving the bolus tube feeding. He also indicated the nurses at times will just check once a shift and think that is okay, but most staff are used to using a tube feeding pump rather than administering the feeding as a bolus. The DON indicated he would check with the dietitian about adjusting the tube feeding flush order. 2. Resident C's record was reviewed on 6/5/25 at 9:18 a.m. The diagnoses included, but were not limited to, respiratory failure with hypoxia, stroke, dysphagia (difficulty swallowing), diabetes, COPD, and dementia. A Care Plan, dated 4/16/25, indicated the resident required enteral nutrition. Interventions included, but were not limited to, check tube placement and gastric contents/residual volume per facility protocol and record, listen to lung sounds as ordered, and provide local care to the G tube site. A Physician's Order, dated 4/16/25, indicated to administer enteral tube feeding continuously and check residual every shift and the nurse was to record the amount. If residual was greater than 100 ml, stop tube feeding and restart in 1 hour. The Medicare 5-day Minimum Data Set assessment, dated 4/20/25, indicated the resident was severely impaired for daily decision making, had a feeding tube and impairment on both sides of the upper extremities. The resident was dependant with all activities of daily living (ADLs), bed mobility and transfers. The April 2025 Medication Administration Record (MAR) indicated tube feeding residual was not recorded on the following dates: 4/16/25 4/17/25 4/18/25 4/19/25 During an interview on 6/5/25 at 2:22 p.m., The DON indicated he understood the concern and had no further information to provide. There was no place on the April 2025 MAR to document residual. 3. On 6/5/25 at 12:35 p.m., Nurse 1 was observed preparing Resident E's bolus feeding. She had donned gown and gloves appropriately and the bolus feed was measured to 175 milliliters (ml). Nurse 1 lifted the resident's shirt and attached the piston syringe to the G tube port and began the bolus feed by gravity. The resident indicated he felt full after he had received 125 ml and requested the feeding be stopped. The Resident then received his 150 ml flush with no complaints. Placement was not verified, and residual was not checked prior to the bolus feeding. During an interview on 6/5/25 at 12:50 p.m., Nurse 1 indicated she did not verify placement or residual. The policy states to check placement as needed. The record for Resident E was reviewed on 6/5/25 at 2:33 p.m. The diagnoses included, but were not limited to, respiratory failure, adult failure to thrive, gastrostomy status, anxiety, high blood pressure, dysphagia (difficulty swallowing), and anemia. A Care Plan, dated 5/1/25, indicated the resident required enteral nutrition. Interventions included, but were not limited to, check tube placement and gastric contents/residual volume per facility protocol and record, listen to lung sounds as ordered, and provide local care to the G tube site. A Physician's order, dated 5/1/25, indicated the resident's diet was nothing by mouth (NPO). The resident may have water or ice chips with no straw. The admission Minimum Data Set (MDS) assessment, dated 5/7/25, indicated the resident was cognitively intact for daily decision making. The resident had impairment on both sides of the upper extremities. The resident was dependent on oral hygiene. Toileting needed supervision or touching assistance. Shower/bathing and upper body dressing needed partial/moderate assistance. Lower body dressing and personal hygiene required dependent assistance. Bed mobility and transfers required supervision or touching assistance. The resident had a feeding tube. A Physician's Order, dated 5/21/25, indicated to administer 175 ml bolus feed of Jevity 1.5 per tube feeding 5 times a day. During an interview on 6/5/25 at 2:33 p.m., the Director of Nursing indicated the resident's G-tube should have been checked for placement and/or residual prior to giving the bolus tube feeding. He also indicated staff would be re-educated on tube feeding policy regarding placement verification and checking for residuals. A policy titled Tube Feeding , received as current by the Director if Nursing on 6/5/25 at 9:15 a.m., indicated the following for bolus tube feeding, .3. Check tube replacement by aspiration or air insertion . 5. Flush tube with amount of water ordered at end of tube feeding . This citation relates to Complaint IN00459895. 3.1-44(a)(2)

Based on observation, record review, and interview, the facility failed to keep the kitchen clean and in good repair related to food not labeled and dated for 1 of 1 kitchen. This had the potential to affect 86 residents who resided in the facility and received food from the kitchen. (The Main Kitchen) Findings include: During the Initial Kitchen Sanitation Tour on 4/21/25 at 9:17 a.m. with the Kitchen Manager, the following was observed: 1. In the dry storage room, there was a large unlabeled storage bin containing a white powder and an unlabeled container partially filled with yellow liquid. 2. In the walk-in cooler, there was a partially full, unlabeled squeeze bottle containing a red/brown substance. There was an uncovered bucket filled with cut-up potatoes and water. There were trays of desserts in a rack that were uncovered and unlabeled. 3. In the walk-in freezer, there was an open, unlabeled bag of fish patties and an open, unlabeled bag of corn. 4. In the food prep area, there was a large plastic bin and a smaller plastic container filled with a white powder. Both were unlabeled. During an interview on 4/21/25 at 9:20 a.m., the Kitchen Manager indicated all food items should have been labeled and dated when opened and the uncovered items should have had lids on them. A policy titled Labeling and Dating Foods, received as current from the Kitchen Manager on 4/24/25 at 8:28 a.m. indicated, . Packaged or containerized bulk food may be removed from the original package and stored in an ingredient bin labeled with the common name of the food, the date the item was opened and the date by which the item should be discarded or used by . A policy titled Storage of Dry Goods/Foods, received as current from the Kitchen Manager on 4/24/25 at 8:28 a.m. indicated, . Opened products are labeled, dated with the use by date and tightly covered to protect against contamination including from insects and rodents . A policy titled Labeling and Dating Foods--Refrigerated Food, received as current from the Kitchen Manager on 4/24/25 at 8:28 a.m. indicated, . If opened, the cold food item is labeled with the date opened and the date by which to discard or use by . 3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to ensure bruises were assessed and monitored for 2 of 2 residents reviewed for non-pressure related skin conditions, signs and symptoms of constipation were monitored for 1 of 1 resident reviewed for constipation, edema was monitored and assessed for 1 of 3 residents reviewed for edema and medications were held per blood pressure parameters for 1 of 5 residents reviewed for unnecessary medications. (Residents 91, 255, 60, 27, and 264) Findings include: 1. During a random observation on 4/22/25 at 10:14 a.m., an area of reddish/purple discoloration was noticed on Resident 91's left forearm. The record for Resident 91 was reviewed on 4/23/25 at 12:17 p.m. Diagnoses included, but were not limited to, type 2 diabetes, severe sepsis with septic shock, and atherosclerotic heart disease. The Admission Minimum Data Set (MDS) assessment, dated 3/28/25, indicated the resident was cognitively intact and he was receiving an anticoagulant (blood thinner). A Care Plan, dated 3/21/25, indicated the resident was receiving anticoagulant therapy. Interventions included, but were not limited to, monitor/document/report as needed (PRN) adverse reactions of anticoagulant therapy such as bruising. Physician's Orders, dated 3/21/25, indicated the resident was receiving Plavix (an antiplatelet) 75 milligrams (mg) by mouth at bedtime and Aspirin 81 mg by mouth daily. A Physician's Order, dated 3/24/25, indicated the resident was receiving Enoxaparin Sodium Solution (a blood thinner) 40 mg/0.4 milliliters (ml), inject 40 mg subcutaneously one time a day to prevent blood clotting for 30 days. The Daily Skilled Nursing Evaluation, dated 4/23/25, indicated there was no documentation related to new and/or existing skin conditions. During an interview on 4/24/25 at 2:04 p.m., the Embers Unit Manager was informed of the discoloration. She indicated documentation should have been completed related to the discoloration. 2. The record for Resident 255 was reviewed on 4/23/25 at 10:21 a.m. Diagnoses included, but were not limited to, orthopedic aftercare following a surgical amputation and osteomyelitis (a bone infection) of the left ankle and foot. The Medicare 5 day Minimum Data Set (MDS) assessment, dated 4/16/25, was in progress and indicated the resident was cognitively intact. A Physician's Order, dated 4/16/25, indicated the resident was to receive Hydrocodone-Acetaminophen Tablet (an opioid pain medication) 5-325 milligrams (mg), give 1 tablet every 6 hours as needed for pain. The April 2025 Medication Administration Record (MAR) indicated the resident received the Hydrocodone-Acetaminophen on 4/16/25 at 5:44 p.m., 4/17/25 at 12:34 p.m., 4/19/25 at 6:03 p.m., and 4/20/25 at 3:22 a.m. The Bowel Elimination Flow Sheet located in the Task section of the electronic medical record indicated the resident did not have a bowel movement on 4/17/25, 4/18/25, and 4/19/25. There was no documentation on 4/20/25. A Nurse's Note, dated 4/20/25 at 9:07 p.m., indicated during shift report the oncoming nurse was told the resident had vomited twice. The resident vomited again right after shift change and the Nurse Practitioner (NP) was notified. An order was received for Zofran (a medication to prevent nausea and vomiting) 4 mg every 6 hours as needed. The first dose was given at 8:00 p.m. Since the first dose was given, the resident continued to vomit and the NP was notified. A Physician's Order, dated 4/20/25, indicated the resident was to have a KUB (kidney, ureter, and bladder x-ray). Physician's Orders, dated 4/21/25, indicated the resident was to receive Docusate Sodium (a stool softener) 100 mg, 1 capsule two times a day for constipation for 30 days, Lactulose (a laxative) oral solution 20 grams/30 ml, give 30 ml every 24 hours as needed for constipation for 30 days, and Glycolax Powder (a laxative) 17 gram scoop, give 17 grams as needed for constipation for 30 days, give 17 grams mixed with 8 ounces of fluid twice daily as needed. The April 2025 MAR indicated the resident received the Docusate Sodium on 4/21/25 at 5:00 p.m. and 4/22/25 at 9:00 a.m. The resident had not received the Lactulose or the Glycolax Powder. A Care Plan was initiated on 4/21/25 related to the resident receiving opioid medications. The Bowel Elimination Flow Sheet indicated the resident had a large bowel movement on 4/21/25. A Nurse's Note, dated 4/22/25 at 2:08 p.m., indicated the resident's KUB showed a mild adynamic ileus (a condition where the bowel's movement is slowed or stopped due to a lack of coordinated muscle activity) in the right mid abdomen with no bowel obstruction. The resident continued with nausea and vomiting and abdominal pain. The resident would be sent to the emergency room for evaluation. During an interview on 4/25/25 at 11:00 a.m., the Director of Nursing and the Nurse Consultant indicated they would follow up on the issue with the resident's constipation. During an interview on 4/25/25 at 11:15 a.m., the C Wing Unit Manager indicated the resident did have a bowel movement on 4/20/25 but it was not documented. The current facility Bowel Protocol policy was provided by the Director of Nursing on 4/29/25 at 4:25 p.m. The policy indicated the resident's drug regimen would be evaluated to identify possible constipating medications and per the bowel protocol, if the resident had no bowel movement or only small documented bowel movements for days outside of the baseline, the provider would determine if additional testing and/or medications were warranted. 32788 3. On 4/22/25 at 9:18 a.m., Resident 60's right hand was observed to be slightly swollen and there was a compression glove on her bedside table. The resident indicated she wore the compression glove on her right hand, but only at night. On 4/22/25 at 2:26 p.m., Resident 60 was observed with the compression glove in place to her right hand. Record review for Resident 60 was completed on 4/23/25 at 11:33 a.m. Diagnoses included, but were not limited to, hypertension, end stage renal disease, and type 2 diabetes mellitus. The Admission Minimum Data Set (MDS) assessment, dated 2/23/25, indicated the resident was moderately cognitively impaired. A Care Plan, dated 3/10/25, indicated the resident had renal insufficiency. The interventions included to elevate feet to help prevent dependent edema and to monitor for signs of hypervolemia (fluid overload) such as dependent edema. There was no specific care plan or interventions related to the right hand edema or the compression glove use. A Physician's Order, dated 3/21/25, indicated to remove the right hand glove to assess the skin every morning for skin breakdown and to document any abnormalities or skin issues. There were no directions on when to apply the compression glove or how long the resident was to wear the glove each day. The Medication Administration (MAR) and Treatment Administration (TAR) Records, dated 4/2025, indicated the compression glove had been removed daily at 9 a.m. The skin was monitored and either a + or - sign was documented. A - sign was documented on 4/1, 4/3, 4/5, 4/6, 4/7, 4/8, 4/11, 4/13, 4/14, 4/15, 4/16, 4/17, 4/19, 4/20, and 4/22/25. A + sign was documented on 4/2, 4/4, 4/9, 4/10, 4/12, 4/18, 4/21, and 4/23/25. There was no definition or key to indicate what the + or - sign meant. During an interview on 4/24/25 at 1:53 p.m., the Director of Nursing indicated he had clarified the compression glove order so it would be less confusing. 4. Resident 27's record was reviewed on 4/23/25 at 4:29 p.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, hypertension, and atrial fibrillation. The Admission Minimum Data Set (MDS) assessment, dated 2/16/25, indicated the resident was cognitively intact. A Care Plan, dated 2/11/25, indicated the resident had an altered cardiovascular status related to atrial fibrillation, coronary artery disease, heart failure, hypertension, and hyperlipidemia. A Physician's Order, dated 2/15/25, indicated hydralazine (a medication used to lower blood pressure) 100 mg (milligrams) three times a day, hold if systolic blood pressure (top number of blood pressure reading) is less than 120. A Physician's Order, dated 2/15/25, indicated Entresto (sacubitril-valsartan, a medication used to treat heart failure that can lower blood pressure) 97-103 mg every morning and at bedtime, hold if systolic blood pressure is less than 120. The Medication Administration Record (MAR), dated 4/2025, indicated the hydralazine was not held per the Physician's Order on the following dates and times: - 4/1/25 at 2:00 p.m., blood pressure 112/63 and 10:00 p.m., blood pressure 112/69 - 4/2/25 at 2:00 p.m., blood pressure 116/63 - 4/3/25 at 6:00 a.m., blood pressure 112/68 - 4/10/25 at 2:00 p.m., blood pressure 115/64 - 4/16/25 at 2:00 p.m., blood pressure 117/63 - 4/17/25 at 2:00 p.m., blood pressure 118/72 - 4/18/25 at 2:00 p.m., blood pressure 118/58 - 4/19/25 at 2:00 p.m., blood pressure 113/65 The MAR, dated 4/2025, indicated the Entresto was not held per the Physician's Order on the following dates and times: - 4/1/25 at 8:00 a.m., blood pressure 112/61 and 8:00 p.m., blood pressure 112/69 - 4/2/25 at 8:00 a.m., blood pressure 116/63 and 8:00 p.m., blood pressure 116/63 - 4/3/25 at 8:00 a.m., blood pressure 113/61 - 4/16/25 at 8:00 a.m., blood pressure 117/63 - 4/18/25 at 8:00 a.m., blood pressure 115/62 - 4/19/25 at 8:00 a.m., blood pressure 113/65 During an interview on 4/25/25 at 12:44 p.m., the Director of Nursing indicated the medications had been given outside the blood pressure parameters. 43293 5. During random observations on 4/22/25 at 9:31 a.m., 4/23/25 at 10:21 a.m., and 4/24/25 at 10:05 a.m., Resident 264 was observed resting in bed. There were purple bruises on the back of both of his hands, and on his right arm. The resident's record was reviewed on 4/23/25 at 10:58 a.m. Diagnoses included, but were not limited to, CHF (congestive heart failure) and diabetes. The 4/12/25 Admission MDS (Minimum Data Set) assessment, indicated the resident had mild cognitive impairment and was dependent in activities of daily living and transfers. A Care Plan, dated 3/24/25, indicated the resident was at risk for adverse reactions related to anticoagulant (blood thinner) therapy. Interventions included monitoring, documenting, and reporting bruising. There was no documentation of an assessment of the bruises. During an interview on 4/24/25 at 10:05 a.m., LPN 3 indicated the bruises were from lab blood draws. The left hand bruise had been present since his last hospitalization , but it was improving. She indicated the bruising should have been monitored and documented in the record. A policy titled, Bruise Identification Monitoring--Indiana, received as current from the Director of Nursing on 4/24/25 at 11:19 a.m., indicated . The staff nurse will obtain a physician order to monitor the new bruise daily until resolved. This monitoring will be recorded on the MAR [medication administration record] or TAR [treatment administration record] . 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure residents who were left to complete nebulizer treatments independently had been assessed for safe self-administration for 1 of 4 residents reviewed for respiratory services. (Resident 29) Finding includes: During a random observation on 4/21/25 at 11:40 a.m., Resident 29 was observed sitting alone in his room. A nebulizer treatment was in progress via a face mask. He removed the face mask and put it in the drawer of his nightstand. At that time, the resident indicated the staff did not stay in the room while he received the nebulizer treatments. They would initiate the treatment, and when he thought it was done, he would remove the mask and put it in his drawer. The resident's record was reviewed on 4/23/25 at 2:57 p.m. Diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease), chronic respiratory failure with hypoxia (low oxygen levels), and dementia. The 4/10/25 Quarterly MDS (Minimum Data Set) assessment, indicated the resident had moderate cognitive impairment, and required partial/moderate assistance with activities of daily living and transfers. The 1/27/25 Self Administration Assessment did not indicate the resident was safe to self-administer nebulizer treatments. There was no physician's order for the resident to self-administer nebulizer treatments. During an interview on 4/24/25 at 11:57 a.m., the DON (Director of Nursing) indicated the resident had not been evaluated for self-administration of nebulizers. A policy titled Self Administration of Medications and Treatments, received as current from the DON on 4/28/25 at 3:31 p.m. indicated, . Self administration of medications and treatments is determined by physician order after determining that the resident is able to self administer . 3.1-11(a)

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed related to terminal prognosis and hospice care for 1 of 27 MDS assessments reviewed. (Resident 44) Finding includes: Resident 44's record was reviewed on 4/28/25 at 10:05 a.m. Diagnoses included, but were not limited to, hypertension, atrial fibrillation, and Alzheimer's disease. The Quarterly MDS assessment, dated 4/9/25, indicated the resident had not received hospice care and did not have a condition or chronic disease that may result in a life expectancy of less than six months. A Physician's Order, dated 10/4/24, indicated the resident was admitted to hospice services. A Care Plan, dated 2/21/25, indicated the resident had a terminal end stage prognosis and was receiving hospice services. The Hospice Certification, dated 2/26/25, indicated the resident was terminally ill with a life expectancy of six months or less. During an interview on 4/28/25 at 3:14 p.m., MDS Nurse 1 and MDS Nurse 2 indicated the resident was receiving hospice care and had a terminal prognosis. They would modify the MDS assessment. 3.1-31(i)

Based on observation, record review, and interview, the facility failed to ensure professional standards of quality were maintained related to a CNA placing a tube feeding pump on hold for 1 of 2 residents reviewed for tube feeding. (Resident 73) Finding includes: During a random observation on 4/23/25 at 3:34 p.m., Resident 73 was observed in her room in bed. The head of the bed was elevated and the resident's tube feeding was infusing at 50 cubic centimeters (cc's). CNA 1 proceeded to enter the resident's room to perform incontinence care. Prior to lowering the head of the bed, the CNA placed the tube feeding pump on hold. After incontinence care was completed, the CNA had a nurse resume the tube feeding. The record for Resident 73 was reviewed on 4/25/25 at 2:10 p.m. Diagnoses included, but were not limited to, gastrostomy (a feeding tube placed through the abdomen and into the stomach to deliver nutrition, fluids, or medications), adult failure to thrive, and dysphagia (difficulty swallowing). The Admission Minimum Data Set (MDS) assessment, dated 2/24/25, indicated the resident had short and long term memory problems and was severely impaired for daily decision making. The resident was receiving the majority of her nutrition through a feeding tube. The Indiana State Department of Health Nurse Aide Curriculum states, . The resident with a feeding infusing should not lie flat . If the bed must be flattened, seek the nurse ' s assistance to turn off the pump prior to the procedure and turn the pump back on after the procedure During an interview on 4/23/25 at 4:08 p.m., the Nurse Consultant indicated it was not within the CNA's scope of practice to put the tube feeding pump on hold and education would be provided. 3.1-35(g)(1)

Based on record review and interview, the facility failed to assist a resident to see an eye doctor for 1 of 1 resident reviewed for vision. (Resident 29) Finding includes: During an interview on 4/21/25 at 11:33 a.m., Resident 29 indicated he could not see with the glasses he had and he had not been evaluated by an eye doctor since before his admission to the facility on [DATE]. During an interview on 4/23/25 at 2:00 p.m., the resident's daughter indicated she had asked Social Worker 1 about setting up an eye doctor appointment for the resident, and he indicated seeing the eye doctor was not part of his care at the facility and they could not make arrangements for him. The resident's record was reviewed on 4/23/25 at 2:57 p.m. Diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease), chronic respiratory failure with hypoxia (low oxygen levels), and dementia. The 4/10/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident had moderate cognitive impairment, and required partial/moderate assistance with activities of daily living and transfers. There was no documentation of vision/eye care for the resident. During an interview on 4/24/25 at 11:08 a.m., the Director of Social Services indicated the resident should be able to see an eye doctor if needed and they would help make those arrangements. 3.1-39(a)(1) 3.1-39(a)(2)

Based on observation, record review and interview, the facility failed to ensure G-tube (gastrostomy tube, a tube inserted directly into the stomach) flushes were instilled via gravity for 1 of 6 residents observed for medication administration. (Resident 202) Finding includes: On 4/24/25 at 1:04 p.m., LPN 2 was observed preparing Resident 202's medications. She crushed each pill and placed it in a separate cup. She entered the resident's room, put the tube feeding on hold, and poured 30 cubic centimeters (cc) of water into a medication cup. She inserted the G-tube syringe into the medication cup and drew up the 30 cc of water. She opened the G-tube and placed the syringe directly into the tube and pushed the 30 cc of water down the tube using the plunger. She diluted each of the medications in 5 cc of water and administered the medications and remaining flushes by gravity. During an interview on 4/24/25 at 1:30 p.m., LPN 2 indicated she should have administered the G-tube flush by gravity. During an interview on 4/24/25 at 1:53 p.m., the Director of Nursing was made aware the G-tube flush had not been administered by gravity. The G-tube medication administration policy was requested. A current facility policy, titled Medication Administration Enteral Tubes, indicated, .9. Remove plunger from syringe and insert syringe into tubing. 10. Flush with water .b. Allow medication to flow down tube via gravity . 3.1-44(a)(2)

Based on observation, record review and interview, the facility failed to ensure residents received the necessary care and treatment related to oxygen administration for 1 of 4 residents reviewed for respiratory care. (Resident 60) Finding includes: On 4/22/25 at 9:18 a.m., Resident 60 was observed with oxygen in place via nasal cannula. The flow rate was set at 1.5 liters. The resident indicated she used oxygen and it was usually set at 2 liters. On 4/22/25 at 2:26 p.m., Resident 60 was observed with oxygen in place via nasal cannula. The flow rate was set at 1.5 liters. Record review for Resident 60 was completed on 4/23/25 at 11:33 a.m. Diagnoses included, but were not limited to, hypertension, end stage renal disease, and type 2 diabetes mellitus. The Admission Minimum Data Set (MDS) assessment, dated 2/23/25, indicated the resident was moderately cognitively impaired and did not receive oxygen therapy. There was no current care plan related to oxygen use. The Physician's Order Summary, dated 4/2025, lacked any orders for oxygen. During an interview on 4/24/25 at 11:58 a.m., the Director of Nursing indicated he was unable to find any current orders for oxygen. A facility policy, titled Oxygen, indicated, 1. Residents who are admitted on oxygen or isolation precautions will have orders recorded in the resident's chart. The oxygen will be administered by the route and liter flow ordered by the physician . 3.1-47(a)(6)

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% for 1 of 6 residents observed during medication administration. Two medication errors were observed during 26 opportunities for error in medication administration. This resulted in a medication error rate of 7.69%. (Resident 66) Finding includes: On 4/24/25 at 9:30 a.m., LPN 1 was observed preparing Resident 66's medications, which included Lantus (insulin glargine, long-acting insulin). LPN 1 removed the resident's insulin pen from the medication cart and donned a gown and gloves. She entered the room, cleaned the top of the insulin pen with an alcohol swab, and put the needle on the pen. She dialed the Lantus insulin pen to 20 units and administered the injection to the resident's left abdomen. She had not primed the insulin pen prior to administering the injection. She then removed her gown and gloves, washed her hands, and disposed of the needle in the sharps container. The record for Resident 66 was reviewed on 4/23/25 at 2:33 p.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus. The Physician's Order Summary, dated 4/2025, indicated Lantus 18 units subcutaneously in the morning. During an interview on 4/24/25 at 9:55 a.m., LPN 1 indicated she had not primed the insulin pen prior to administering the injection. The insulin pens were primed when they were new and first opened. She had administered 20 units of insulin, and the resident was supposed to receive 18 units. During an interview on 4/24/25 at 10:44 a.m., the Director of Nursing was made aware of the medication errors. The insulin administration policy was requested. A facility policy, titled Insulin Administration Procedure, indicated, .Insulin Pens: .8. Turn the dose selector to 2 units. Hold the pen with the needle pointing up, and tap the cartridge gently a few times. This moves the air bubbles to the top. 9. Press the push button all the way in until the dose selector is back to a 0. A drop of insulin should appear at the tip of the needle. This will ensure proper dosing and avoid injecting air onto the patient .12. Turn the dose selector to the number of units needed to inject. The pointer should line up with the correct dose . 3.1-48(c)(1)

Based on observation, record review, and interview, the facility failed to ensure a comprehensive care plan was developed and in place for edema, compression glove use, and oxygen for 1 of 27 resident care plans reviewed. (Resident 60) Finding includes: On 4/22/25 at 9:18 a.m., Resident 60 was observed with oxygen in place via nasal cannula. The flow rate was set at 1.5 liters. Her right hand was slightly swollen and there was a compression glove on her bedside table. The resident indicated she used oxygen and it was usually at 2 liters. She wore the compression glove on her right hand, but only at night. Record review for Resident 60 was completed on 4/23/25 at 11:33 a.m. Diagnoses included, but were not limited to, hypertension, end stage renal disease, and type 2 diabetes mellitus. The Admission Minimum Data Set (MDS) assessment, dated 2/23/25, indicated the resident was moderately cognitively impaired and did not receive oxygen therapy. A Care Plan, dated 3/10/25, indicated the resident had renal insufficiency. The interventions included to elevate feet to help prevent dependent edema and to monitor for signs of hypervolemia (fluid overload) such as dependent edema. There was no specific care plan or interventions related to the right hand edema or the compression glove use. There was no current care plan related to oxygen use. During an interview on 4/24/25 at 1:53 p.m., the Director of Nursing was made aware of the lack of care plans. He indicated he would put in care plans for oxygen, edema, and compression glove use. 3.1-35(a)

Based on record review and interview, the facility failed to ensure the physician was notified of elevated blood sugars, blood pressure medications and insulin being held, and medication refusals for 3 of 3 residents reviewed for notification of change. (Residents 52, 154, and 264) Findings include: 1. The record for Resident 52 was reviewed on 4/24/25 at 3:03 p.m. Diagnoses included, but were not limited to, type 2 diabetes and end stage renal disease. The Admission Minimum Data Set (MDS) assessment, dated 3/2/25, indicated the resident was cognitively intact. A Physician's Order, dated 3/20/25, indicated the resident was to receive Lantus insulin, 25 units subcutaneously (injecting a medication into the fatty tissue layer beneath the skin) at bedtime. The Physician was to be notified if the resident's blood sugar level was less than 60 or greater than 400. The March 2025 Medication Administration Record (MAR) indicated the resident's blood sugar was 425 on 3/20/25 at 9:00 p.m. On 3/21/25 at 9:00 p.m., the resident's blood sugar was 433. There was no documentation indicating the physician and/or the nurse practitioner (NP) were notified of the blood sugars greater than 400. During an interview on 4/29/25 at 2:09 p.m., the Director of Nursing indicated the physician and/or the NP were not notified of the resident's blood sugars above 400 on 3/20/25 and 3/21/25. 2. The record for Resident 154 was reviewed on 4/23/25 at 11:34 a.m. Diagnoses included, but were not limited to, dementia with mood disturbance, type 2 diabetes, hypertension, and acute kidney failure. The Admission Minimum Data Set (MDS) assessment, dated 4/14/25, indicated the resident was moderately impaired for daily decision making. A Physician's Order, dated 4/12/25, indicated the resident was to receive Midodrine HCl (a medication used to treat low blood pressure) 5 milligrams (mg) by mouth three times a day for hypotension (low blood pressure). There were no blood pressure parameters indicating when the medication should be held. The April 2025 Medication Administration Record (MAR), indicated the resident's blood pressure was 132/79 on 4/19/25 at 9:00 a.m. and 145/69 at 5:00 p.m. The Midodrine was not given at 9:00 a.m. and 5:00 p.m. There was no documentation indicating the physician and/or the nurse practitioner (NP) were notified of the medication being held. During an interview on 4/24/25 at 12:00 p.m., the Director of Nursing indicated the physician and/or the NP should have been notified that the Midodrine was held. 43293 3. Resident 264's record was reviewed on 4/23/25 at 10:58 a.m. Diagnoses included, but were not limited to, CHF (congestive heart failure) and diabetes. The 4/12/25 Admission Minimum Data Set (MDS) assessment indicated the resident had mild cognitive impairment and was dependent for activities of daily living and transfers. A Physician's Order, dated 4/6/25, indicated Insulin Lispro (a fast-acting insulin) 18 units before meals. There were no parameters for holding the insulin. The April 2025 Medication Administration Record (MAR) indicated the resident refused the morning dose of insulin on 4/14/25. The nurse held the 4/16/25 evening insulin dose when the resident's blood sugar was 70. There was no documentation indicating the physician was informed of the insulin doses not given. During an interview on 4/25/25 at 1:00 p.m., the Director of Nursing indicated the staff should have informed the physician of the refused and held doses of insulin. 3.1-5(a)(3)

Based on record review and interview, the facility failed to communicate and obtain a Physician's Order for a resident's code status related to wanting to be a Do Not Resuscitate (DNR) status, which resulted in the unwanted initiation of CPR (Cardio [MEDICAL CONDITION] Resuscitation) to a resident who was found unresponsive, was subsequently revived and sent to the hospital on life support for 1 of 34 residents reviewed for advance directives. (Resident K) Finding includes: The Immediate Jeopardy began on [DATE] when Social Service Designee 1 was informed by the resident's responsible party of his wishes to be a DNR. The resident became unresponsive with no pulse on [DATE] at 12:15 p.m. CPR was initiated, the resident was revived and sent to the hospital, sustained a ruptured lung, and was placed on life support until family arrived and made the decision to discontinue support, resulting in delayed traumatic death of the resident. The Administrator, Assistant Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy at 5:22 p.m., on [DATE]. The Immediate Jeopardy was removed and the deficient practice corrected on [DATE], prior to the survey and was therefore Past Noncompliance. The closed record for Resident K was reviewed on [DATE] at 3:15 p.m. He was admitted on [DATE]. [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was severely cognitively impaired for decision making. A Physician's Order, dated [DATE], indicated the resident was a Full Code. A Social Service Progress Note, documented as a late entry on [DATE] at 12:14 p.m., effective on [DATE] at 11:58 a.m., indicated the resident wished to be a DNR. There was no documentation to indicate a Physician's Order was obtained to reflect the resident's wishes. A Nursing Progress note, dated [DATE] at 12:15 p.m., indicated the resident was resting with his eyes closed at the nurses' station table. Upon assessment he was found to be unresponsive. His vitals were taken, no pulse. AED (automated external defibrillator), CPR, and oxygen were initiated, and 911 was called. New orders were received to send the resident to the hospital. Interview with Social Service Designee 1 on [DATE] at 3:37 p.m., indicated he met with the resident and his responsible party on [DATE], during the interview the resident's code status was discussed, and it was his wishes to be a DNR. At the time of that interview, the resident's responsible party was not provided with Advance Directives to be signed. The information was communicated to a nurse on the unit, however, he could not recall which nurse he gave the information to. He indicated it was the nursing staff's responsibility to obtain signatures for the Advance Directive Notices and to obtain Physician's Orders to change residents' code status. Interview with the DON on [DATE] at 4:04 p.m., indicated at the time of the incident she was not aware of the resident's wishes to be a DNR. The Social Service Designee 1 was counseled on [DATE] related to the facility policy related to the Advance Directives procedures. Education was given to the Social Service Staff as well as the Nursing Leadership and nursing regarding code status procedures and a house wide audit was conducted to ensure all code status orders were accurate on [DATE]. Follow up interview with the DON and Administrator on [DATE] at 6:40 a.m., indicated the following system was put in place for all new admissions: On [DATE], a whole house audit was completed to compare social service documentation to code status orders and education was given to Social Service and Nursing Leadership regarding code status procedure. Education was provided to the nursing staff upon hire and again after the incident regarding code status procedure, including process for initiating code status upon admission. Unit Managers completed an informal inservice with the staff on their units on [DATE] after the occurrence. SS Designee 1 was independently counseled on [DATE]. All new admits would be reviewed weekly in the Resident At Risk meeting to ensure accuracy and monthly in QAA meetings. Interviews completed on [DATE] & [DATE] with all unit managers, SS staff, day shift and night shift nursing staff indicated knowledge of the correct procedures to follow and each departments involvement related to code status upon admission. Interview with the Social Service Director on [DATE] at 8:02 a.m., indicated for new admissions, related to code status, the resident's cognitive status was first assessed, if they indicated they wanted to be a DNR status, and were not fully alert, the family was then interviewed. If there was a Living Will or Power of Attorney (POA) documents available, they were to be added to the resident's medical record. For residents with a BIMS (Brief Interview for Mental Status) score of 12 or higher (indicating cognitively intact), the facility would follow the resident's wishes. She further indicated, SS was to communicate the DNR status to nursing, and it was the SS staff's responsibility to obtain the Advance Directive Notice and have the resident and/or the POA sign the form, then communicate the information to nursing to obtain a Physician's order for the DNR status. She also indicated in the PIC (Partners In Care) meetings after admission, they again review the resident's code status with the resident and the family. That was standard procedure. She has 2 SS Designees for which she now audits their work to ensure code status forms are signed by the resident and/or the family and to ensure nursing was informed of residents' wishes at the time of admission. Interview with Resident K's family member on [DATE] at 11:25 a.m., indicated they had met with Admissions on [DATE] to complete paperwork for admission and they told this person (staff name) the resident was a DNR and that person told them to bring the paperwork the next day. She also said her and her husband were under the impression the DNR paperwork just transferred with the resident from the hospital. When the facility first called her on [DATE], staff informed her they did CPR, but the resident passed away. When she called the facility back to clarify what they needed to do at that point, she was told they had gotten a faint pulse & the resident would be transferred to the hospital. She told them to stop because he was a DNR and the facility indicated they did not have that information. She then indicated when they arrived at the hospital, the resident was intubated with a tube in his mouth and he was on the ventilator. The Doctor indicated the resident had a tube in his nose that went directly into his stomach to prevent him from choking. The drainage was from that tube was red tinged. The Physician told her and her husband they popped his lung while doing CPR. The decision was then made to discontinue life support and he was pronounced dead at that point. The Past Noncompliance Immediate Jeopardy began on [DATE]. The Immediate Jeopardy was removed and corrected on [DATE] when the facility implemented a systemic plan which included the following: the facility completed audits of all SS documentation and Physician's orders regarding code status, reducated all SS and nursing staff regarding code status procedure, individually counseled the SS designee involved, put into place a weekly new admission meeting audit in regards to code status, and added code status monitoring to their facility Quality Assurance program. This Federal tag relates to Complaint IN 738. 3XXX,[DATE](A)(ii)

Based on record review and interview, the facility failed to notify the Physician of abnormal laboratory tests results in a timely manner for 2 of 3 residents reviewed for change of condition in a sample of 9. This resulted in a resident being hospitalized to be treated for [REDACTED]. (Residents #D and #G) Findings include: 1. The closed record for Resident #D was reviewed on 7/19/16 at 3:10 p.m. The resident's [DIAGNOSES REDACTED]. The 6/2016 Physician orders [REDACTED]. A physician's orders [REDACTED]. The most recent Basic Metabolic Panel noted in the resident's record was completed on 6/6/16. The results indicated the BUN (Blood Urea Nitrogen) level was 56 (normal BUN levels were noted to be 8-28). A BUN level repeated on 6/9/16 indicated the residents BUN level was 60. The 6/13/16 laboratory test results were not located in the resident's record. The facility staff called the laboratory on 7/20/16 to obtain the results. The results indicated the resident's BUN level was 89. Review of the 6/2017 Nursing and physician progress notes [REDACTED]. The 6/2016 Nursing Progress Notes were reviewed. There was no record of the Nursing staff notifying the Physician or Nurse Practitioner of the 6/13/16 BNP laboratory tests. An entry made on 6/16/16 at 3:55 a.m. indicated the resident was sent to the hospital via ambulance transfer per physician's orders [REDACTED]. The resident's hospital records were reviewed. A H&P (History and Physical) report was completed by a Physician on 6/16/16 at 5:52 a.m. The report indicated the resident had acute kidney failure, [MEDICAL CONDITION], and [MEDICAL CONDITION] (a low sodium level) and would require admission to the Intensive Care Unit. The report also indicated the acute [MEDICAL CONDITION] appeared to be pre-renal and the Physician noted the resident's prognosis was poor. A Basic Metabolic Panel was completed at the hospital on [DATE] at 3:12 p.m. The results indicated the residents BUN was 98, The Physician and the Nurse Practitioner were interviewed together on 7/20/16 at 1:25 p.m. The Physician indicated he recalled seeing the resident on 7/13/16, as physician progress notes [REDACTED]. The Nurse Practitioner indicated she could not recall being aware of the 6/13/16 elevated BUN level. When interviewed on 7/20/16 at 3:00 p.m. the Assistant Director of Nursing indicated the staff can notify the Physician via email. The Assistant Director of Nursing indicated she checked the system and did not find verification the Physician had been notified via e-mail. The Assistant Director of Nursing indicated the Physician should have been notified of the lab results. 2. The closed record for Resident #G was reviewed on 7/19/16 at 11:24 a.m. The resident's [DIAGNOSES REDACTED]. Review of the Laboratory test results indicated a BNP (B-Natdiuretic Peptide) level was completed on 6/23/16. The BNP level was 242.1 (normal level range was to 2-100). There results were signed as reviewed by the Physician on 6/27/16. Review of the June 2016 Nursing Progress Notes indicated there was no record of the Physician being notified of the above test results When interviewed on 7/20/16 at 10:20 a.m., the Assistant Director of Nursing indicated the Physician should have been notified of the abnormal lab tests in a timely manner. This Federal Tag relates to Complaints IN 477 and IN 639. 3.1-49(f)(2)