Every finding on record at Kendallville Manor

Based on interview and record review, the facility failed to ensure residents were treated with respect and dignity during communication and care for 6 of 6 residents reviewed for dignity (Resident B, Resident C, Resident D, Resident E, Resident F, and Resident G). Findings include:1. The record for Resident B was reviewed on 8/27/26 at 12:05 P.M. Diagnoses included stroke and impulsive behaviors. A quarterly Minimum Data Set (MDS) assessment, dated 8/8/26, indicated Resident B had severely impaired cognition. He was dependent on staff for all activities of daily living (ADL). A care plan, dated 5/4/26, indicated Resident B had difficulty communicating with words due to strokes. Staff were to talk with him when giving care and encourage him to communicate. Resident B was impulsive and had behaviors of throwing himself off the bed and onto the floor. Staff were to approach him calmly; explain what care was to be given and ask for permission to help him. Staff were not to argue with him. For safety, the care plan indicated the resident was to have 2 full size mattresses on the floor, next to his bed, to prevent injury when throwing himself off the bed and crawling around. A report, dated 8/16/26, alleged Registered Nurse (RN) 2 had been verbally inappropriate in manner and tone to Resident B. On 8/27/26 at 12:25 P.M., Employee (E3) 3 was interviewed. The employee indicated, during the evening, on 8/16/26, they had observed RN 2 push Resident B over onto his side in bed and heard RN 2 yell and curse at the resident. The resident had been attempting to get up from his bed unassisted. RN 2 was heard telling the resident to stay the f--- in bed. 2. The record for Resident C was reviewed on 8/27/26 at 2:43 P.M. Diagnoses included fractured leg and diabetes. An admission MDS assessment, dated 7/30/2026, indicated Resident C had moderately impaired cognition. A care plan, dated 7/29/26, indicated Resident C had a nutritional problem. The resident was concerned about problems with swallowing. Staff were to monitor for difficulty swallowing and report signs to the physician. On 8/27/26 at 12:25 P.M., during an interview, Employee (E) 3 indicated on 8/16/26 in the evening, she observed RN 2 giving Resident C her medications. Resident C asked RN 2 to break her pills in half because they were hard to swallow. RN 2 was overheard telling Resident C to take a chill pill-I am getting there and you never asked me to do this before. Resident C was upset by the nurse's comment and replied, Excuse you. RN 2 replied not excuse me, excuse you. 3. The record for Resident D was reviewed on 8/27/26 at 1:00 P.M. Diagnoses included dementia. Quarterly MDS assessments, dated 4/2/26 and 7/3/26, indicated Resident D's cognition fluctuated between no cognitive impairment and moderately impaired cognition. Resident D was not identified by the facility as being able to be interviewed. A facility witness statement, dated 8/16/26, indicated Employee (E) 3 reported RN 2 had mocked Resident D and had stated her name was [Resident D] and (she) needed to go the f--- to bed. E3 hadn't known if the resident had heard RN 2's comment. On 8/27/26 at 12:25 P.M., Employee (E3) 3 was interviewed. They indicated RN 2 routinely mocked Resident D and would argue with her whenever giving medications. In a confidential interview, on 8/27/26, Resident E indicated RN 2 refused to speak with them when giving medications. RN 2 would place her medications on the overbed table and walk over to her roommate. RN 2 would talk to her roommate but ignore her. Resident E indicated RN 2 made her feel like she wasn't even there. In a confidential interview, on 8/27/26, Resident F indicated RN 2 was mean to her roommate. The nurse wouldn't speak to her roommate and ignored her. She indicated RN 2 would purposefully be late in giving evening medications to she and her roommate. The resident and her roommate went to bed early and wanted their evening medications right after supper. The other nurses would bring the evening medications at their preferred time, but RN 2 would not. Many times, RN 2 would bring their medications after they had fallen asleep and would wake them up. Resident F indicated she'd reported RN 2's attitude and lack of respect, but nothing changed. She wasn't going to report it again and risk RN 2 getting mad. In a confidential interview, on 8/27/26, Resident G indicated they had overheard RN 2 yell and curse at other residents several times. RN 2 would yell and curse at residents who were unable to talk back. Resident G indicated RN 2 was just rude to them but gave no further information. Resident G had not provided names of residents RN 2 was alleged to have yelled and cursed at. Confidential staff interviews, on 8/27/26, indicated: -Employee (E) 4 indicated RN 2 had been observed yelling and cursing at residents at various times. They were afraid of RN 2 and would be yelled at and cursed at if complaints were made about the nurse. E4 tried to stay out of RN 2's way and avoided her as was able. When asked, E4 indicated a few residents had complained about RN 2's attitude, irritability, and disrespect when speaking to them. -Employee (E) 5 indicated having worked with RN 2 for several years. RN 2 would get irritated with residents who had behaviors or wanted things a certain way. RN 2 frequently argued with Resident D and lacked patience with the resident's demands. -Employee (E) 6 indicated RN 2 had no patience with residents. She would often say she didn't have time for this s-t. RN 2 was like this and seemed to be her personality. E6 indicated RN 2 often cursed at both residents and staff during her shift. The Director of Nursing (DON) was interviewed on 8/27/26 at 2:35 P.M. She indicated having worked with RN 2 for the past 4 years. She had been aware of RN 2's direct way of speaking to staff and residents but had no complaints voiced to her from residents. The DON indicated RN 2's attitude was something she continually worked on and was evaluated each year during employee annual reviews. The DON indicated residents were to be treated with respect, kindness, and dignity. The incident and follow up interviews with residents and staff indicated RN 2 had not supported these resident rights. RN 2 was terminated from employment at the facility. On 8/27/26 at 2:56 P.M., RN 2 was interviewed and questioned about the incident with Resident B. RN 2 indicated she had the bed elevated while providing a treatment to the resident. After the treatment, she had been lowering the bed when the resident put his legs over the side and tried to get out of bed. She told him to stay in bed as she rolled him over onto his side while at the same time, pulled the floor mattress over to the side of the bed. She hadn't wanted him to fall onto the floor. When asked about her approach with other residents, she spoke only of Resident D. RN 2 indicated Resident D always wanted to argue about something. She would tell the resident she hadn't the time to sit and argue with her. A current facility policy, titled Resident Rights was provided on 8/27/26 at 2:45 P.M., by the DON which indicated: Residents had a right to a dignified existence; be treated with respect, kindness, and dignity; and be supported by the facility in exercising his or her rights. This Citation relates to Intake 3168288. 410 IAC (Indiana Administrative Code) 16.2-3.1-3(a)

Based on observation, interview and record review, the facility failed to ensure a comfortable environment was maintained for residents in 4 of 7 resident rooms observed. During an observation on 01/21/25 at 10:04 AM, in room [ROOM NUMBER], the wall nearest the bed headboard had missing paint and exposed drywall in vertical marks too many to count approximately 3 feet from the floor, in 3 feet wide by 12 inches to less than 1 inch in length. The opposite wall had scrape marks 12 inches from the floor and approximately 5 feet wide. The exterior bathroom wall was missing 12 inches of cove base trim. The interior bathroom wall was missing 4 inches of cove base trim. During an observation on 1/21/25 at 10:29 AM, in the bathroom of room [ROOM NUMBER], the floor had black specks at the square tile seams and a heavier distribution in the corners of tiles. The interior bathroom wall had missing paint and drywall down to the wire mesh measuring approximately 4 inches x 1.5 inches. 1 of 5 light bulbs over the mirror were not functioning. Caulk was missing between the counter and the vertical trim to both sides of the counter. In an interview on 1/22/25 at 2:25 PM, LPN 3 indicated she would report bed, oxygen, or equipment malfunction to maintenance using verbal communication or written work order. During an interview on 1/22/25 from 2:30-2:40 PM, the Maintenance Director indicated no knowledge of the missing cove base pieces nor problems with the walls in rooms 209-217. He indicated replacing cove bases would be quick and there would be no need to vacate a resident from a room. He also indicated that The Administrator and Director of Nursing (DON) try to plan for vacant room maintenance, but this had been difficult. In a continuous interview and observation on 1/24/25 at 09:50-10:05, Housekeeper 9 indicated the black substance on the bathroom floor of room [ROOM NUMBER] was likely wax build up or glue from underneath the tile and may be removed with scrapping. Housekeeper 9 indicated there were stains on the tile floor unable to be removed. Housekeeper 9 indicated wall damage such as cracks or holes, water leaks, or lights not working would be reported with a written work order. Housekeeper 9 indicated resident beds have caused damage to the walls. During an observation on 1/24/25 at 10:00 AM, the 200s hall wall had a thin crack approximately 3 feet long from the ceiling. During an observation on 1/27/25 at 11:01 AM, room [ROOM NUMBER] had an exterior bathroom wall with a section of scrapped paint approximately 2 feet x 3 inches approximately 9-12 inches from the floor. During an observation on 01/27/25 at 11:03 AM, room [ROOM NUMBER] had missing paint and white primer approximately 4 inches x 0.5 inch at approximately 5 feet from the floor. In an interview, on 01/27/25 at 09:31 AM the DON indicated, residents need to be vacated from a room for larger repairs. The DON indicated, the facility replaced a bed that damaged the wall. The DON indicated, the facility has one maintenance employee. In an interview, on 1/27/25 at 10:30 AM, the Maintenance Director indicated the Administrator, would review work orders entered into the TELS program (TELS is a building management platform designed for Asset Management, Life Safety, and Maintenance solutions). A regional consultant for maintenance within the cooperation would also be able to see work orders. The Maintenance Director indicated he had a repair list for every room except 2 rooms completed since he started in August, 2024. The Maintenance Director indicated the facility had been approved to get new flooring in 3 residents' rooms. The Maintenance Director was unable to produce repair list or list of work orders for review. A current policy received on 01/27/25 at 09:36 AM titled Maintenance/Environmental Policy and Procedures, from the Maintenance Director, indicated all room shall be maintained in a clean and good order without defect or damage that effects usability and provide a homelike environment for the residents. For minor touch ups to scrapes and damaged paint in occupied rooms, every effort will be made to conduct minor repairs without inconvenience or displacement to the resident. All maintenance issues must have a work order entered in the TELS program. A monthly audit will be conducted by maintenance to identify any areas that need attention. The areas that need attention will be added to a project list to address in a timely manner. (Not to exceed 30 days.) When a room becomes vacant, an assessment will be conducted (room turn) to determine any necessary repairs. A current policy, received on 1/22/25 at 3:30 PM, from the Maintenance Director, titled Work Order Policy dated 9/1/2022, indicated all work order be either written on the log in front of the maintenance office or entered into TELS program. Work orders that are properly entered into the system will be acted upon within 72 hours and reviewed by The Administrator daily through the TELS logs. Telling the maintenance director or anyone else on the floor something is broken will not get it fixed. It MUST be in writing and include the exact location of the problem and the date of that finding. 3.1-19(e)

Based on observation, interview, and record review the facility failed to ensure oxygen orders were obtained and implemented for 1 of 3 residents reviewed (Resident 47). Findings include: During an observation, on 1/21/25 at 11:02 AM, Resident 47 was observed lying in bed wearing a nasal cannula attached to an oxygen concentrator running at 1.75 liters per minute (lpm). A piece of tape attached to the concentrator read 3.5 lpm. Resident 47's record was reviewed on 1/21/25 at 1:16 PM. Diagnoses included adult failure to thrive and personal history of pulmonary embolism. Resident 47's current quarterly Minimum Data Set (MDS), dated [DATE], indicated their Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact). The MDS indicated Resident 47 used supplemental oxygen. Resident 47's current care plan titled alteration in respiratory status . indicated the resident had a problem of difficulty breathing, with a goal date of 3/19/25. Interventions included providing oxygen as ordered. Physician orders, dated 12/23/24 ,indicated oxygen tubing and a respiratory bag should be changed weekly on Mondays, oxygen humidification water levels should be checked each shift and replaced as needed. No physician orders for oxygen administration and rate of flow were available for review. In an interview, on 1/21/25 at 11:26 AM, Licensed Practical Nurse (LPN) 2 indicated an oxygen flow rate is determined and ordered by the physician. LPN 2 indicated he reviewed the current physician's orders and was unable to find any current orders. He indicated the oxygen was currently running at 1.75 lpm and he did not know what the oxygen flow rate should be. In an interview, on 1/21/25 at 11:30 AM, the Director of Nursing (DON) indicated Resident 47's oxygen order may not have carried over after a recent hospitalization . She indicated a physician's order for administration of oxygen and a flow rate should be present in the medical record for all residents receiving oxygen. In an interview, on 1/21/25 at 11:55 AM, the DON indicated she reviewed readmission orders from the hospital and Resident 47 should have been receiving oxygen at 1 lpm. A current policy dated October 2010, provided by the DON on 1/21/25 at 12:07 PM indicated staff should verify the physician's order before administering oxygen. 3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure pharmacy recommendations were followed for 1 of 5 residents reviewed (Resident 1). Findings include: Resident 1's record was reviewed on 1/24/25 at 7:46 AM. Diagnoses included primary hypertension and diabetes. Resident 1's Annual Minimum Data Set, (MDS) dated [DATE], indicated the resident's Brief Interview for Mental Status (BIMS) score was 12 (cognitively intact). A physician order, dated 2/5/24, indicated Resident 1 was to be administered Maxitrol Ophthalmic Suspension (antibiotic eye drops) to each eye 4 times a day for eye inflammation. A pharmacy note, dated 2/29/24, indicated Resident 1's antibiotic eye drops should be stopped on 3/7/24. Resident 1's physician agreed the antibiotic eye drops should be stopped on 3/7/24. Resident 1's Medication Administration Record, (MAR) dated 3/1/24 through 3/31/24 indicated the resident had been administered antibiotic eye drops 4 times a day every day through 3/31/24. A pharmacy note, dated 4/22/24, indicated Resident 1's antibiotic eye drops were to be stopped on 3/7/24. The pharmacy note indicated the antibiotic eye drops should be discontinued. Resident 1's MAR, dated 4/1/24 through 4/30/24, indicated the resident had been administered the eye drops 4 times a day from 4/1/24 through 4/22/24. A pharmacy note, dated 10/22/24, indicated the pharmacist recommended discontinuing Resident 1's sliding scale insulin and decreasing Resident 1's blood sugar checks from 4 times a day to once a day. The physician agreed. Resident 1's MAR, dated 10/1/24 through 10/31/24, indicated the resident's orders for reduction of blood sugar checks and sliding scale insulin had not been discontinued. The resident's blood sugar had been assessed 4 times a day every day from 10/1/24 through 10/31/24. The MAR indicated Resident 1 had been administered sliding scale insulin 22 times from 10/23/24 until 10/31/24. A pharmacy note, dated 11/19/24, indicated the pharmacist recommended Resident 1's sliding scale insulin be discontinued and their blood sugar checks decreased from 4 times a day to once daily. The physician agreed. Resident 1's MAR, dated 11/1/24-11/30/24, indicated Resident 1 had their blood sugar assessed 4 times a day from 11/1/24 until 11/20/24. The MAR indicated Resident 1 had been administered sliding scale insulin 19 times from 11/1/24 until 11/20/24. In an interview, on 1/24/25 at 3:00 PM, the Director of Nursing (DON) indicated they did not know the reason Resident 1's eye drops did not get discontinued as the pharmacist had recommended. The DON indicated Resident 1's sliding scale insulin should have been discontinued and blood sugar tests should have been decreased as recommended by the pharmacist on 10/22/24. In an interview, on 1/27/25 at 9:18 AM, the DON indicated Resident 1 had brought the antibiotic eye drops with them when they were admitted on [DATE]. The DON indicated the eye drops did not have a stop date on the prescription bottle. The DON indicated the facility had ordered more eye drops on 3/7/24. The DON indicated Resident 1's daughter had reported the resident had been on the eye drops intermittently since the resident's eye surgery. The DON indicated the facility should have clarified the stop date for the eye drops. A current facility policy, titled Guidelines for Notifying Physicians of Clinical Problems, dated 2005 and revised 2/2014, provided by the DON on 1/24/25 at 2:05 PM indicated the facility should notify the physician of significant medication errors immediately. The policy indicated the physician should be notified of medication errors that did not affect the resident's condition during the next routine communication with the physician. 3.1-25(h) 3.1-25(i)

Based on interview and record review the facility failed to ensure residents were free from abuse for 2 of 6 residents reviewed (Resident A and Resident B). Findings include: A report to the Indiana Department of Health dated 8/6/24 indicated there was a concern about residents being abused by a staff member. 1. Resident A's record was reviewed on 8/27/24 at 10:00 AM. Diagnoses included cerebral palsy, aphasia, (inability to speak) major depressive disorder, anxiety disorder and mood disorder. Resident A's Quarterly Minimum Data Set, (MDS) dated [DATE], indicated the resident's Brief Interview for Mental Status (BIMS) score was 8 (moderate cognitive impairment). The MDS indicated Resident A required extensive assistance for activities of daily living (ADLs). The MDS indicated Resident A had a suprapubic indwelling urinary catheter and a feeding tube. A progress note date 8/5/24 at 9:10 PM indicated a staff member had made physical contact with the resident's right arm. A Trauma Evaluation, dated 8/6/24 at 8:53 AM, indicated Resident A had stuck their arm out in front of Certified Nurse Aide (CNA) 10 as CNA 10 was walking by. The progress note indicated CNA 10 flung Resident A's arm out of their way. The progress note indicated Resident A had been known to place their arm in front of other residents and staff members to gain their attention due to Resident A being nonverbal. An undated, written statement by CNA 10, indicated CNA 10 had pushed Resident A's hand down to pass by the resident to answer a call light. A written statement by CNA 30, dated 8/5/24, indicated they witnessed CNA 10 push Resident B's arm away. In an interview on 8/27/24 at 1:17 pm, CNA 10 indicated they had worked a stressful shift at the facility on 8/5/24. CNA 10 indicated the shift was stressful due to unproductive staff members and numerous residents with mental health disorders. CNA 10 indicated they did not abuse residents. CNA 10 indicated they did not hit Resident A. CNA 10 indicated they pushed Resident A's hand out of the way to pass by. 2. Resident B's record was reviewed on 8/27/24 at 10:45 AM. Resident B's diagnoses included cognitive communication deficit, unspecified mild dementia, major depressive disorder, anxiety disorder and behavioral disorders. Resident B had resided at a homeless shelter prior to admission to the facility. Resident B's Quarterly MDS, date 6/19/24, indicated the resident's BIMS score was 15 (cognitively intact). The MDS indicated Resident B required minimal assistance for ADLs. A Nursing Note, dated 8/6/24 at 9:17 AM, indicated on 8/5/24 CNA 10 had been attempting to enter Resident B's room to provide care for their roommate. Resident B had told CNA 10 they were not permitted to enter their room, slammed the door and held the door shut. CNA 10 then pushed the door open forcefully. A Trauma Evaluation, dated 8/6/24 at 10:28 AM, indicated Resident B had closed and held their room door shut to prevent CNA 10 from entering the room to care for their roommate. CNA 10 had pushed on the door while Resident B was holding the door shut. An identified trigger was Resident B's resistance to interacting with others they perceived as having lower function. Resident B indicated they became upset with others when others were stupid. A Behavior Note, dated 8/9/24 at 2:18 PM, indicated Resident B had displayed unkind behaviors to others as evidenced by sticking their tongue out, yelling, using profane language and raising their middle finger. Resident B had been angry with a staff member, refused a rational explanation and had refused alternate accommodations. In an interview on 8/27/24 at 12:05 PM, Resident B indicated they did not feel like talking. Resident B reported they were angry with another resident who didn't know anything. A written statement by CNA 20, dated 8/5/24, indicated CNA 10 had engaged in a verbally abusive conservation with Resident B. Resident B held their room door closed. CNA 10 then placed both hands on the door and pushed with excessive force. CNA 20 prevented the door from striking Resident B. In an interview on 8/27/24 at 1:17 pm CNA 10 indicated on 8/5/24 Resident B had an attitude all day. CNA 10 indicated Resident B was abusive when slamming the door in CNA 10's face. CNA 10 indicated they could have handled themselves better. CNA 10 indicated they regretted using foul language. In an interview on 8/27/24 at 11:45 AM, Licensed Practical Nurse (LPN) 40 indicated CNA 10 could be impatient with the residents. In an interview on 8/27/24 at 12:29 PM, Resident C indicated CNA 10 was scary when they were mad. Resident C indicated CNA 10 displayed negative body language when they were angry. In an interview on 8/27/24 at 12:39 PM, the Director of Nursing (DON) indicated they were aware of the abuse allegations being supported by evidence. A current facility policy, dated 9/2022, provided by the DON on 8/27/24 at 10:40 AM indicated residents should not be abused by other residents, volunteers, family members, legal guardians, friends or facility staff. This citation relates to Complaint IN00440431. 3.1-27(a)

Based on observation, interview, and record review the facility failed to ensure dishwasher chemical checks were completed consistently. 47 of 50 residents residing in the facility were served food prepared in the kitchen. Findings include: During an observation and interview on 2/2/24 at 9:57 AM, Cook 3 was observed washing dishes in the dishwasher. The Dietary Manager (DM) indicated he was unable to locate the test strips to test the dishwasher sanitizer levels. In a record review beginning 2/2/24 at 9:55 AM a document titled Dishwashing temp (temperature)/PPM (parts per million) Feb (February) 2024 was reviewed. The document contained a grid with dates and columns labeled breakfast reading/initial, lunch reading/initial, and dinner reading/initial. The document indicated the temperature should be 120-140 degrees and PPM should be 50-100. The 2/1/24 breakfast temperature reading was 121, but no ppm reading was recorded. The 2/1/24 lunch temperature reading was 125, but no ppm reading was recorded. No ppm readings were recorded for 2/1/24 dinner or 2/2/24 breakfast. In an interview, on 2/2/24 at 9:57 AM, Cook 3 indicated the employee assigned to do the dishes was assigned to fill out the dishwasher log. She indicated she was frequently assigned to do the dishes, but she did not know how to test the chemicals. In an observation and interview, on 2/2/24 at 12:11 PM, the DM indicated he had obtained test strips from another facility. During the chemical test, the strips registered 0 ppm. In an observation and interview, on 2/2/24 at 1:10 PM, the DM indicated he had used incorrect strips on the previous test. The test strips were labeled QT Hydrion and had 5 color indicator strips. The strips were labeled 0, 150, 200, 400, and 500. The DM indicated he was unable to determine whether the PPM reading was between 50 and 100, so he estimated a reading. A current policy titled Dish Machine Temperatures (Low Temperature Machines) and Sanitizer Testing dated 7/2003 provided by the DM on 2/2/24 at 10:07 AM indicated the dish machine should be checked at each meal cycle using a chlorine test strip. Sanitizer strength should be 50-100 PPM hypochlorite. 3.1-21(i)3

Based on observation, interview, and record review the facility failed to ensure medications were secured for 1 of 4 residents reviewed (Resident 17). Findings include: During an observation on 2/6/24 at 8:36 AM a cup containing 6 white pills was observed sitting on top of the medication cart beside a cup containing applesauce. The pills were in plain sight of anyone passing by the cart. No staff member was attending to the cart. 3 unidentified residents passed by during the observation. During an observation and interview on 2/6/24 at 8:39 AM, the Administrator shook his head when informed of the presence of pills accessible on top of the cart and indicated he would stay at the cart and supervise the pills until the staff member in charge of the cart returned to the area. Resident 17's record was reviewed on 2/6/24 at 9:55 AM. Diagnoses included cerebral palsy, chronic obstructive pulmonary disease, and aphasia. Resident 17's current quarterly Minimum Data Set (MDS) dated [DATE] indicated his Basic Interview for Mental Status (BIMS) score was 7 (cognitively impaired). Current physician's orders included orders for the following medications to be administered at 9:00 AM on 2/6/24: Bumex 1 mg, 1 tablet (a diuretic, or medication to release excess fluid from the body) Simethicone 80 mg, 2 tablets (digestive aid) Buspirone 10 mg, 1 tablet (anti-anxiety medication) Lamotrigine 25 mg, 2 tablets (anti-convulsant or seizure medication). In an interview on 2/6/23 at 9:09 AM, the Director of Nursing (DON) indicated staff should not leave pills unattended on top of the medication cart. She indicated she had interviewed Qualified Medicine Aide (QMA)4. She indicated QMA 4 had prepared the medication for Resident 17 and left the cart to assist another staff member. A current policy titled Medication Administration General Guidelines dated 5/20/20 provided by the DON on 2/4/24 at 10:04 AM indicated medications should not be left on top of the cart unattended. 3.1-25 (m) 46756

Based on observation, interview, and record review the facility failed to ensure the facility was maintained in a clean and sanitary manner for 2 of 24 residents reviewed (Resident 30 and Resident 31). Findings include: 1. During an observation on 2/5/24 at 9:23 AM, a urinal containing 150 ml of yellow fluid was observed on the bedside stand beside Resident 30's bed. Resident 30's mattress was uncovered, and no linens were on the bed. Resident 30's roommate indicated Resident 30 had left the building for some appointments and was not expected to return until around 5:00 PM. During an observation on 2/5/24 at 10:47 AM, an unidentified housekeeper was observed cleaning Resident 30's room. The urinal, containing the yellow fluid, was visible from the doorway in the same position on the bedside stand. During an observation on 2/5/24 at 1:49 PM, Resident 30's bed was made up with linens and the urinal, with yellow fluid, was observed on the bedside stand. During an observation and interview on 2/5/24 at 2:30 PM, Qualified Medicine Aide (QMA) 2 indicated the urinal should have been emptied and put away. During an interview on 2/6/24 at 2:41 PM, Resident 30 indicated he had left the building around 8:00 AM on 2/5/24 to attend appointments and returned around 5:00 PM. Resident 30's record was reviewed on 2/7/24 at 9:40 AM. Diagnoses included chronic kidney disease stage 5, diabetes mellitus with foot ulcer, and dependence on renal dialysis. Resident 30's current quarterly Minimum Data Set (MDS), dated [DATE], indicated his Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact). In an interview, on 2/5/24 at 2:33 PM, the Director of Nursing (DON) indicated residents who could independently use urinals should be checked for needs at least every 2 hours. She indicated staff who are in the room to clean or make the bed should empty and clean urinals when they had been used. A current policy titled Bedpan/Urinal Offering/Removing dated 2/2018 provided by the Director of Nursing (DON) indicated urinals should be emptied, cleaned, dried, and put away after use. 2. During an observation in Resident 31's room on 2/2/24 at 2:40 PM, a dark brown substance measuring about 2 inches by 4 inches was viewed on the wall adjacent to the bathroom, about 2 feet from the bathroom door and about 6 inches from the floor. When standing next to the wall, a smell consistent with bowel movement was detected. During an observation in Resident 31's room on 2/5/24 at 10:18 AM, a dark brown substance was viewed on the wall in the same location as the 2/2/24 observation with a slightly smaller and darker appearance. During an observation and interview on 2/5/24 at 2:30 PM Qualified Medicine Aide (QMA) 2 indicated the substance in Resident 31's room appeared to be dried bowel movement and should have been cleaned off the wall. Resident 31's record was reviewed on 2/7/24 at 10:10 AM. Diagnoses included schizophrenia, post-traumatic stress disorder, chronic, and chondrocostal junction syndrome. A review of Resident 31's current Minimum Data Set (MDS) dated [DATE] indicated her Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact). The MDS indicated Resident 31 used substantial assistance with toileting hygiene. In an interview on 2/5/24 at 2:33 PM, the DON indicated walls in resident rooms should be clean and staff should wash off any visible debris when present. A current policy titled Cleaning Spills or Splashes of Blood or Body Fluids dated 1/2012 provided by the Assistant Director of Nursing (ADON) on 2/6/24 at 10:23 AM indicated appropriately trained staff should clean any surfaces contaminated with body fluids as soon as practical to prevent exposure. 3.1-19(f)5

Based on interview and record review, the facility failed to ensure a resident was free from physical restraints for 1 of 1 residents reviewed (Resident B). Findings include: A facility reported incident to the Indiana Department of Health, dated 3/11/23 at 1:06 p.m., indicated Resident B had been secured in her wheelchair with use of a gait belt. On 3/22/23 at 10:15 A.M., Resident B's record was reviewed. Diagnoses included recent hemorrhagic stroke (brain bleed), altered mental status, and diabetes. An admission MDS (Minimum Data Set) assessment, dated 3/13/23, indicated the resident had severely impaired cognition. Her speech was clear and able to be understood. She had no hallucinations or delusions but had 1-3 days of physical behaviors towards others. She required extensive assistance from 2 staff for transfers, bed mobility, and toileting. An initial fall care plan, dated 3/8/23, indicated the resident was at high risk for falls due to being unaware of safety needs with history of falls. Interventions included: anticipate and meet the residents needs, follow fall protocol, therapy to evaluate and treat, and use a bed/chair alarm. A physician order, dated 3/6/23, indicated the resident was to participate in activities, social, nursing and restorative, therapy, and psychosocial programs as tolerated. There was no order for a physical restraint. Nurse progress notes indicated: -3/7/23 at 4:55 p.m., a Nurse Practitioner (NP) note indicated the resident had poor safety and environmental awareness due to a hemorrhagic stroke. This put her at high risk for falls and/or injuries. -3/9/23 at 8:10 p.m., the resident had a fall in the hallway after standing up from her wheelchair. -3/10/23 at 10:01 a.m., the resident had a fall the previous evening when she had been agitated and kept attempting to get up by herself. Fall interventions were for the NP to review her medications and check labs. At 1:58 p.m., the resident was alert but disoriented. She was wheelchair dependent but could stand and then would fall. At 9:24 p.m., the resident was continuously getting out of her chair. -3/11/23 at 4:37 p.m., staff had secured Resident B into her wheelchair because she had been unsteady on her feet. She was released from the gait belt that secured her in the chair and was assessed with no injuries observed. Staff involved in the incident were removed from the schedule and family and physician were notified. A facility investigation, initiated on 3/11/23 indicated RN 2 (Registered Nurse) instructed QMA 3 (Qualified Medication Aide) to assist her in placing a gait belt around Resident B's abdomen and wheelchair. The gait belt was secured at the back of the resident's wheelchair where she was unable to reach it. A written statement by RN 2, dated 3/11/23 indicated she and QMA 3 placed the gait belt around the resident and her wheelchair at 7:25 a.m. The resident kept standing up and she believed it was safer for the resident rather than she falling and sustaining injury. She indicated she had needed to get her medications passed and had a job to do. A written statement by QMA 3, dated 3/11/23 indicated she had followed the direction of her nurse-RN 2, to assist her in placing a gait belt around the resident and her wheelchair at 7:25 a.m. Resident B was repeatedly standing, sitting and would not stay seated. QMA 3 believed she was going to fall and get hurt. She indicated everyone was busy trying to do their jobs and protect her. On 3/22/23 at 11:18 A.M., Resident B and her spouse were interviewed. Her speech was clear and easily understood. She had no memory of having a gait belt placed around her in her wheelchair. Her spouse indicated the resident had some improvements with her memory and her anxiety had decreased but she continued with intermittent confusion. On 3/22/23 at 1:07 P.M., the Director of Therapy was interviewed. She indicated on 3/11/23 at approximately 7:40 a.m., RN 2 told her she had placed a gait belt around Resident B because she kept trying to get up from her wheelchair. RN 2 was stressed and indicated she knew they weren't supposed to restrain the residents but she needed to get things done and was unable to sit with the resident. The Therapy Director indicated she went to the dining room where the resident sat and assisted her to eat her breakfast. After breakfast, she took the resident to the therapy room, removed the gait belt and placed her in a different wheelchair. She then contacted the Director of Nursing to report the incident. She indicated the resident had the gait belt around her for 45-60 minutes and hadn't seemed to notice something was around her waist. On 3/22/23 at 2:45 P.M., the Director of Nursing was interviewed. She indicated on 3/11/23, during the day shift when the incident occurred, the facility was fully staffed with 2 RN's, 1 QMA, and 5 CNA's working and caring for 46 residents. She indicated staff were never allowed to restrain a resident for purposes of convenience. RN 2 and QMA 3 were both terminated for their actions. A current Abuse Policy, provided by the Administrator on 3/22/23 at 9:40 A.M., stated the following: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation .This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms .Definitions: Convenience is defined as the result of any action that has the effect of altering a resident's behavior such that the resident requires a lesser amount of effort or care, and is not in the resident's best interest .Physical restraint is defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: Is attached or adjacent to the resident's body; Cannot be removed easily by the resident; and Restricts the resident's freedom of movement or normal access to his/her body This Federal tag relates to Complaint IN00403856. 3.1-3(w)

Based on record review and interview, the facility failed to implement non-pharmaceutical interventions (NPIs) regarding pain relief for 3 of 3 residents reviewed (Resident 99, Resident 10, and Resident 8). Findings include: 1) Resident 99's record was reviewed on 1/31/2023 at 2:50 PM. Diagnoses included age related osteoporosis without current pathological fracture, age related physical debility, diabetes mellitus due to underlying condition with diabetic neuropathy, and unspecified chronic kidney disease. A Brief Interview for Mental Status (BIMS) Assessment, dated 11/16/2022, indicated Resident 99 had a score of 10 (moderate cognitive impairment). A physician order, dated 1/17/2023, indicated to monitor for pain every shift, attempt non-pharmacological interventions for pain management such as: relaxation, light touch, imagery, exercise, music, etc., every shift. A physician order, dated 12/10/2022, indicated to give Acetaminophen tablet 650 milligrams (mg) (medication used to treat pain and/or fever), 1 tablet by mouth every 4 hours as needed for general discomfort, not to exceed 3000 mg of acetaminophen daily. The order indicated to document non-pharmacological interventions effective/ineffective: 1. relaxation/massage, 2. reposition, 3. food/fluid, 4. diversional activity, 5. toilet, 6. adjust room temperature, 7. adjust lighting in the room, 8. quiet place. A physician order, dated 8/24/2022, indicated to give Tramadol HCl tablet 50mg (narcotic medication used to treat pain), 1 tablet by mouth every 8 hours as needed for pain. The order indicated to document non-pharmacological interventions effective/ineffective: 1. relaxation/massage, 2. reposition, 3. food/fluid, 4. diversional activity, 5. toilet, 6. adjust room temperature, 7. adjust lighting in the room, 8. quiet place. A current care plan, dated 1/31/2023, indicated Resident 99 had acute pain/chronic pain related to osteoporosis. The goal was Resident 99 would not have an interruption in normal activities due to pain through the review date. Interventions included administer analgesia (medications used to treat pain) as ordered, give 1/2 hour before performing treatments or care, anticipate Resident 99's need for pain relief and respond immediately to any complaint of pain or non-verbal sign of pain, encourage Resident 99 to call for assistance when in pain, reposition self, ask for medication, tell staff how much pain was experienced, tell staff what increased or alleviated pain, and encourage Resident 99 to try different pain-relieving methods (positioning, relaxation therapy, progressive relaxation, bathing, snack or drink). A Medication Administration Record (MAR), dated January 2023, indicated Resident 99 received Acetaminophen tablet 650mg, 1 tablet by mouth on 1/13/23 at 9:09 PM, 1/19/23 at 1:45 AM, 1/19/23 at 7:12 AM. There was no documentation of the nonpharmacological interventions (NPI) attempted before administering Acetaminophen tablet 650mg on 1/13/23 at 9:09 PM (NPI marked 0), 1/19/23 at 1:45 AM (NPI marked NA), and 1/19/23 at 7:12 AM (NPI marked NA). A review of progress notes, dated 1/1/23 to 2/1/23, indicated no documentation of the nonpharmacological interventions attempted or attempted before administering Acetaminophen tablet 650mg to Resident 99. A MAR, dated January 2023, indicated Resident 99 received Tramadol HCl tablet 50mg, 1 tablet by mouth on 1/1/23 at 7:48 PM, 1/3/23 at 5:16 AM, 1/4/23 at 7:27 PM, 1/5/23 at 7:18 PM, 1/6/23 at 7:13 AM, 1/6/23 at 8:23 PM, 1/7/23 at 9:30 AM, 1/7/23 at 7:37 PM, 1/8/23 at 8:05 PM, 1/9/23 at 9:09 PM, 1/14/23 at 3:00 AM, 1/15/23 at 7:53 AM, 1/21/23 at 2:15 AM, 1/21/23 at 9:24 PM, 1/23/23 at 8:47 PM, 1/24/23 at 8:28 PM, 1/25/23 at 8:39 PM, 1/26/23 at 8:53 PM, 1/28/23 at 12:20 AM, 1/28/23 at 7:23 PM, 1/29/23 at 8:50 PM, and 1/31/23 at 8:41 PM. The MAR indicated no documentation of the nonpharmacological interventions attempted before administering Tramadol HCl tablet 50mg to Resident 99. A review of progress notes, dated 1/1/23 to 2/1/23, indicated no documentation of the nonpharmacological interventions attempted or attempted and refused by Resident 99 before administering Tramadol HCl tablet 50mg to Resident 99 on 1/1/23 at 7:48 PM, 1/3/23 at 5:16 AM, 1/4/23 at 7:27 PM, 1/5/23 at 7:18 PM, 1/6/23 at 7:13 AM, 1/7/23 at 9:30 AM, 1/8/23 at 8:05 PM, 1/9/23 at 9:09 PM, 1/15/23 at 7:53 AM, 1/21/23 at 9:24 PM, 1/23/23 at 8:47 PM, 1/24/23 at 8:28 PM, 1/25/23 at 8:39 PM, 1/26/23 at 8:53 PM, and 1/31/23 at 8:41 PM. 46156 2) On 2/1/23 at 10:36 AM, Resident 10's record was reviewed. Diagnoses included chronic kidney disease, acute of chronic combined systolic congestive heart failure, emphysema, type 1 diabetes mellitus with unspecified complications and chest pain. Resident 10's comprehensive Minimum Data Set (MDS) assessment, dated 1/3/23, indicated the resident's BIMS score was 11 (moderate cognitive impairment), she was orient but not interviewable. The MDS indicated she had no pain at the time of assessment. A review of the resident's order, dated 12/23/22, indicated Resident 10 could receive a 500mg Acetaminophen tablet every 6 hour as needed for pain or fever not to exceed 3 grams in 24 hours, The order indicated NPIs of : 1) relaxation /massage, 2) reposition 3) food/fluid 4) diversional activity 5) toilet, 6) adjust room temperature, 7) adjust lighting in room, 8) quite place were to be implemented first and documented as effective/ineffective. An order, dated 1/26/23, indicated Resident 10 could receive a 5-325mg Percocet tablet every 4 hours as needed for chest pain not to exceed 4 grams in 24 hours from all sources. The order indicated NPIs of: 1) relaxation /massage, 2) reposition 3) food/fluid 4) diversional activity 5) toilet, 6) adjust room temperature, 7) adjust lighting in room, 8) quite place were to be implemented first and documented as effective/ineffective. A review of Resident 10's MAR indicated the resident was administrated a 500mg Acetaminophen tablet on 1/5/23 at 2:36 AM for a pain level of 6 and at 1:56 PM for a pain level of 5. There was no documentation in the MAR identifying NPIs implemented or refused prior to the administration of the pain medication. The resident's MAR indicated she was administered a 5-325mg Percocet tablet on 1/4/23 at 8:42 AM for pain level of 3, on 1/16/23 at 11:39 AM for pain level of 5 and on 1/16/23 at 2:44 PM for pain level of 5 (1-10 scale). There was no documentation in the MAR identifying NPIs implemented or refused prior to the administration of the pain medication. A review of the resident's progress notes, dated 1/5/23, indicated a 500mg Acetaminophen tablet was administered for pain to Resident 10 at 2:36 AM and 1:56 PM; there was no documentation of NPIs implemented or refused prior to the administration of the pain medication. Resident 10's progress notes, dated 1/4/23, indicated the resident had returned from the emergency room following a fall and reported pain. A progress note, at 8:42 AM, indicated a 5-325mg Percocet tablet was administered to control pain; there was no documentation of any NPIs implemented or refused prior to the administration of pain medication. Resident 10's progress note, date 1/16/23, indicated the resident was administered 5-325mg Percocet tablet at 11:39 AM and at 2:44 PM for complaint of generalized pain; there was no documentation of NPIs implemented or refused prior to the administration of the pain medication. 45794 3) A record review on 1/31/23 at 9:27 am indicated Resident 8's diagnoses included dementia, diabetes mellitus, chronic kidney disease dependent on dialysis, congestive heart failure, morbid obesity, and major depressive disorder. A quarterly Minimum Data Assessment (MDS) dated [DATE] indicated the resident had a slight cognitive deficit. The MDS pain assessment was blank. A physician order dated 1/25/23 indicated the resident was to be administered Norco every 6 hours as needed for pain. The physician order indicated the resident was to be monitored for pain every shift and alternate NPIs were to be offered. A care plan focus dated 4/9/21 and revised 1/25/23 indicated the resident was at risk for acute and chronic pain. An intervention for pain initiated on 1/19/23 indicated the resident was to be encouraged to attempt pain relief methods of positioning, relaxation therapy, progressive therapy, bathing, and having a snack or drink. The resident's MAR for January 2023 indicated the resident was administered hydrocodone on 6 occasions. The MAR did not indicate NPIs were offered when the resident was administered Norco. During an interview on 1/2/23 at 10:37 am the Assistant Director of Nursing (ADON) indicated NPIs were recorded on the MAR as to which NPI was offered and whether the NPI was effective. During an interview on 2/1/23 at 10:04 AM, the Director of Nursing (DON) indicated NPIs were on the resident's January 2023 MAR for acetaminophen. She indicated NPIs were not on the resident's January 2023 MAR for Norco. In an interview on 2/1/23 at 2:24 PM, the DON indicated the physician order for Resident 8 to offer NPIs probably did not get entered as it should have due to the resident's late return from the hospital In an interview on 2/1/2023 at 3:13 PM, the Director of Nursing (DON) indicated documentation of non-pharmacological interventions should be done on the MAR/Treatment Administration Record (TAR) or in a progress note. On the MAR/TAR, the documentation of the non-pharmacological intervention attempted should be the number corresponding to the number of the non-pharmacological intervention listed on the order. An entry of 0 or NA should not be used. The documentation in a progress note should be the description of the nonpharmacological intervention attempted. On 2/1/23 at 2:00 PM, a current procedure titled Pain Assessment and Management, revised March 2015, provided by the DON indicated the procedure's purpose was to help the staff identify pain and develop interventions. The procedure indicated pain management was a multidisciplinary care process that included the developing and implementing approaches to pain management, identifying and using specific strategies for different levels and sources of pain, monitoring for effectiveness and modifying approaches as necessary. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to identify and manage triggers relative to psychogenic nonepileptic seizures for 1 of 1 resident reviewed for behavioral health services (Resident 37). Findings include: On 1/30/23 at 11:15 AM Resident 37 was observed coloring in his room. He indicated he had been admitted to the facility during the summer of 2022. He indicated he was anticipating being discharged to his own apartment soon. He indicated he had lived in his car for 3 years prior to being admitted to the hospital. During a record review on 1/31/23 at 11:14 AM the resident's demographic sheet indicated his diagnoses included anemia, aneurysm of other precerebral arteries, hypertension, nonspecific intraventricular block, diabetes mellitus, morbid obesity, muscle weakness, skin infection, overactive bladder, other seizures, and constipation. A hospital discharge summary printed on 7/21/22 at 12:45 PM indicated the resident had diagnoses of anxiety, panic attacks, and psychogenic nonepileptic seizures (PNS). The summary indicated the PNS were thought to be related to a conversion disorder secondary to trauma. The summary indicated the resident had normal neurological testing in 2015. The summary indicated the PNS episodes were exacerbated by increased anxiety. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident did not have a diagnosis of anxiety. The MDS indicated the resident was able to be interviewed. An admission Social Service Evaluation dated 7/22/22 indicated the resident had been living in his car and was unsure about discharge plans. The admission evaluation indicated the resident had a diagnosis of anxiety. The admission evaluation indicated the resident had been feeling sad and had concentration difficulties. The evaluation indicated the resident felt sad and was easily distracted on his father's birthday A Trauma Related Events Interview dated 7/21/22 indicated the resident did not have a diagnosis of Post-Traumatic Stress Disorder or trauma associated event. A quarterly Social Service Evaluation dated 10/27/22 indicated the resident had lived in his car for 3 years. The quarterly evaluation indicated the resident had been feeling sad due to his mother being sick. The quarterly evaluation indicated the resident did not need mental health services. A quarterly Social Service Evaluation dated 1/27/23 indicated the resident was on a waiting list for an apartment. The resident was in the process of obtaining a landlord statement. The evaluation indicated the resident had been feeling a little down, had difficulty sleeping, and felt tired. The evaluation indicated the resident did not need mental health services. The resident's care plan dated 7/21/22 did not indicate the resident had anxiety, panic attacks, feeling sad, difficult concentration, or trouble sleeping. A care plan focus dated 1/17/23 indicated the resident had PNS. An intervention indicated the staff was to attempt to identify possible triggers of PNS. The care plan did not indicate the PNS were secondary to trauma. A progress note dated 11/22/22 at 3:34 PM indicated the resident had been frequently experiencing episodes of being dizzy and sweating profusely after meals. The note indicated the resident's vital signs and blood sugar were stable during the episodes. The Nurse Practitioner (NP) was made aware of the resident's symptoms and blood tests were ordered. A progress noted dated 11/22/22 at 4:12 PM indicated the resident had an episode of slurred speech, having a hot flash and feeling a rapid drain of energy. The resident's vital signs and blood sugar were stable. A progress note dated 11/23/22 at 5:11 PM indicated the resident was to have an evaluation by the psychiatric NP due to the resident having a history of PNS. A progress note dated 11/28/22 at 10:00 AM indicated the resident had been evaluated by a psychiatric NP due to having a history of PNS secondary to trauma. The progress note indicated he had been struggling due to recently learning his mother had been admitted to a nursing home. The note indicated the resident was diagnosed with panic disorder. The resident indicated he had been quite emotional last week due to his mother being admitted to a nursing home. The resident indicated it was his mother's birthday. The resident indicated he had not seen his mother in 3 years due to a series of unfortunate events. The resident indicated in 2019 his trailer was condemned, he was evicted, and his nephew went to jail. The resident lived in his car until he was hospitalized . A progress note dated 11/30/22 at 12:51 PM indicated the resident had an episode of being more lethargic and continued to lie in bed while lunch trays were being passed. The resident was fluttering his eyes open, and then half shut. The resident's vital signs and blood sugar were stable. The episode resolved when resident was advised he would not be able to smoke if he were unable to stay awake and sit upright. The resident's NP was notified, the nurse was reminded of the resident's diagnosis of PNS. A progress note dated 12/5/22 at 10:30 AM indicated the resident had been in a bad mood due to his breakfast being wrong. The resident reported that he said to take him out back and shoot him. The resident denied suicidal ideation or plan. He indicated he was speaking out of frustration. A progress note dated 12/15/22 at 5:31 PM indicated the resident had another episode of dizziness in the dining room. The progress note indicated the resident has previously had a few spells in the dining room. The progress note indicated the resident's vital signs and blood sugar were stable and the episodes seem to always occur during meals. A progress note dated 12/21/22 at 5:31 PM indicated the resident had a history of PNS secondary to trauma. The resident had an episode while eating dinner. Vital signs and blood sugar were stable. During an interview on 2/1/22 at 11:45 AM the ADON (Assistant Director of Nursing) indicated the resident's PNS were stress induced. She indicated the resident zones out, lowers his head and does not respond to verbal cueing. She indicated he had recovered from a PNS after staff suggested he would not being able to smoke in that condition. She indicated she was aware of the resident's mother being a trigger for the PNS episodes. She indicated the known trigger should have been added to the resident's care plan. She indicated she was unaware of the resident having past trauma in reference to the diagnosis of PNS secondary to trauma. She indicated the trauma screen assessment was negative upon admission. She indicated the trauma screen assessment was not specific for the resident's situation. During an interview on 2/3/23 at 10:19 AM the DON (Director of Nursing) indicated the resident's diagnosis of PNS secondary to trauma was not on the MDS or care plan due to it was not an admission diagnosis. She indicated diagnoses could be added at admission if the diagnoses were listed on the hospital discharge summary. She indicated the resident's diagnoses of anxiety, panic attacks, and PNS should have been included in the admission assessment. She indicated she was unaware of the NP progress note dated 11/28/22 adding panic disorder as a diagnosis. She indicated the NP did not write an order for the diagnosis of panic disorder. She indicated the nurses should have made the SSD of the resident's new diagnosis of panic disorder. She indicated new issues were discussed at daily morning meetings. She indicated there is no documentation to indicate the issues discussed at the daily morning meetings. She indicated the morning meetings consisted of a verbal report and staff generally took their own notes. She indicated panic disorder and anxiety should have been added to the resident's care plan. During an interview on 2/2/23 at 11:17 AM the SSD (Social Services Director) indicated the resident's admission trauma screening was negative for trauma. She indicated she had a care plan meeting with the resident earlier in the day and he did not voice any traumatic events. She indicated she had not witnessed a PNS and was unaware of any possible triggers. She indicated the nursing staff advises her of new diagnoses or behaviors. During an interview on 2/3/23 at 9:15 AM with Resident 37 indicated he was unaware of any specific events prior to the PNS. He indicated he knows he usually experienced the PNS when he is feeling overwhelmed or stressed out. He indicated he would get overwhelmed and black out. He indicated he did not recall the events during the PNS or afterwards. The resident indicated he did not remember what happened or how he got where he is. He indicated he started having PNS in 2014 or 2015. He indicated he had been evicted from a condemned trailer that belonged to his parents. He indicated both his parents were now in a nursing home. He indicated he lived with his nephew briefly before the nephew went to jail, then he indicated he lived in his car approximately 3 years. He indicated he no longer had access to his car as the car had also been condemned after he was admitted to the hospital in the summer of 2022. During an interview on 2/3/23 at 10:52 AM the Assistant Director of Nursing (ADON) indicated she was unable to locate a policy for mental health services. 3.1-43(a)(1)

Based on interview, observation and record review, the facility failed to arrange dental services to treat an abscessed tooth for 1 of 1 resident reviewed for dental care. (Resident 37). Findings include: During an interview on 1/30/23 at 11:15 AM Resident 37 indicated he had an infected tooth. He indicated the facility was arranging a dental appointment. The resident's lower teeth were observed to be black. During a record review on 1/31/23 at 11:14 AM the resident's demographic sheet indicated his diagnoses included anemia, aneurysm of other precerebral arteries, hypertension, nonspecific intraventricular block, diabetes mellitus, morbid obesity, muscle weakness, skin infection, overactive bladder, other seizures, and constipation. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident did not have dental pain. The MDS indicated the resident had not received pain medications. The MDS indicated the resident had received antibiotics for 2 of the last 7 days. The resident's care plan initiated 7/21/22 indicated the resident was at risk for dental problems due to having some decay and broken teeth. An intervention revised 8/2/22 indicated dental pain was to be reported to a physician. A progress note dated 10/9/22 at 4:27 AM indicated the resident received acetaminophen for tooth pain. The progress note indicated the resident's tooth was decayed and broken. A progress noted dated 10/9/22 at 10:40 AM indicated the resident's right upper tooth was black. The progress note indicated the resident was to begin an antibiotic and tramadol for tooth pain. A progress note dated 10/18/22 at 7:49 AM indicated the facility attempted to make a dental appointment for the resident but the resident did not have dental coverage. A progress note dated 10/25/22 at 8:00 PM indicated the resident received acetaminophen. A progress note dated 10/25/22 at 8:37 PM indicated the resident's antibiotic for a tooth infection was completed. The resident was encouraged to perform oral care after meals. A progress note dated 11/9/22 at 1:38 PM indicated the resident received tramadol for abscessed tooth pain. A progress note dated 11/11/22 at 5:51 PM indicated the resident received tramadol for abscessed tooth pain. A progress note dated 11/17/22 at 7:25 PM indicated the resident received tramadol for abscessed tooth pain. A progress note dated 11/20/22 at 11:44 AM indicated the resident received tramadol for abscessed tooth pain. A progress note dated 12/3/22 at 2:25 AM indicated the resident received tramadol for abscessed tooth pain. A progress note dated 12/4/22 at 8:03 AM indicated the resident received tramadol for abscessed tooth pain. A progress note dated 12/26/22 at 8:30 PM indicated the resident received tramadol for abscessed tooth pain. A progress note dated 1/15/23 at 4:18 PM indicated the resident received tramadol for abscessed tooth pain. A progress note dated 1/23/23 at 4:33 PM indicated the resident received tramadol for abscessed tooth pain. During an interview on 2/3/23 at 10:19 AM the DON indicated she was unaware of the resident's need for a dental appointment. She indicated the Social Service Director (SSD) was responsible for scheduling appointments. She indicated the nurses should have made the SSD of the resident's need for dental care. She indicated new issues were discussed at daily morning meetings. She indicated there is no documentation to indicate the issues discussed at the daily morning meetings. She indicated the morning meetings consisted of a verbal report and staff generally took their own notes. During an interview on 2/3/23 at 11:37 AM the SSD indicated she was unaware of the resident's continued need to see a dentist. During an interview on 2/3/23 at 11:40 AM the Business Office Manager (BOM) indicated the resident got approved for full Medicaid which covered dental services on 12/1/22. She indicated the coverage was retroactive starting 8/1/22. She indicated she made staff aware of policy changes via electronic mail. During an interview on 2/3/23 at 10:52 AM the Assistant Director of Nursing (ADON) indicated she was unable to locate a policy for dental services. She indicated an attempt was made to schedule a dental appointment, but the resident had an outstanding bill. She indicated she would call a different dentist. 3.1-24

Based on interview and record review, the facility failed to ensure interventions were initiated related to bowel incontinence and constipation for 1 of 3 residents reviewed. (Resident B). Findings include: On 11/28/22 at 10:58 A.M., Resident B's record was reviewed. Diagnoses included left sided hemiplegia/hemiparesis due to stroke, diabetes with polyneuropathy, chronic kidney failure, constipation, history of fall with clavicle fracture, and history of recurrent sepsis due to urinary tract infections. The resident was currently hospitalized following a diagnosis of ileus (temporary lack of muscle contractions of the intestines) which could be caused from a blockage, certain medications such as narcotics, infections, kidney or lung disease, or decreased blood supply to the intestines. A significant change MDS (Minimum Data Set) assessment, dated 8/4/22, indicated the resident had a BIMS (Brief Interview Mental Status) of 15, no cognitive impairment. She had no behaviors or rejection of care. She was dependent on 2 staff members and hoyer lift for transfers. She required extensive assistance of 2 for toileting and personal hygiene. Resident B was frequently incontinent of bowel and was not on a bowel toileting program. The resident was prescribed a narcotic medication for pain she received all days of the assessment. A Comprehensive Bladder and Bowel Evaluation form, dated 6/7/22 at 11:45 a.m., indicated the resident was incontinent of bowel with symptoms of constipation. The assessment indicated that a stroke and diabetes could affect her bowel function as well as use of anti-depressant medication. There was no further evaluation completed to restore her bowel function, if possible. Her bowel incontinence was to be managed with scheduled incontinence care. A Comprehensive Bladder and Bowel Evaluation form, dated 7/27/22 at 3:32 p.m., indicated the resident was continent of bowel but required extensive assistance to total dependence with bowel management, a risk factor for bowel incontinence. The evaluation hadn't addressed how the resident's change in mobility (from a stand up lift to a hoyer lift) would affect her ability to use the toilet nor how the use of routine narcotics would impact her constipation. Review of care plans indicated there was no plan developed to address the cause or management of the resident's bowel incontinence, diagnosis of constipation, use of constipation causing medications, or change in ability to sit on the toilet for bowel elimination. On 11/28/22 at 3:14 P.M., the Director of Nursing was interviewed. She indicated Resident B should've had interventiona implemented for her bowel incontinence and constipation. A current facility policy, titled Bowel and Bladder Evaluation, revised 6/1/2019, stated the following:Residents are evaluated for continence on admission/readmission, quarterly, and with significant change in status. Residents who have been determined to be incontinent without a documented irreversible cause .will be further evaluated for potential for bowel or bladder management .On admission, residents without a documented reversible cause for bowel and bladder incontinence will have a bowel and bladder evaluation completed and will have bowel and bladder elimination pattern evaluation completed .Scheduled toileting programs, re-training programs, and routine incontinent care will be added to the resident care plan. This Federal tag relates to Complaint IN00394874. 3.1-35(a)

Based on interview and record review, the facility failed to assess and monitor chronic urinary tract symptoms for 1 of 1 residents reviewed. (Resident C) Findings include: On 8/9/22 at 10:33 A.M., Resident C's record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission MDS (Minimum Data Set) assessment, dated 6/10/22, indicated the resident had no cognitive impairment. She required assistance of 2 staff for toileting and was frequently incontinent of bladder and bowel. Care Plans indicated the following: Dated 6/6/22, the resident was on antibiotic therapy for prophylaxis of [CONDITION(S)]'s (Urinary Tract Infection). The goal was she would be free from discomfort or adverse side effects of antibiotic therapy. Interventions were to administer medication as ordered; monitor for secondary infections due to antibiotics; observe for possible side effects; and report pertinent lab results to the physician. Dated 6/13/22, the resident had bladder incontinence due to impaired mobility. The goal was she would be continent at all times. The intervention was to encourage fluids during the day to promote prompted voiding responses. Resident C was admitted to the facility from another skilled facility where she had chronic [CONDITION(S)]'s and had been prescribed [MEDICATION(S)] (antibiotic) 50 milligrams (mg) by mouth every day for prevention of [CONDITION(S)]'s. While at the previous facility, she had hematuria (blood in urine) and had been referred to a Urologist (bladder specialist) with an appointment scheduled on 6/21/22. Upon admission to the current facility, she was prescribed and administered daily, [MEDICATION(S)] 50 mg by mouth beginning on 6/3/22 and continuing until 7/13/22. A Nurse Practitioner (NP) note, dated 6/6/22 at 7:55 a.m., indicated the resident had been seen due to being newly admitted . The resident was assessed to have recurrent [CONDITION(S)]'s, a repeat urinalysis would be done once she completed her antibiotic ([MEDICATION(S)]) and she would be referred to urology. At 8:20 p.m., the NP wrote another progress note. The note indicated the resident had been seen for hematuria and Resident C would be prescribed [MEDICATION(S)] ([MEDICATION(S)]) 50 mg every day for [CONDITION(S)] prevention and would follow up with urology. A urinalysis report, dated 6/8/22, indicated the resident's urine was cloudy and concentrated; had a moderate amount of blood, white blood cells, red blood cells and many bacteria present. A culture and sensitivity report, dated 6/12/22, indicated the resident had over 100,000 Escherichia Coli and 51,000-100,000 Proteus Mirabilis bacteria present. The Escherichia Coli bacteria was sensitive to [MEDICATION(S)] however, the Proteus bacteria were resistant to the antibiotic. The NP was notified of the urinalysis and culture and sensitivity report on 6/12/22 at 7:40 p.m. There were no new orders. An after visit summary from the Urologist, dated 6/21/22, indicated new orders for a urinalysis with culture and sensitivity to be done as well as an abdominal xray. The summary indicated the resident had urinary urgency, malodorous urine, and incontinence. An antibiotic would not be prescribed until the urine culture results came back. An abdominal x-ray was to be done to evaluate the resident for kidney stones. The summary listed her current medications but did not indicate she was on [MEDICATION(S)] daily for prophylaxis of [CONDITION(S)]'s. The resident was to return for a follow up visit on 8/16/22. A urinalysis report, dated 6/21/22 at 9:00 p.m., indicated the residents urine was cloudy and concentrated; had a moderate amount of blood, white blood cells, red blood cells, nitrites, and many bacteria present. A culture and sensitivity report, dated 6/24/22, indicated the resident had over 100,000 Escherichia Coli and over 100,000 Proteus Mirabilis bacteria present. The Escherichia Coli bacteria were sensitive to [MEDICATION(S)] however, the Proteus bacteria were resistant to the antibiotic. Nurse notes indicated the urinalysis report and abdominal x-ray reports were faxed to the urologist office on 6/22/22 at 12:03 p.m. and again on 6/23/22 at 4:58 p.m. with no response. A nurse note, dated 6/24/22 at 10:51 a.m., indicated the residents urinalysis, culture and sensitivity report and abdominal x-ray reports were faxed to the urology office for review. There were no new orders at that time. Resident C remained with complaints of urinary urgency, burning, and had foul smelling urine. There was no further documentation completed after 6/24/22, regarding the residents urinary complaints of urgency, burning or foul smelling urine, until 7/11/22. A nurse note, dated 7/11/22 at 1:49 p.m., indicated new orders were received by the facility NP for [MEDICATION(S)] (medicine for bladder spasms) 200 mg by mouth 3 times per day for dysuria (pain with urination) for 3 days. On 7/13/22 at 12:59 p.m., a change in condition form indicated the resident had weakness and was short of breath. Orders were given to transport the resident to the hospital where she was admitted . On 8/10/22 at 9:25 A.M., the Director of Nursing was interviewed. She indicated there should have been a care plan developed for the resident's chronic [CONDITION(S)]'s and nursing staff should have assessed and documented the residents continued urinary tract symptoms and complaints. This Federal tag relates to Complaint IN 539. 3.1-41(a)(2)

Based on interview and record review, the facility failed to obtain a pressure relieving device to promote healing of a stage 4 pressure ulcer for 1 of 3 residents reviewed with pressure ulcers (Resident T). This resulted in the wound worsened in size. Findings include: On 3/22/22 at 11:33 A.M., the record for Resident T was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Stage 4 (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed and often includes undermining and tunneling) pressure ulcer to the sacral region, diabetes, and birth defect of the spine and spinal cord. Upon admission, the resident's stage 4 sacral pressure ulcer measured 4 cm (centimeters) in length by 7 cm in width by a depth of 1 cm. A quarterly MDS (Minimum Data Set) assessment, dated 1/14/22, indicated Resident T had no cognitive impairment. She required extensive assistance from 2 staff members for bed mobility and transfers; was always incontinent of bowel and continent of bladder with a [MEDICATION(S)] (an opening in the skin where urine flows out and into a pouch); and had no behaviors or rejection of care. A care plan, revised on 2/23/22, indicated the resident had a stage 4 pressure ulcer to her coccyx related to her spinal birth defect. The goal was that the pressure ulcer would show signs of healing and remain free from infection. Interventions included, but were not limited to, air mattress for pressure relief-check function every shift, assist with turning and repositioning as needed, and pressure reduction cushion to wheelchair to prevent skin breakdown as ordered. Resident T's wound was evaluated by the wound clinic on 1/25/22. The stage 4 sacral pressure ulcer measured 4.6 cm in length by 5 cm width by a depth of 1.8 cm. The wound had undermining (destruction of tissue or ulceration extending under the skin edges so that the pressure ulcer is larger at its base than at the skin surface) with a depth of 4.5 from the 7 to 1 o'clock position. The wound bed was red and moist without evidence of necrosis (death of skin tissue). The wound had a large amount of yellow drainage with a faint odor. The treatment ordered was for Dakin's solution and to cover the wound with a dry dressing twice daily. A Roho cushion (used to provide pressure relief and help the healing process) was recommended for her wheelchair. Wound clinic visits for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] 2/1/22-the wound measured 4.5 x 5.5 x 1.5 cm with undermining 5cm at 9 to 2 o'clock position. The wound had a large amount of serous drainage and no odor. Treatment remained unchanged. The wound clinic was going to try and help the resident get the Roho cushion for her chair. 2/8/22-the wound measured 4 x 6 x 2 cm with undermining 4.5cm at 9 to 2 o'clock position. The wound had a moderate amount of serosanguineous drainage with no odor. Treatment remained unchanged. The wound clinic indicated the resident needed a Roho cushion which they were unable to obtain because the resident lived at the facility. Resident T's family was going to contact a local organization for help paying for a Roho cushion. The resident was to stop her prostat and start boost nutritional drink to promote healing. On 2/15/22 at 12:25 p.m., the resident was seen by the facility's new wound NP (Nurse Practitioner). The wound had a large amount of undermining with no drainage or foul odor however there were no wound measurements. On 2/16/22, a facility wound flow sheet indicated the wound measured 4 x 6 x 2 cm with undermining 4.5cm at 9 to 2 o'clock position. The wound had a scant amount of serosanguineous drainage and no odor. Treatment remained unchanged. The resident resumed visits at the wound clinic as follows: 2/22/22-Wound measurements remained unchanged as was the treatment. They recommended she be on an air loss mattress to relieve pressure and be turned/positioned every 2 hours. The wound clinic note indicated they had left a message for the Director of Nursing (DON) to discuss obtaining a Roho cushion. The resident was placed on a low air loss mattress. 3/1/22-The wound measured 5.8 x 5.5 x 2 cm with undermining 4 cm at 11 to 1 o'clock position. The wound bed was red and moist with some eschar (dead skin) present. There was a moderate amount of serosanuineous drainage and no odor. The wound was debrided (dead skin cut away) with post-debridement measurements of 5.8 x 5.5 x 2.1cm. The treatment was changed to normal saline, pack the wound, and cover with an ABD pad twice daily. The note asked that the resident be provided with a Roho cushion. 3/8/21-The wound measured 4.7 x 6.2 x 2 cm with undermining 3.4 at 9 to 2 o'clock position. The wound had tunneling (passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) at a depth of 3.5 cm at the 12 o'clock position. Skin surrounding the wound was excoriated and macerated. There was moderate serosanguineous drainage without odor. The wound was debrided with post-debridement measurements of 4.7 x 6.2 x 2.1cm. The treatment remained unchanged. 3/15/22-The wound measured 5.5 x 6.2 x 2.3 cm with undermining 3.4 at 9 to 2 o'clock position. There was tunneling at a depth of 3.8 cm at the 12 o'clock position and 3.5 cm at the 10 o'clock position. The wound bed was moist and skin surrounding the wound was red, excoriated, and macerated. Edges of the wound were rolled and there was moderate serosanguineous drainage with moderate odor. The assessment was that the wound was larger, there was an odor, and redness around the wound. The facility had not obtained the Roho cushion as recommended. On 3/22/22 at 1:58 P.M., the DON was interviewed. She indicated the facility had tried to obtain the Roho cushion without success. She provided copies of requests made on 3/8 and 3/16/22 by the therapy department to obtain the needed cushion. The DON indicated she had spoken with the wound clinic about difficulty getting the cushion but had not documented it. A current facility policy, titled Skin and Wound Management System was provided by the DON on 3/22/22 at 1:55 P.M. and stated: It is the policy of this center's Sin Management System to identify and assess residents with wounds and/or pressure ulcers, as well as those at risk for skin compromise. Such residents are then provided appropriate treatment to encourage healing and/or integrity .5. Residents identified with skin impairments will have appropriate interventions implemented to promote healing .7. The Interdisciplinary Care Plan should address .positioning requirements, redistribution and proper body alignment This Federal tag relates to Complaint IN 519. 3.1-40

Based on interview and record review the facility failed to implement physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident 30). Findings include: A record review, began on 2/9/22 at 11:59am, indicated Resident 30 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold insulin if the resident did not consume meals. The order indicated to give [MEDICATION(S)] insulin per sliding scale. 200-250 give 4 units, 251-300 give 6 units, 301 to 350 give 8 units, 352-450 give untis, abouve 450, call physician, do not give insulin. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 30's blood sugar prior to lunch, at 11:00AM, was 563, there was no indication the MD was called or any orders received. 10 units of [MEDICATION(S)] insulin were given. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Food consumption records for 1-7-2022 indicated the resident had zero percent meal consumed for breakfast and lunch. A progress note dated 1/7/22 at 5:25PM, indicated the resident was nonresponsive at 4:30PM. Resident 30's blood sugar was noted to be 28. There was no documentation the order for [MEDICATION(S)] was followed. The physician was called, and an order was received to send to emergency room via ambulance. Ambulance personnel administered IV glucose. After the medication was administered prior to leaving facility, Resident 30's glucose was up to 54. The MAR (medication administration record) dated January 2022 indicated the resident was prescribed [MEDICATION(S)] HypoKit for IM administration for blood sugar below 70 and resident was unable to take oral glucose. The order's start date was 11/16/21. There was no documentation on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 30 was given 8 units of coverage on 1/13 after not consuming breakfast. On 1/14 the resident received 10 units of coverage after dinner without any documentation regarding amount of meal eaten. On 1/19 the resident received 10 units of coverage without any documentation of amount of meal eaten prior. On 1/27 10 units of insulin coverage were given after lunch and 8 units of insulin coverage after dinner with no documentation on lunch or dinner meal consumed. On 1/28 Resident 30's am blood sugar was 48. On 2/2 10 units of insulin coverage was given after breakfast with zero consumption of breakfast recorded as intake. On 2/4 10 units of insulin coverage was given after breakfast, after lunch and after dinner Meal consumptions for breakfast and lunch were recorded as zero intake and there was no documentation for consumption after dinner. On 2/5, 6 units of insulin coverage is recorded after lunch and zero percent of lunch documented as eaten. On 2/9, 8 units of insulin coverage given after dinner when there was no documentation of amount of dinner eaten. Resident 30's most recent care plan indicated a focus of diabetes with insulin coverage and poor eating habits. The goal for this focus was the resident would have no complications related to diabetes through the next review period, The interventions were to administer medications as ordered, dietary consult, fasting serum blood sugar per MD orders, monitor, document and report to MD any signs of [CONDITION(S)] and [CONDITION(S)] (low and high blood sugar), observe for breaks in skin, obtain labs as ordered, and to offer substitutes for food not eaten. An interview with the DON on 2/10-22 at 2:10 PM indicated the IM (intramuscular) glucose ([MEDICATION(S)]) should have been administered. The DON was unable to state whether the [MEDICATION(S)] was available to be administered because she was not employed at facility during that time. 3.1-37

Based on observation, interview and record review, the facility failed to ensure wound assessments, interventions and treatments were implemented for 1 of 1 resident reviewed. (Resident 14) Findings include: The clinical record for Resident 14 was reviewed on 2/10/22 at 10:15 AM. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order indicated to cleanse, pat dry, loosely pack with gauze, cover with calcium alginate, and cover with foam border dressing. This order did not include wound care for right hip. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 2/10/22 at 11:40 AM with LPN 8 indicated there was no wound on the left hip and the order should have been for wound care to sacrum and right hip. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order indicated the pressure ulcers to the sacrum and the right hip were to be cleansed, patted dry, packed with Dakin's solution moistened gauze, and cover with an ABD dressing. Wound care was observed on 2/11/22 at 9:10 AM. The right buttock area had a foam dressing in place dated 2/10/22. The sacrum and right hip had ABD dressings in place dated 2/10/22. LPN 9 removed the dressings from the sacrum, right hip and right buttock, then cleansed all areas with soap and water. LPN 9 packed the sacral and right hip wounds with Dakin's solution-soaked gauze then covered the wounds with ABD dressings. LPN 9 indicated that she was unaware of the wound to right hip. LPN 9 left the Stage 1 wound to the right hip uncovered and indicated that she could not apply a dressing without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview with the DON on 2/11/22 at 1:56 PM, she indicated the wound to the right buttock was diagnosed by wound clinic staff on 2/7/22. The DON also indicated the wound care order for the right buttock pressure injury was ordered on 2/8/22. The DON indicated she received the order via fax from the wound clinic on 2/9/22. The DON indicated she made LPN 8 aware of the new order on 2/10/22. The DON further indicated that LPN 8 performed the proper wound care to the right hip, but she failed to transcribe the order into the clinical record. The DON indicated LPN 8 should have documented the wound to the right buttock, entered the wound care order into the clinical record and reported the wound to the next shift. Weekly skin assessments dated 11/8/21 through 2/7/22 were completed 6 times out of 13 opportunities. Weekly skin assessments were not documented as ordered for the dates of: 11/8/21, 11/22/21, 12/6/21, 12/13/21, 12/27/21, 1/3/22, 1/24/22. Weekly shower sheets dated 12/9/21 through 12/30/21 did not require skin assessment documentation. A skin assessment dated [DATE] indicated there were pre-existing wounds. There was no documentation of a wound to the right buttock. 3.1-40

Based on observation, interview and record review the facility failed to provide services to prevent further decline in range of motion for 2 of 18 residents reviewed. (Resident 15 and Resident 29) Findings include: 1) An interview with Resident 15, on 2/11/22 at 10:19AM , indicated that she was happy with all services except physical therapy. Resident 15 indicated that she would like to go back to walking in the halls with nursing staff and a cane. Resident 15 was not happy walking with a walker. A record review, 2/11/22 at 11:40AM, indicated Resident 15 had a BIMS score of 15 indicating she was interviewable. Resident 15's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident15's most recent care plan indicated a focus of decline in ability to complete active range of motion due to diagnosis. The goal was to complete active range of motion exercises as indicated in restorative nursing program through next review. The interventions, were to notify the nurse if complains of pain, notify nurse if experiences decline in their ability to complete AROM tasks, nurse to review program routinely along with progress toward meeting goals, and record minutes of task completed in POC. There were no specific goals the nurse was to be monitoring regarding progress specifics or current ability. The restorative care documentation for Resident 15 indicated the following: Received appropriate time 4 of 28 days (20 min). Nothing reported for 1/19/22; 1/26/22; 1/27/22; 1/28/22; 2/3/22. There were 5 min or less reported on 1/17/22; 1/24/22; 1/31/22; 2/8/2, One refusal was recorded. The remaining 14 dates have 15 mins as recorded time. The task stated: active ROM; was to complete 2 sets of 20 reps in each joint motion of BUE; including digits; wrists. elbows and shoulders. She was to complete 20min of NuStep at level 3 in therapy room daily. There was no documentation whether the minutes were Range of Motion or the NuStep. 2) An interview with Resident 29's mother on 2/8/22 at 11:42AM indicated Resident 29 used to have more mobility in the left hand such as making waving motion with fingers spread out. Resident's mother indicated he had lost some of his previous abilities. Resident 29's mother was upset regarding lack of physical, occupational or restorative care provided by this facility. Mother indicated Resident 29 was previously frequently able to stand in specialized chair, but the facility had never used the chair. An observation of Resident 29 on 2/8/22 at 11:42AM, noted the resident's right hand had thumb and pointer finger out and straight. The remainder of the fingers on that hand were tightly in a fist. Resident 29 was unable or unwilling to open either hand. There was no observation of Residnet 29 wearing positional boots. A record review began on 2/8/22 at 2:16PM indicated Resident 29 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 29's care plan date indicated a focus on traumatic brain injury. The goal was stated TBI its effect on positioning through the next review. Interventions related to this goal were all initiated on same date 7/2021. A focus on alteration in musculoskeletal status r/t contracture and stiffness with goal of remaining free of pain or at a level of acceptable to the resident through review. Interventions for this goal included administer analgesics, anticipate needs, encourage resident to comply with wearing boots while out of bed per family (decision maker) request, monitor risk of falls, monitor/document/report to MD signs of complications related to arthritis, joint pain, joint stiffness, swelling, decline in mobility and contracture formation and joint shape changes. A care plan with a focus on at risk for acute and chronic pain was initiated 2/1/22 without the knowledge of Resident 29's mother (power of attorney). The care plan did not specify any restorative care or passive range of motion exercises. The MDS dated ,d+[DATE] indicated Resident 29 was totally dependent in all areas. Section I of the MDS listed active diagnosis, but did not include contracture. Section O, (Special treatments, procedures and programs) indicated Resident 29 received zero minutes of occupational, physical or restorative nursing program. Section O indicated the resident therapy start date was 9/2021 and end date of 10/2021. Occupational therapy notes provided by Physical Therapy Director, 2/11/22 at 11:53AM, indicated Resident 29 was in occupational therapy in July 2021 discharged to acute hospital with restorative program to be in place upon the resident's return. Occupational therapy notes included a restorative program was trained and established with staff and had a good prognosis with consistent follow through. Physical therapy notes from 7/2021 indicated he was discharged due to progress varies upon resident compliance and [CONDITION(S)] with an in service to nursing for lower extremities passive range of motion. Occupational therapy in 8/2021 indicated Resident 29 could not use custom chair per doctor's orders and was to wear boots when sitting up. Occupational therapy restarted in 9/2021 with some electric impulse work. An inservice with nursing in 10/2021 for restorative nursing passive range of motion exercises was completed. During an interview with Physical therapist 1, she indicated Resident 29 was at times resistant to treatment and unwilling or unable to do exercises. Physical therapist 1 denied the resident had a pain medication prior to treatments and had not had a discussion with the doctor regarding resident moods. There was no documentation to indicate the staff had followed through with exercises, boots, or contracrure devises for his hands. 3.1-42 (a)(2)

Based on observation and record review the facility failed to maintain acceptable parameters of nutrition for 1 of 3 residents reviewed. (Resident 30) Findings include: An observation of Resident 30, on 2/8/22 at 10:06AM, indicated the resident's shoulder bones were easily visible through clothing. The resident was resting in bed with eyes closed. A record review, on 2/9/22 at 9:28AM, indicated Resident 30's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 30 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The following weights were noted under the vital signs tab: 11/22/21 96.8 lbs 12/2/22 96.2 lbs 12/6/21 99.2 lbs 12/13/21 98.2 lbs 12/27/21 87.2 lbs 1/1/22 84 lbs 1/3/22 80.4 lbs 1/13/22 83.4 lbs 1/17/22 84.3 lbs 1/25/22 87.2 lbs 1/31/22 80.8 lbs 2/1/22 80.8 lbs 2/2/22 80.8lbs 2/9/22 79.8 lbs a loss of 17 pounds or 17.56% in less than 3 months. Resident 30's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The following refusals were noted in January and February 2022 1/1 at 7:30AM, 1/3 at 4PM, 1/4 at 4PM, 1/5 all three shakes 1/6 all three shakes 1/7 at 4PM 1/12 at 4PM 1/13 at 4PM 1/14 all three shakes 1/17 at 4PM 1/18 all three shakes 1/19 at 4PM 1/20 at 4PM 1/24 at 4PM 2/1 at 4PM There were no progress notes to indicate a notification to the provider had been completed regarding continued refusals. A review of Resident 30's meal consumption indicated the resident consumed 50% or less of meals from November 10th through 30th, 2021 for 18 out of 63 meals. Four additional meals were not recorded. In December 2021, the resident's meal consumption was reported as less than 50% for 31 meals out of 93. An additional 2 meals were not recorded. In January 2022, meal consumption was recorded as 50% or less for 34 meals and nothing was recorded for 19 meals. In February, 15 out of 31 meals were reported as less than 50% consumed;, and 10 were not documented. The dietician notes were reviewed. The notes indicated Resident 30's body mass index (BMI) was 13.56 (BMI less than 18.5 indicates underweight) the note indicated estimated idea body weight should be136 lbs. the note indicated the resident had malnutrition, excessive weight loss, and poor intakes. Suggestions from the dietician included daily weights, and adding an appetite stimulant (resident has not been ordered any additional stimulants since the hospital stay). Resident 30's most recent care plan, provided by DON on 2/10/22 at 12:30pm, indicated a focus of resident refusal of meals and significant weight loss. The care plan was initiated 11/2021. A goal indicated the resident would accept staff comfort, support, redirection, show cooperation by eating meals, taking medications as ordered etc, through next review period. The interventions were to allow time to express feelings, approach in calm manner, keep MD and social services informed of behaviors, observe for and document behaviors. There were no interventions to address taking supplements, or monitoring intakes and actions to take when intakes were below 50%. 3.1-46(a)(1)(2)

Based on interview and record review the facility failed to address pain effectively for 1 of 1 residens reviewed for pain. (Resident 25) Findings include: An interview with Resident 25 on 2/9/22 at 9:59 AM indicated the resident's pain was not under control. Resident 25 indicated the staff do nothing to help with pain other than administer medications. Resident 25 indicated when he first arrived, the facility did not have pain medication available, so he went without. Resident 25 indicated he continued to be in pain every day. Resident 25 rated the pain a 6 on the scale of 1 to 10 with 10 being the worst pain. The resident indicated he did have pain at home, but it was not as constant and unable to be relieved. Resident 25's clinical record was reviewed 2/9/22 at 3:06 PM. Resident 25's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 25's BIMS score was 15 and indicated the resident was interviewable. Resident 25's care plan did not include a problem area of pain, no goal or interventions were identified in other sections for this care area. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no regularly scheduled pain medications ordered. In the month of January 2022, Resident 25 received the following doses of medication for pain: 1/21 Acetaminophen 650 mg for pain level 5 1/22 [MEDICATION(S)]-acetaminophen 10-325 mg twice for a pain level of 7 each times 1/23 [MEDICATION(S)]-acetaminophen 10-325 mg twice for a pain level reported as 7 each times 1/24 [MEDICATION(S)]-acetaminophen 10-325 mg 3 times for a pain level reported respectively as 8;9;8 1/25 [MEDICATION(S)]-acetaminophen 10-325 mg 3 times for a pain level reported as 8 each time, Acetaminophen 650 mg 3 times for a pain level of 2;5 and 5 respectively. 1/26 [MEDICATION(S)]-acetaminophen 10-325 mg for a pain level reported as 8 1/27 [MEDICATION(S)]-acetaminophen 10-325 mg twice for a pain level reported as 6 and 5 respectively. [MEDICATION(S)]-acetaminophen 10-325 mg for a pain level of 4. 1/28 [MEDICATION(S)]-acetaminophen 10-325 mg for a pain level of 6. [MEDICATION(S)]-acetaminophen 10-325 mg 3 times for a pain level of 4, 8 and 8 respectively. 1/29 [MEDICATION(S)]-acetaminophen 10-325 mg for a pain level of 8. [MEDICATION(S)]-acetaminophen 10-325 mg 3 times for a pain level reported as 8 each time. 1/30 [MEDICATION(S)]-acetaminophen 10-325 mg three times for a pain level of 8 each time. [MEDICATION(S)]-acetaminophen 10-325 mg twice with pain level of 8 each time. 1/31 [MEDICATION(S)]-acetaminophen 10-325 mg twice for a pain level of 8 each time. [MEDICATION(S)]-acetaminophen 10-325 mg twice for a pain level reported as 8 each times. From February 1 to February 9, 2022 Resident 25 received the following doses of medication for pain: 2/1 [MEDICATION(S)]-acetaminophen 10-325 mg 3 times for a pain level reported as 8 each time. [MEDICATION(S)]-acetaminophen 10-325 mg tablet twice for a pain level of 8 each time. This medication was discontinued on this date. 2/2 [MEDICATION(S)]-acetaminophen 10-325 mg 4 times for a pain level reported as 7, 7, 8, and 8 respectively. 2/3 [MEDICATION(S)]-acetaminophen 10-325 mg 5 times for a pain level reported as 8,7,8,8, and 7 respectively. 2/4 [MEDICATION(S)]-acetaminophen 10-325 mg 5 times for a pain level reported as 8,8,9,8, and 8 respectively. 2/5 [MEDICATION(S)]-acetaminophen 10-325 mg 4 times for a pain level reported as 7,8, 8, and 6 respectively. 2/6 [MEDICATION(S)]-acetaminophen 10-325 mg 5 times for a pain level reported as 7,7,8, 7 and 6 respectively. 2/7 [MEDICATION(S)]-acetaminophen 10-325 mg twice for a pain level reported as 4 and 8 respectively. 2/8 [MEDICATION(S)]-acetaminophen 10-325 mg 5 times for a pain level reported as 8 each time. 2/9 [MEDICATION(S)]-acetaminophen 10-325 mg 5 times for a pain level reported as 9,9,10,7, and 6 respectively. No acetaminophen 650 mg or [MEDICATION(S)] 300 mg were documented as administered in February 2022. There was no monitoring for pain recognition, anticipation, factors that precipitate or make pain worse monitored or recorded. There was no discussion with the physican or care planning team documented regarding the possibility of routine pain medications. 3.1-37(a)

Based on interviews and record review, the facility failed to ensure the safety of a resident, who left the facility unattended and failed to develop a plan to prevent the incident from reoccurring. This resulted in the potential for serious harm for 1 of 1 resident, who left the facility unattended, in a sample of 3. (Resident #B) The immediate jeopardy began on 7/25/11, when a resident left the facility unattended. The Administrator, Administrator in Training, Social Services Director and the Assistant Director of Nursing were notified of the immediate jeopardy on 8/23/11 at 2:15 p.m. The immediate jeopardy was removed on 8/24/11 but the non-compliance remained at a lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: On 8/23/11 at 10:10 a.m., during interview, CNA #1 indicated she came to work one morning toward the end of July 2011 and LPN #2 told her, during the night, Resident #B went to a store in his scooter and was escorted back to the facility by the police. CNA#1 indicated the ADON (Assistant Director of Nursing) was notified and came to the facility. The clinical record of Resident #B was reviewed on 8/23/11 at 10:30 a.m., and indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) Assessment, dated 7/15/11, indicated Resident #B received a score of 15 on the Brief Interview of Mental Status indicating he had no cognitive impairments. The MDS indicated the resident required extensive assistance for transfer, dressing, bathing and toileting, and had no behaviors coded. Elopement risk assessments dated 3/25/11 and 8/10/11, respectively, indicated Resident #B was not at risk for elopement. The 8/10/11, elopement assessment indicated the resident had no history of elopement. The August 2011, MAR (Medication Administration Record) indicated the resident received, among other medications, the following psychoactive medications: Haloperidol Decanoate 200 mg, intramuscularly, every 21 days; Risperidone 1.5 mg, three times daily; Depakote 250 mg, three times daily and Ativan 0.25 mg, every eight hours The resident requested additional PRN (as needed) Ativan for anxiety/panic attacks 10 times in August 2011. There was no documentation in the clinical record regarding the elopement incident, and there was no care plan related to elopement. On 8/23/11 at 11:00 a.m., the Administrator indicated, around 3:00 a.m. on 7/25/11, staff got Resident #B up and he went out to smoke. The Administrator indicated, about 20 to 30 minutes later, the nurse received a call from the police saying Resident #B was at a store which was about 0.5 miles from the facility. The Administrator indicated the night shift staff were not aware the resident was missing until the police called. The Administrator further indicated, the incident was not reported to the ISDH (Indiana State Department of Health), because the resident was not cognitively impaired and the facility did not have to call the police because the police called the facility. On 8/23/11 at 11:15 a.m., the ADON (Assistant Director of Nursing) indicated she was called by LPN #2 on 7/25/11 at 3:30 a.m. and she came into the facility. Resident #B was assessed and had no injuries. The ADON indicated there was no documentation of the incident in the clinical record, no incident report and no investigation because the resident was not cognitively impaired and was free to come and go. On 8/23/11 at 12:40 p.m., LPN #2 indicated she had worked the night shift on 7/25/11. LPN #2 indicated she got Resident #B up around 2:30 a.m. and he went out back in the fenced patio area for a smoke while she and the aide were doing rounds. She indicated she was not aware he had left the facility grounds until the police called and felt he must have left through the front door. LPN #2 indicated the alarm on the front door was not turned on, and she was not aware the alarm on the front door should be turned on until after the incident. On 8/23/11 at 3:00 p.m., during interview, Resident #B indicated the nurse woke him up to ask if he wanted a suppository, and he could not get back to sleep so he got up to have a smoke. The resident indicated, after he finished smoking, he came back into the facility, no staff were present so he went out the front door. Resident #B indicated, when he left, the front door was unlocked and did not alarm. Resident #B indicated he went down Dowling Road and turned on a side street. His plan was to go to the store and back, but the police stopped him and called the facility. The resident indicated the police followed him back to the facility while he drove his motorized wheelchair. The police report indicated LPN #2 "advises he is not supposed to be off the property and (Resident #B's Name) was returned safely on 7/25/11 at 3:40 a.m." Interview with a night nurse, RN #3, on 8/24/11 at 7:40 a.m., indicated she had been employed at the facility for approximately three weeks. RN #3 indicated she had been trained to lock the front doors to keep people out, but had not been trained to turn on the alarm at the front door, until last night, 8/23/11. Interview with the Administrator-in-training, who was the former Director of Nursing at the facility, on 8/24/11 at 8:15 a.m., indicated there was no policy to turn on the alarm to the front door. In practice, they were locking the front door but not turning on the alarm. They lock the doors at 10:00 p.m., and this kept people from coming in but did not prevent people from going out, since the door would open when the bar was pushed from the inside. The Administrator provided a list of five residents at risk of elopement on 8/23/11. Resident #B was not on this list. On 8/24/11 at 8:30 a.m., the Administrator indicated all residents had been assessed for elopement risk, and there are now seven residents identified as at risk of elopement in the facility, and this included Resident #B. The immediate jeopardy that began on 7/25/11 was removed on 8/24/11, when the facility assured alarms were turned on, were present on the exit doors, and inserviced staff, but the noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the need for ongoing monitoring. This Federal tag relates to Complaint IN 654. 3.1-45(a)(2)