Every finding on record at Kingston Health Center of Fort Wayne

Based on interview, observation and record review the facility failed to follow sanitation methods to maintain a clean environment in the kitchen area. 107 of 107 residents who resided in the facility ate food prepared in the kitchen.Findings include:During an observation, on 11/19/25 at 10:20 AM, 22 plus live gnats were observed in the dining room corner, on the opposite wall from the dishwasher. There were 3 carts covered in dried yellow and white liquid. There were also 3 carts of leftover food from breakfast waiting to be washed.During an interview, on 11/19/25 at 10:21 AM, the Dietary Manager (DM) indicated pest control had treated the gnats and it had resolved. The DM indicated there had been increased cleaning of the area and the carts were cleaned nightly. The DM indicated there was no documentation for nightly cart cleaning. The DM indicated the carts observed in the dining room had not been cleaned nightly based on appearance.During an interview, on 11/19/25 at 10:37 AM, the Maintenance Director indicated the pest control company had treated the area for gnats last week.A pest control log was provided by the Maintenance Director on 11/19/2025 at 10:37 AM. The log indicated on 10/31/25 pest control observed fruit flies in the kitchen area. On 11/13/25, the log indicated drain flies were found in the kitchen sinks, there was food over the dishwasher area and the kitchen/dining room area needed improved sanitation.During an interview, on 11/20/25 at 10 AM, the Administrator indicated the carts were not cleaned nightly as required. The Administrator indicated the area should have been cleaned to maintain sanitation and prevent pests.The was no documentation of regular cleaning to the area or carts.A current policy, dated 10/2024, titled Cleaning and Disinfection of Environment, was provided by the Administrator on 11/20/25 at 10 AM. The policy indicated surfaces and floors were cleaned on regular basis and when visibly soiled.A current policy, dated 9/2019, titled Cleaning Food Carts, was provided by the Administrator on 11/20/25 at 10 AM. The policy indicated the food carts were cleaned and sanitized after each use and meal.This finding relates to Intake 2651582.3.1-21(i)(3)

Based on interview, observation and record review the facility failed to follow sanitation methods to prevent pests. 107 of 107 residents who resided in the facility ate food prepared in the facility kitchen.Findings include:During an observation on 11/19/25 at 10:20 AM, 22 plus live gnats were observed in the dining room corner, on the opposite wall of the dishwasher. There were 3 carts covered in dried yellow and white liquid. There were also 3 carts of leftover food from breakfast waiting to be washed.During an interview on 11/19/25 at 10:21 AM, the Dietary Manager (DM) indicated pest control had treated the gnats and it had resolved. The DM indicated there had been increased cleaning of the area and the carts were cleaned nightly. The DM indicated there was no documentation for nightly cart cleaning. The DM indicated the carts observed in the dining room had not been cleaned nightly based on appearance.During an interview, on 11/19/25 at 10:37 AM, the Maintenance Director indicated the pest control company had treated the area for gnats last week.A pest control log was provided by the Maintenance Director on 11/19/2025 at 10:37 AM. The log indicated on 10/31/25 pest control observed fruit flies in the kitchen area. On 11/13/25, the log indicated drain flies were found in the kitchen sinks, there was food all over the dishwasher area and the kitchen/dining room area needed improved sanitation. There was no documentation the area had been treated again for the gnats.During an interview on 11/20/25 at 10 AM, the Administrator indicated the carts were not cleaned nightly as required. The Administrator indicated the area should have been cleaned to maintain sanitation and prevent pest.The was no documentation of regular cleaning to the area or carts.A current policy, dated 10/2024, titled Cleaning and Disinfection of Environment, was provided by the Administrator on 11/20/25 at 10 AM. The policy indicated surfaces and floors were cleaned on regular basis and when visibly soiled.A current policy, dated 9/2019, titled Cleaning Food Carts, was provided by the Administrator on 11/20/25 at 10 AM. The policy indicated the food carts were cleaned and sanitized after each use and meal.This finding relates to Intake 26515823.1-19(f)(4)

Based on interview and record review the facility failed to follow physician orders for 1 of 4 records reviewed. (Resident B).Findings include:In an interview on 11/19/25 at 12 PM, Resident B's family indicated Resident B re-admitted to the facility on [DATE] evening from the hospital. Resident B's family indicated Resident B missed her antiseizure medication on 11/19/25 at 8 PM and 11/20/25 at 8 AM. Resident B's family indicated they were notified on 11/20/25 Resident B had a seizure on 11/20/25 at 6 PM. Resident B's family indicated they were not notified of the missed medication dosage or unavailability of medication. Resident B's family indicated when Resident B missed a dose of her antiseizure medication, Resident B had a seizure.Resident B's record was reviewed on 11/19/25 at 12:16 PM. Diagnosis included epilepsy, hemiplegia and diffuse traumatic brain injury. A Hospital Medication Administration Record (MAR), dated 10/13/25 - 10/19/25, indicated Resident B received lacosamide/vimpat (antiseizure medication) 10 mg/mL solution 200 mg every 12 hours orally on 10/19/25 at 9:46 AM and the next dosage was due 10/19/25 at 9 PM.An admission evaluation, dated 10/19/25, timestamped 8 PM - 9:12 PM, indicated Resident B had returned to the facility.Active orders, dated 10/20/25, indicated to give lacosamide oral solution 10 mg/mL - give 20 ml by mouth every 12 hours for seizure prevention.The MAR, dated 11/2025, indicated Resident B did not receive her antiseizure medication on 11/19/25 at 8 PM nor on 11/20/25 at 8 AM.A nursing note, dated 10/20/25 at 3 PM, indicated Unit Manager (UM) 3 called the pharmacy and requested a STAT order of Resident B's antiseizure medication.A nursing note, dated 10/20/25 at 6 PM, indicated the nurse observed Resident B had a seizure and the family was notified.There was no documentation indicating the family was notified of the missed medication or unavailability of the medication.A provider note, dated 10/21/25, indicated the provider completed a medication review due to a seizure on 10/20/25. The provider indicated Resident B missed 2 doses of her anti-seizure medication, once on 10/19/25 evening and the 10/20/25 morning dose.During an interview, on 11/20/25 at 9:37 AM, the Director of Nursing (DON) and UM 3 indicated upon return from the hospital scripts are sent to the pharmacy and then delivered to the facility during 3rd shift. UM 3 and the DON indicated on 10/19/25 Resident B arrived at the facility late evening and the facility did not have Resident B's antiseizure medication in the emergency kit. UM 3 indicated on 10/20/25 around 3 PM, he was notified Resident B's antiseizure medication had not arrived at the facility yet. UM 3 indicated he then called the pharmacy for a STAT order. UM 3 indicated Resident B had a seizure on 10/20/25 around 6 PM.In an interview, on 11/20/25 at 10:38 AM, Licensed Practical Nurse (LPN) 4 indicated upon admission the nurse entered the discharge orders from the hospital. LPN 4 indicated another nurse would review the orders entered. LPN 4 indicated when a medication was not given due to unavailability the Nurse Practitioner and family were notified.A policy dated, October 2024, titled Pre-Admission/admission process, was provided by the Administrator on 11/20/25 at 10 AM. The policy indicated that all orders are entered prior to the resident arriving at the building and the primary physician is contacted to verify the orders. After verification of orders the medication list should be sent to the pharmacy.This finding relates to Intake 2653113.3.1-37

Based on record review and interview the facility failed to ensure a license was current for 1 of 159 licensed staff. (Qualified Medical Assistant (QMA) 9). Findings include: A review of the facility licensure book, on [DATE] at 12:PM, indicated QMA 9's license expired on [DATE]. In an interview, on [DATE] at 1:45PM, the Administrator was informed QMA 9's license was expired. In an interview, on [DATE] at 10:30AM, the administrator provided QMA 9's license renewed [DATE]. The Administrator was unsure if QMA 9 had worked any hours while the license was expired. In an interview, on [DATE] at 11:15 AM, the DON indicated the dates QMA 9 worked in the facility without a license was [DATE] and [DATE]. A timesheet was provided by the DON, on [DATE] at 12:18PM, for QMA 9 indicated she had worked on [DATE] and [DATE] administering medications on a hall to 10 residents. No policy was provided by time of exit. 3.1-17(b)(1)

Based on observation and interview, the facility failed to ensure safe sanitization parameters were maintained for cleaning solutions used in the kitchen. 106 of 109 residents eat food prepared in the facility kitchen. Findings include: During an observation, on 06/19/25 at 09:15 AM, the following was observed: the Dietary Manager (DM) performed dipstick testing on the red sanitization bucket in the main kitchen. The solution did not cause the test strip to change color. The DM indicated the test strip should change color to confirm the solution is a minimum of 150ppm (parts per million). The DM indicated chemical release towels were used that [NAME] chemical solution into the water in the bucket The bucket was emptied, refilled, and new chemical release towels were placed in the water. During an observation, on 06/19/25 at 10:30 AM, the Dietary Manager performed dipstick testing in the main kitchen and the test strip did not change colors. The DM indicated the water still did not meet the minimum requirements of 150ppm. Employee 8 indicated they just changed the bucket with new water and chemical release towels, but the solution did not have time to [NAME] into the water yet. During an observation, on 06/19/25 at 11:30 AM, the Dietary Manager performed dipstick testing in the main kitchen and the test strip changed colors to meet minimum parameters for 150ppm. The dipstick test in the sanitization bucket in the secondary kitchen did not change colors to meet the minimum test strength. The DM indicated the solution should meet the minimum strength to effectively sanitize. The bucket was emptied, then taken to the main kitchen and filled from the wall-mounted sanitizer solution dispenser. The solution then was tested at 300ppm. There were no policies provided regarding the use of towels as a replacement for wall-mounted sanitization units. 483.60(i)(1)(2)

Based on record review and interview the facility failed to ensure a bed hold policy was given prior to discharge to 3 of 3 residents reviewed. (Resident 26, Resident 28, and Resident 109) Findings include: 1) Resident 26's record review began on 06/20/25 at 01:11 PM. Diagnoses included stroke, heart failure, and seizures. A reveiw of progress notes, dated 10/14/24, indicated Resident 26 was sent to the hospital. There was no mention of a bed hold being explained to her or family in the progress or event notes. The facility provided an unsigned and undated discharge packet, The notice of transfer and discharge had a section requiring a signature and date which was left blank. The [NAME] Bed Holds and Leaves of Absence form had a place to designate whether the resident or resident representative prefers a bed to be held or do not hold a bed. The Bed Hold form further required a signature and date. On the form given, dated 10/14/24, all of the information was left blank. Progress notes indicated, on 11/21/24, Resident 26 was sent to the hospital. There was no mention of a bed hold being explained to her or family in Resident 26's medical record. The facility was unable to provide proof a bed hold was given prior to discharge. There was no discharge packet documented for 11/21/24. In an interview, on 06/24/25 at 08:08 AM, the Administrator indicated the facility did not have a bed hold for Resident 26 on the date of 11/21/24. The Administrator indicated the facility attempted to give discharge packets prior to leaving the building when for any reason the facility was not able to mail the form the following day. The Administrator indicated she was unaware of any requirement to show documentation of a bed hold being given or discussed prior to discharge requiring a signature. 2) Resident 28's record review began on 6/19/25 at 2:35PM. Diagnoses included diabetes, respiratory disease, and heart failure. Progress notes indicated Resident 28 was sent to the hospital on [DATE]. There was no mention of a bed hold being explained to him or his family in the medical record. The Facility provided an unsigned and undated discharge packet. The notice of transfer and discharge had a section requiring a signature and date which was left blank. The [NAME] Bed Holds and Leaves of Absence form had a place to designate whether the resident or resident representative prefered a bed to be held or do not hold a bed. The Bed Hold form further required a signature and date. On the form given for 12/2/24 all of the information was left blank. 3) Resident 109's record review began on 6/24/25 at 10:22AM. Diagnoses included dementia, heart failure, and respiratory disease. Progress notes indicated Resident 109 was sent to the hospital on 4/2/25. There was no mention of a bed hold being explained to her or her family in Resident 26's medical record. The facility was unable to provide proof a bed hold was given prior to discharge. There was no discharge packet found dated 4/2/25. In an interview, on 06/24/25 at 11:21 AM, the Administrator indicated no bed hold policy was available dated 4/2/25. A current policy titled, Bed Hold, Transfer and Discharge Notice dated March 2025 provided by the Administrator on 6/24/25 at 10:48AM, indicated .at the time of transfer to an Acute Care Facility or in cases of emergency, within 24hours the residing and their representative will be issued the appropriate [NAME] Bed Hold Notice and Bed Hold Policy via the preferred communication method No state rule applies.

Based on observation, interview and record review the facility failed to ensure facial hair and nail care was provided for 1 of 10 residents reviewed (Resident 41). Findings include: During an observation, on 6/20/25 at 1:36 PM, Resident 41 was observed in the dining room with many white chin hairs about 2 cm long and dark brown debris present under her first, second, and third fingernails of her right hand. During an observation, on 6/23/25 at 9:12 AM, Resident 41 was observed in the dementia care dining room eating her breakfast with dark brown debris under the nails of her right 2nd 3rd and 4th fingernails and 4th and 5th fingernails of her left hand. Her breakfast meal was scrambled eggs and toast, with no food item matching the color of the debris under her nails. Resident 41 had many white hairs about 3 cm long on her chin and upper lip. During an interview, on 6/23/25 at 9:23 AM, Certified Nurse Aide (CNA) 4 indicated Resident 41 had dark brown debris under her fingernails on both hands. She indicated it was dark brown and did not match the color of any item she ate that morning. She indicated Resident 41's hands should have been washed and nails cleaned prior to being served her breakfast. She indicated her facial hair was long and should have been groomed. She indicated Resident 41 had not been resistant to facial hair and nail care in the past. Resident 41's record was reviewed on 6/20/25 at 2:16 PM. Diagnoses included dementia without behavioral disturbance, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. A review of Resident 41's current quarterly Minimum Data Set Assessment (MDS) indicated their Basic Interview for Mental Status (BIMS) score was 3 (cognitively impaired). The MDS indicated Resident 41 did not have any occurrences of rejection of care and needed substantial assistance with personal hygiene. A review of Resident 41's current care plan titled Resident requires activity of daily living (ADL) assist indicated the resident had a problem of a recent stroke affecting her right side and weakness, with a goal date of 7/5/25. The care plan indicated Resident 41 should receive appropriate assistants for ADLs. Interventions included staff should document the care provided in dressing and grooming. Resident 41's current care plan titled Altered cardiac output indicated Resident 41 had a problem of dysarthria, hemiplegia and hemiparesis with a goal date of 7/5/25. Interventions included providing ADL assistance as appropriate. A review of progress notes for 6/2025 did not include any documentation of care refusal. In an interview, on 6/23/25 at 1:48 PM, the Director of Nursing (DON) indicated residents' hands and nails should be clean prior to meal service. Facial hair on female residents should be removed unless they indicate a preference to not receive the care. She indicated care refusal should be documented in the progress notes. She indicated trends of refusal of care or preferences not to receive specific care should be noted in the care plan. A current policy, dated 1/24, provided by the Administrator on 6/23/25 at 1:07 PM, indicated facial shaving should be provided to promote cleanliness and provide skin care. The policy indicated any refusals should be documented. A current policy, dated 5/23, provided by the Administrator on 6/23/25 at 1:07 PM, indicated nail care included regular cleaning and trimming. The policy indicated debris should be gently removed from under the nails during cleaning. 3.1-38(a)(3)(D) 3.1-38(a)(3)(E)

Based on observation, interview and record review the facility failed to ensure an exit door remained secure for 1 of 5 residents reviewed (Resident 98). Findings include: Resident 98's record was reviewed on [DATE] at 10:19 AM. Diagnoses included Alzheimer's disease with early onset, restlessness and agitation, and psychotic disorder with delusions due to known physiological condition. A review of Resident 98's current admission Minimum Data Set Assessment (MDS), dated [DATE], indicated their Basic Interview for Mental Status (BIMS) score was 10 (cognitively impaired). The MDS indicated Resident 98 had displayed verbal behavioral symptoms toward others 1-3 days per week and puts others at risk of significant risk of physical injury. The MDS indicated Resident 98 wandered with a significant risk of getting into potentially dangerous places. A review of Resident 98's current care plan titled Risk for Elopement indicated the resident had a problem of being independently ambulatory, having dementia, exit seeking behaviors, and poor safety awareness with a goal date of [DATE]. Interventions included using a wanderguard and checking the wanderguard's function. An elopement assessment, dated [DATE] at 1:48 PM, indicated Resident 98 was fully ambulatory, wandered aimlessly with redirectable behavior, and was content with placement. The assessment indicated Resident 98 had not made any attempts to leave the facility. A review of physician orders dated [DATE] at 2:09 PM, indicated a wanderguard was ordered to be placed on Resident 98's left ankle and staff should check placement and function each shift. A physician's order, dated [DATE] at 7:50 PM, indicated Resident 98 could reside in the facility's locked memory care unit. A review of progress notes, dated [DATE] at 7:00 PM, indicated Assistant Director of Nursing (ADON) 3 was notified by phone Resident 98 exited the building using a side exit and was promptly escorted back into the building. Progress notes, dated [DATE], did not include an account of Resident 98 exiting the facility, any immediate intervention or physical assessment. Progress notes, dated [DATE] at 7:20 PM, indicated Resident 98 had moved to the memory care unit due to increased wandering and family request. No assessments were included in the progress note. An elopement assessment, signed by the Director of Nursing (DON) on [DATE] with an effective date of [DATE] at 7:00 PM, indicated Resident 98 was fully ambulatory, wandered aimlessly, voiced desire to leave, was difficult to redirect and made at least one attempt to leave the facility. In an interview, on [DATE] at 11:17 AM, ADON 3 indicated he was on call when he received notice of Resident 98 exiting the building. He indicated Resident 98 was originally admitted to a room that was not located on the secured memory care unit. On the day of his admission, Resident 98 was observed to exit the facility through the service hall doorway by a dietary employee who was placing trash in the dumpster located about 50 feet from the service hall doorway. The dumpster was in an outdoor area open to the parking lot near the rehabilitation entrance to the facility. He indicated the door was not armed with wanderguard locking devices, but had alarms in place that should have sounded when the door was pushed open. He indicated the staff did not hear the alarm go off. He demonstrated opening the door with no sounding of the alarm. He indicated the alarm should have sounded and did not know why it had been disarmed. He placed a key in the lock on the push bar on the door, turned it, and pushed on the door. The door alarmed loudly when pushed and released after 15 seconds. He indicated each unit nurse had a key to the door to activate the lock clearly marked. He indicated he did not know who had disarmed the door or for what purpose. He indicated the door should be armed when not in direct attendance by staff. In an interview, on [DATE] at 1:19 PM, Maintenance Assistant 6 indicated he checked the service hall exit door earlier on [DATE]. The door had been armed, alarmed and locked properly. He indicated he was not aware of who disarmed the door or for what purpose. He indicated the door alarm should have sounded, and the door should have been locked when pushed. In an interview, on [DATE] at 1:28 PM, the Administrator indicated the door had not locked when pushed because the door became armed after a one-minute delay after the door closed. In an interview, on [DATE] at 1:30 PM, The ADON indicated he had not been aware of the one-minute delay on the service exit door. During a record review, on [DATE] at 1:30 PM, in-service documents provided by the Administrator on [DATE] at 9:00 AM indicated 17 staff members signed in-service sign-in forms beginning [DATE], conducted by the DON pertaining to the topic of the elopement policy. In-service sign-in forms indicated 60 staff members signed in for in-services provided by the Administrator, beginning [DATE] on secured door systems, discussion and demonstration. An employee listing provided by the Administrator on [DATE] at 9:00 AM indicated 199 employees worked at the facility. In an interview, on [DATE] at 1:41 PM, the Director of Nursing (DON) indicated she had presented in-services to staff after the elopement event and covered the information in the elopement policy. She indicated the Administrator performed additional in-servicing including a demonstration of the secured door system. She indicated the facility utilized agency staff to supplement facility staffing to ensure staffing needs were met. During an observation, on [DATE] at 1:51 PM, the DON entered the door code and opened the service hallway door to the outside of the building. About 10-15 seconds later, she pushed the door, and it opened without delay. The door alarm sounded upon opening. The DON indicated she was not aware of any delay in the locking mechanism engaging after the door closed. During an observation, on [DATE] at 1:58 PM, the Administrator entered the door code and opened the service hallway door to the outside of the building. After allowing the door to close, she waited until a red light appeared on the push bar of the door and pushed on the door again. The door remained locked, and the alarm sounded. She indicated she had performed this demonstration during her in-service to show staff how to ensure the door was armed. She indicated staff were instructed to push on the door after closing it to ensure the alarm sounded. During an interview, on [DATE] at 6:02 AM, Certified Nurse Aide (CNA) 2 indicated the code pad on the wall next to the door armed the door. She indicated when the door was closed it was armed and should alarm when open. She indicated she was not aware of any delay between when the door closed and when it would arm. During an observation, on [DATE] at 6:03 AM, CNA 2 entered a code into the keypad and opened the service hallway door to the outside of the building. She pushed on the door about 15 seconds after it closed. The alarm sounded and the door opened immediately. She indicated she did not know why the locking mechanism did not engage when the door closed. In an interview, on [DATE] at 12:14 PM, the Administrator indicated the exit door used by Resident 98 to exit the facility was about 349 feet from the road. The road was a 4-lane main city thorofare. A document titled Chexit, manufacturers guidelines for use of a controlled egress device was provided by the Administrator on [DATE] at 8:01 AM. The document indicated the Chexit device should sound an alarm and keep the door secured for 15 seconds following an exit attempt with immediate release upon fire. The guideline indicated a rearm delay was the amount of time after the key switch was activated before the alarm sounded. The guideline indicated the rearm time could be changed from 2 seconds to 28 seconds in 2 second increments. The document indicated if the rearm time was set to 30 seconds and a door position switch (DPS) was used, the door would not alarm after the rearm time expired. The Chexit would not rearm until the door was closed. If not using a DPS, the Chexit would rearm in 30 seconds. If the DPS detected the door closed during a rearm delay, the Chexit ended the rearm delay and allowed 2 seconds for the latch to clear the strike before rearming. A current policy, dated 11/23 provided by the Administrator on [DATE] at 1:31 PM, indicated the facility staff should immediately assist the resident in returning to the building and document the event in the medical record. This citation is related to complaint IN00459756. 3.1-45(a)(2)

Based on observation, interview, and record review the facility failed to ensure physician's orders were followed for 1 of 1 residents reviewed. (Resident 112) Findings include: During an observation, on 06/19/25 at 09:25 AM, the oxygen concentraor in Resident 112's room was turned off, and the nasal cannula was secured in a plastic bag on top of the machine. Resident 112 was in the bed with his eyes closed. During an observation, on 06/20/25 at 09:40 AM, the oxygen machine in Resident 112's room was turned off, and the nasal cannula was secured in a plastic bag on top of the machine. Resident 112 was resting in bed. His respirations were easy. During an observation, on 06/23/25 at 09:29 AM, oxygen was placed on Resident 112 via nasal cannula at 5LPM (liters per minute). Employee 5 indicated in an interview, on 6/23/25 at 9:30 AM, Resident 112 had a change in condition and oxygen was placed on him via nasal cannual at 5LPM. During an observation, on 06/23/25 at 01:41 PM, Resident 112's oxygen was running via nasal cannula at a rate of 5LPM. During an observation, on 06/24/25 at 08:45 AM, oxygen was placed on Resident 112 via nasal cannual at 5LPM. In an interview, on 6/24/25 at 8:46 AM, Employee 5 indicated Resident 112's oxygen was set to 5LPM, and their oxygen saturation was 95%. Employee 5 indicated their oxygen should be set at 2LPM per physician order, then was observed to turn the resident's oxygen down to 2LPM. Employee 5 indicated the oxygen levels should be checked at least once per shift. In an interview, on 06/24/25 at 08:56 AM, the Director of Nursing (DON) indicated when a resident requires more or less oxygen than indicated on the physician's order, then they would need to obtain a new physician order. Resident 112's record was reviewed on 06/24/25 at 12:30 PM, diagnoses included Parkinson's, restlessness and agitation, and squamous cell carcinoma. A review of physician's orders dated 06/24/25 at 12:30 PM indicated oxygen should be titrated via nasal cannula between room air and 2LPM to keep oxygenation greater than or equal to 90% every shift. A current policy, dated 06/24/25, provided by the DON, indicated physician orders and progress notes shall be maintained in accordance with current OBRA regulations and facility policy. The policy did not indicate physician orders should be followed. 3.1-47(a)(4)(5)(6)

Based on record review and interview, the facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for 2 of 3 residents reviewed. (Resident 17 and Resident 163) Findings include: 1) Resident 17's record review began on 06/23/25 at 02:17 PM. Resident 17's diagnoses included end stage renal disease, diabetes, and hypertension. Resident 17 had a physician order for dialysis on Tuesdays, Thursdays, and Saturdays. A review of Resident 17's dialysis communication book indicated the Hemodialysis communication forms had the following missing information: - 6/14/25 Had no communication from the dialysis center. No vital signs. No weight. No run time. No dry weight. No post dialysis assessment. No information regarding if there were any complications. No information regarding medications given. No information regarding if labs were drawn. - 6/17/25 Had no communication from the dialysis center. No vital signs. No weight. No run time. No dry weight. No post dialysis assessment. No information regarding if there were any complications. No information regarding medications given. No information regarding if labs were drawn. A review of Resident 17's medical record indicated there was no documentation the facility further attempted to get the information from the dialysis center. 2) Resident 163's record review began on 06/19/25 at 11:42 AM. Resident 163's diagnoses included end stage renal disease, diabetes, and hypotention. Resident 162 had a physician order for dialysis on Tuesdays, Thursdays, and Saturdays. A review of Resident 163's dialysis communication book indicated the Hemodialysis communication forms had the following missing information: - 6/14/25 Had no communication from the dialysis center. No vital signs. No weight. No run time. No dry weight. No post dialysis assessment. No information regarding if there were any complications. No information regarding medications given. No information regarding if labs were drawn. - 6/17/25 Had no communication from the dialysis center. No vital signs. No weight. No run time. No dry weight. No post dialysis assessment. Indicated medications were given and to see attachment. There was no attachment or medications with dosages written. - 6/21/25 the form had vital signs but no weights pre dialysis weight and dry weight to see how much was taken off. There were no post dialysis vital signs. Indicated medications were given and to see attachment. There was no attachment or medications with dosages written. A review of Resident 163's medical record indicated there was no documentation the facility further attempted to get the information from the dialysis center. In an interview, on 06/23/25 at 02:04 PM, the Assistant Director of Nursing (ADON) indicated the importance of communication with the dialysis center was to ensure there were no complications to monitor and to know the follow up required to properly care for the resident. The ADON indicated the expectation was to call the dialysis center and get information, then either write it onto the form or to make a progress note in the resident's medical record. A current policy titled Dialysis dated October 2019 indicated The facility shall provide a safe environment for residents receiving treatments, including monitoring the resident before, during, and after dialysis treatments .collaborates with an End Stage Renal Disease facility to provide dialysis care coordination . 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure grievances were thoroughly investigated, contained required documentation, and appropriate corrective actions taken for 1 of 3 residents reviewed with grievances (Resident Q). Findings include: A report, dated 4/23/25, alleged Resident Q was rushed and handled roughly during personal care provided by Certified Nurse Aide (CNA) 2. On 5/14/25 at 12:55 P.M., Resident Q's record was reviewed. Diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) following a stroke affecting the right side. A nurse note, dated 4/6/25 at 1:26 p.m., indicated Resident Q had arrived to the facility from the hospital. She was alert, oriented and able to make her needs known to staff. She'd had a recent stroke with expressive aphasia (difficulty speaking fluently) and paralysis on the right side. She reported having some pain on her entire right side. She required assistance of 1 with completing her activities of daily living (ADL). A respiratory therapy note, dated 4/10/25 at 9:55 a.m., indicated Resident Q was to receive assistance with using her incentive spirometer but had refused due to being upset about how the CNA had gotten her up. A nurse note, dated 4/10/25 at 11:12 a.m., indicated Resident Q's daughter had gone to the nurses station to speak with the nurse about the morning care her mother had received from CNA 2. The nurse immediately went to the resident's bedside to check on her where no bruising or other concerns were observed. Management was notified. There was no follow up documentation in the medical record after Resident Q's daughter had expressed care concerns on 4/10/25 through the resident's discharge from the facility on 4/23/25. On 5/14/25 at 1:30 P.M., the Social Services Director (SSD) was interviewed. She indicated the facility hadn't used grievance forms and when a concern was brought to a staff members attention, staff were to address the issue at the time. When asked, the SSD was unsure of how the facility was tracking grievances or concerns to ensure prompt efforts were being made to resolve the grievance, prevent further potential violations, and ensure appropriate corrective actions were taken while the grievance/concern was being reviewed. The SSD indicated she had no concerns or grievances reported to her for the month of April or May. On 5/15/25 at 3:15 P.M., the Administrator was interviewed and a current copy of the facility policy for grievances provided. The Administrator indicated the SSD was the facility's designated Grievance Officer who was responsible for overseeing the grievance process, receiving and tracking grievances through to conclusion and leading any necessary investigations by the facility. The Administrator indicated the facility used grievance forms, located outside the door of the SSD for residents, staff, families or visitors to use to convey grievances. On 5/15/25 at 3:20 P.M., the Director of Nursing (DON) was interviewed regarding care concerns of Resident Q, reported on 4/10/25. She indicated she wasn't sure if a formal grievance had been written but she and the Unit Manager followed up with the resident and her daughter on 4/11/25. The resident had indicated CNA 2 had rushed her and pulled on her right/paralyzed side while providing care. Resident Q indicated she hadn't been hurt but was rushed. The DON indicated she didn't know why there had been no follow up documentation in the resident's record to indicate the grievance had been addressed promptly or actions taken to prevent further violation of the resident's rights while the grievance/concern was investigated. During an observation on 5-14-25 through 5-15-25, no grievance or concern forms were readily available at common area, nurse's stations or at the SSD office. A current copy of the facility policy, titled Grievance Policy/Grievance Officer, was provided by the Administrator on 5/15/25 at 3:15 P.M., and stated: [Facility] ensures the right of residents, and the resident representative to voice and have prompt resolutions to their grievance .maintains a formal policy when the Grievance Officer (GO) is approached .The Grievance Officer is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility .Other concerns are addressed via the concern form and if there is not resolution the concern will be brought to the GO by the resident or resident representative .3. If there is a grievance that needs to be given to the GO, the GO will lead the investigation. This will be tracked on the tracking log. 4. The Grievance Officer will follow up with the person who brought forward the concern in approximately 72 hours following review of the concern .After the investigation the GO will issue final decision to the resident and/or representative This Citation relates to Complaint IN00458140. 3.1-7(a)(2)

Based on interview and record review, the facility failed to ensure a surgical wound was assessed and monitored for 1 of 3 residents reviewed (Resident P). Findings include: On 3/14/25 at 11:15 A.M., Resident P's record was reviewed. Diagnoses included dementia with behavioral disturbance and fracture of the right femur (12/23/24). A nurse note, dated 12/17/24 at 6:35 p.m., indicated Resident P had a fall and was observed on the floor of room in his doorway. The resident was yelling in pain and holding his right hip. He was sent to the emergency room for evaluation and treatment. A hospital operative report, dated 12/19/25, indicated the resident had fallen and fractured the top of his right femur. A right hip cemented hemiarthroplasty (replacing the ball at the top of the femur bone with a metal implant and securing with cement-National Institue of Health) was performed and the surgical incision closed with staples. An Admission Evaluation, dated 12/23/24 at 4:00 p.m., indicated Resident P was readmitted to the facility from the hospital. He was alert and denied pain. He was bed bound at the time following surgery related to fractures. Skin observation indicated the resident had no skin issues. A Baseline Plan of Care, dated 12/23/24 included the resident would be comfortable, would receive therapy services, was at risk for falls, had impaired skin integrity due to a skin tear on his left lower extremity, was at risk for further impaired skin integrity due to decreased mobility, and had pain related to osteoarthritis. The Admission Evaluation with Baseline Plan of Care did not indicate the resident had a surgical wound incision, closed with staples, or dressings present or not present. There was no description of the surgical incision and no documentation of signs or symptoms of infection. An admission Minimum Data Set (MDS) assessment, dated 12/28/24, indicated the resident had a surgical wound and received surgical wound care (Surgical wound care may include any intervention for treating or protecting any type of surgical wound. Examples may include topical cleansing, wound irrigation, application of antimicrobial ointments, application of dressings of any type, suture/staple removal, and warm soaks or heat application-Resident Assessment Instrument [RAI] 2024). A care plan, dated 1/8/25, indicated the resident was at risk for impaired skin integrity related to decreased mobility, impaired circulation, impaired sensation, and incontinence. Interventions included: encourage/assist to turn/reposition; pressure reduction surface in wheelchair; pressure redistribution surface to bed; and treatments as ordered. A Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated December 2024, did not indicate the resident received surgical wound care, surgical wound assessment, monitoring, nor observation for signs and symptoms of infection. A nurse note, dated 12/24/24 at 1:39 p.m., indicated the resident had moderate bleeding to his right hip and the dressing was changed. The note did not indicate notification to the physician had occurred nor further assessment completed of the surgical wound appearance. There was no further documentation completed on the resident's surgical wound, status of staples, signs or symptoms of infection, bleeding, nor dressings applied from 12/25/24 through 1/6/25. A nurse note, dated 1/7/25 at 2:51 p.m., indicated a follow up appointment with the orthopedic surgeon was made for 1/22/25 at 2:45 p.m. pending response from the orthopedic (ortho) team regarding staple removal. Skilled nurse notes, dated 1/9/25 at 1:25 a.m., 1/10/25 at 6:48 p.m., 1/11/25 at 6:57 p.m., 1/12/25 at 7:00 p.m., 1/13/25 at 3:11 p.m., and 1/15/25 at 9:52 a.m. indicated Resident P had no surgical wounds. A nurse note, dated 1/10/25 at 2:39 p.m., indicated clarification of staple removal had been given by the ortho team. Staples were to remain in and not to be removed by staff. The staples would be removed at his appointment on 1/22/25. An electronic MAR (eMAR), dated 1/19/25 at 7:27 p.m., indicated staples were dry and intact without signs or symptoms of infection. A nurse note, dated 1/22/25 at 4:00 p.m., indicated Resident P had returned to the facility from his orthopedic appointment with new orders for showering and may get incision wet. A TAR, dated January 2025, indicated an order, dated 1/15/25-1/22/25, was for staff to monitor staples to the residents right hip and notify the physician of signs or symptoms of infection every shift. There was no care plan put in place to assess, monitor, or observe the surgical wound for signs or symptoms of infection. Skilled nurse notes didn't indicate Resident P had a surgical wound. Assessment of the surgical wound occurred 1 time on 1/19/25 when it had been assessed as dry, intact, and without signs or symptoms of infection. Evaluation of Surgical Wounds was retrieved from woundsource.com on 3/14/25 which indicated: A general physical examination including current pain assessment should be completed and documentation of the wound completed which includes the anatomic location and length of the surgical incision, the closure method such as sutures or staples, bleeding, inflammation (redness/swelling) or drainage present. Assess and monitor any sutures, staples, and glue sites and make sure an order is in place for removal-timing of suture or staple removal varies from 3-21 days. Monitoring the surgical site can prevent or minimize surgical site infections. Symptoms of infection may include fatigue, malaise, fever, warmth/redness around the incision, excessive bleeding or foul smelling drainage. On 3/14/25 at 11:59 A.M., Registered Nurse (RN) 2 was interviewed. She indicated upon admission, the resident's skin was to be assessed including any wounds-surgical or pressure, and documented in the progress notes. Resident P's surgical wound should have been assessed and documented upon admission and the wound assessed and monitored for signs of infection daily. On 3/14/25 at 12:36 P.M., the Director of Nursing (DON) was interviewed. She indicated Resident P's surgical wound should have been assessed upon admission and every shift until removal of the staples or follow up with the surgeon had occurred. Staff should've observed the surgical incision for signs of non-healing, signs of infection, and obtained a date for staple removal when he returned from the hospital. A current facility policy, titled Wound and Skin Management Protocol was provided by the DON on 3/14/25 at 2:03 P.M. The DON indicated the facility had no specific policy regarding surgical wound care and the current policy was used for all resident skin impairments. The protocol indicated: An admission assessment/observation should be completed within the first 8 hours but no greater than 24 hours .a plan of care for skin integrity was to be initiated including treatment orders if applicable and appropriate interventions put in place This Citation refers to Complaint IN00454446. 3.1-37

Based on interview and record review, the facility failed to ensure complete and accurate medical records were maintained for 1 of 3 residents reviewed (Resident D). Findings include: On 10/18/24 at 2:21 P.M., Resident D's spouse was interviewed. During the interview, she indicated several concerns with the care provided the resident during his stay. She alleged Resident D's medication to treat his bi-polar disorder was decreased and a new medication given. She had spoken with the Nurse Practitioner (NP) and indicated she had not wanted the residents medication to be decreased and had not wanted him to be placed on a new medication. Additionally, she alleged the staff hadn't noticed the resident had no teeth or dentures and had not served him soft foods. She indicated the resident was given food he was unable to chew so he just hadn't eaten. On 10/18/24 at 3:07 P.M., Resident D's record was reviewed. Diagnoses included bradycardia (slow heart rate), chronic obstructive pulmonary disease (COPD), chronic kidney disease, diabetes, dementia and bi-polar disorder. 1. A physician order, dated 9/13/24, was written for Lithium Carbonate (used to treat bi-polar disorder) 300 milligrams (mg) extended release (ER) by mouth, 2 times per day to treat bi-polar disorder. On 9/18/24 at 8:47 a.m., the Psychiatric NP visited with the resident. The resident had recently been sent to the hospital from his assisted living (AL) apartment. The NP had been providing services to the resident for the past 3 years. During the visit, the resident was observed to be weak and confused and it took him a few minutes to recall who the NP was. He had intermittent tremors in both of his arms. He was to continue his current dose of Lithium 300 mg ER by mouth 2 times per day. -At 2:39 p.m., the Medical NP visited the resident to review his lab results obtained on 9/17/24. There were no new orders. A Lab Results Report, collected on 9/20 and reported on 9/21/24, indicated the residents blood lithium level was elevated at 1.6 (normal 1.0-1.2 mmol/L). There was no physician order documented to indicate the residents blood lithium level was to be drawn and there were no nurse notes documented on 9/20/24 to indicate labs had been drawn from the resident. There were no nurse notes, documented on 9/21/24, to indicate the doctor or NP had been notified of the abnormal lab results. On 9/23/24 at 11:04 a.m., the medical NP visited the resident for his increased tremors and review of lab results. Tremors in both arms/hands had increased over the past week interfering with his ability to help care for himself. Lab results from 9/20/24 were reviewed. His lithium level was elevated at 1.6. His dosage of Lithium ER 300 mg, 2 times per day would be decreased to 1 time per day for 4 days, then resume 2 times daily dosing. His lithium level would be rechecked on 9/26/24. If his tremors worsened, she would prescribe Amantadine (antiviral medicine used to treat tremors) 100 mg by mouth daily. On 9/24/24 at 9:32 a.m., the medical NP documented she had spoken with the resident's wife the night before (9/23/24) by phone. His wife indicated the resident had taken Lithium for years due to his drastic mood changes when not taking the medication regularly and she hadn't wanted his dosage changed. The NP reordered the resident's Lithium ER 300 mg woul back to 2 times per day and his blood lithium level rechecked on 9/26/24. If his tremors worsened, he could be given Amantadine 100 mg by mouth daily. A physician order, dated 9/24/24 at 9:06 a.m., was to give Lithium ER 300 mg by mouth 2 times per day. -At 8:00 p.m., Lithium ER 300 mg by mouth 2 times per day was discontinued by the psychiatric NP and decreased to Lithium (immediate release) 150 mg by mouth 2 times per day. There was no nursing documentation to indicate the reason for or the change in the Lithium orders. On 10/21/24 at 10:57 A.M., the psychiatric NP was interviewed. She indicated she had received a secure message from the medical NP indicating the concern with the residents increased tremors and elevated blood lithium level. She had reviewed the secure message, the evening of 9/24/24, had responded back to the facility, and decreased Resident D's lithium dosage. On 10/21/24 at 11:36 P.M., the Director of Nursing (DON) was interviewed. She indicated it was a company policy to allow the use of secured messaging between healthcare professionals providing care to residents at the facility but facility nursing staff were expected to document new order changes in the residents record. 2. A Nursing Admission/Observation form, dated 9/13/24 at 1:18 p.m., indicated an observation of Resident D's oral (mouth/teeth/gums) status was completed. The observation indicated there were no issues observed. The resident was prescribed a no concentrated sweet diet (NCS) (low carbohydrate due to diabetes) which was regular texture with thin liquids. There was no documentation Resident D was endentulous (without teeth) A Speech Therapy Evaluation and Plan of Treatment, dated 9/17/24, indicated the resident had been referred to speech therapy to assess the residents cognition and safety awareness. A swallow study was suggested due to the resident indicating he had difficulty taking multiple pills at once, needed his food cut into smaller pieces, and had difficulty chewing and swallowing food like lettuce. A consultation, evaluation, and management report for dysphasia (difficulty swallowing), dated 9/17/24, indicated the resident was being evaluated due to coughing when swallowing and feeding/swallowing difficulties. The evaluation was done to determine the safest diet for the resident. On visual inspection of the residents mouth, he was observed with no teeth. He indicated his dentures no longer fit well so he didn't wear them. There were no physician orders documented for a speech therapy evaluation or a swallow study to be completed due to chewing and swallowing difficulties. Resident care plans hadn't indicated the resident was edentulous (lacking teeth) and required meals with soft foods. In an interview, on 10/21/24 at 2:54 PM, the DON indicated there was not a policy regarding documentation. A policy regarding complte and accurate documentation was not available for review by time of exit. This Citation relates to Complaint IN00444543. 3.1-50(a)(1) 3.1-50(a)(2)

Based on observation, interview, and record review the facility failed to ensure a sanitary environment for dining in the crown dining room. 20 residents of 108 residents residing in the facility consumed meals in the crown dining room. Findings include: During an observation and interview on 8/21/24 at 1:19 PM, Resident 77 picked up plates, glasses and silverware from tables, placing them in a large dishpan on top of a cart. No gloves were worn, and no hand hygiene was observed. A white fluffy substance was observed on Resident 77's hand, consistent in appearance to the mashed potatoes served at the lunch meal. Resident 77 propelled herself by grabbing the tables where residents were seated. She grabbed the handle on Resident 49's wheelchair and pulled her wheelchair forward. Resident 77's hands still contained remnants of white fluffy residue. She had not utilized had hygiene. [NAME] 8 indicated Resident 77 liked to help, but she was not capable of maintaining sanitation standards. [NAME] 8 indicated she had difficulty stopping Resident 77 from bussing the tables because she was busy serving other residents and she was the only employee in the dining room. In an interview on 8/23/24 at 9:21 AM, Resident 76 indicated she had bussed tables in the dining room to help the staff before. She indicated no training or oversight was provided. In the same interview, Resident 82 indicated residents bussing tables in the dining room was not an unusual occurrence. She indicated residents frequently help when short staffing occurs. She indicated no training about hand washong had been provided. 1) Resident 49's record was reviewed on 8/23/24 at 1:01 PM. Diagnoses included major depressive disorder, unspecified dementia, moderate, with other behavioral disturbance, and generalized anxiety disorder. Resident 49's current quarterly, Minimum Data Set (MDS) dated [DATE] indicated their Basic Interview for Mental Status (BIMS) score was 8 (cognitively impaired) 2) Resident 76's record was reviewed on 8/23/24 at 1:40 PM. Diagnoses included major depressive disorder recurrent severe without psychotic features, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and dysphagia following cerebral infarction. Resident 76's current quarterly MDS dated [DATE] indicated her indicated her Basic Interview for Mental Status score not available due to not being assessed. Resident 76's quarterly MDS dated [DATE] indicated her BIMS score was 15 (cognitively intact) 3) Resident 77's record was reviewed on 8/23/24 at 10:15 AM. Diagnoses included hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left dominant side, unspecified psychosis not due to a substance or known psychological condition, and generalized anxiety disorder. Resident 77's current quarterly Minimum Data Set (MDS) dated [DATE] indicated her Basic Interview for Mental Status) BIMS score was 15 (cognitively intact). Resident 77's current care plan titled .displays manipulative behavior .indicated the resident had a problem of needing diversional activities, with a goal date of 10/22/24. Interventions included removing Resident 77 from the public area when behavior was disruptive and providing a diversional activity. Resident 77's current care plan titled .choices are important .indicated Resident 77 wanted to do therapeutic work, such as collecting dirty dishes with a goal date of 10/22/24. Interventions included educating the resident and family on infection control policy. 4) Resident 82's record was reviewed on 8/23/24 at 12:36 PM. Diagnoses included chronic kidney disease, stage 3, unspecified, generalized anxiety disorder, and essential hypertension. Resident 82's current quarterly MDS dated [DATE] indicated her BIMS score was 15 (cognitively intact). In an interview on 8/22/24 at 10:25 AM, the Director of Nursing (DON) indicated education on hand hygiene, instructions to not interfere with others while they eat and sanitation principles for Resident 77 was not available for review. The DON indicated she could not recall when her appropriateness to perform bussing activities was last reviewed. A current policy titled Policies and Practices - Infection Control dated August 2019 provided by the Administrator on 8/20/24 at 10:30 AM indicated the facility's policies and procedures are intending to facilitate maintaining a safe, sanitary and comfortable environment to help prevent and manage transmission of diseased and infections. The policy indicated infection control policies and practices apply equally to all personnel, residents and visitors. The policy indicated training should occur when indicated. The policy indicated having an objective of maintaining a safe, sanitary and comfortable environment. 3.1-18(a)

Based on observation, interview, and record review the facility failed to ensure a dignified dining experience for 5 of 20 residents reviewed (Resident 49, Resident 76, Resident 77, Resident 82, and Resident 100). Findings include: During an observation on 8/21/24 at 12:46 PM, Resident 49, Resident 76 and Resident 82 were seated together at a table. Resident 49 and two unidentified residents had plates of food in front of them, but Resident 76 and Resident 82 had not yet been served. [NAME] 8 served trays to each table where other residents were waiting before taking lunch orders for Residents 76 and 82. Resident 76 and Resident 82 were served lunch at 1:18 pm. Resident 49 did not engage in eating tasks until her tablemates were served. Resident 49 indicated her food had become cold while she waited to eat. During an observation and interview on 8/21/24 at 1:19 PM, Resident 77 picked up plates, glasses and silverware from tables, placing them in a large dishpan on top of a cart. Resident 77 propelled herself by grabbing the tables where residents were seated while they were eating their lunch, and grabbed the handle on Resident 49's wheelchair, pulling the wheelchair forward. Resident 77 indicated she was trying to help the staff because they were running behind. She indicated she was concerned the room would not be cleared in time for the BINGO activity to start as scheduled at 2:00 PM. Resident 77 approached Resident 100 asking if she could clear his dishes from the table. Resident 100 had an irritated facial expression, shook his head, and indicated he did not understand what Resident 77 was trying to prove. [NAME] 8 spoke to Resident 100 and indicated Resident 77 was just trying to help. Resident 77 approached Resident 49, Resident 76 and Resident 82 and began taking their plates and silverware without asking. Resident 76 and Resident 82 had not had time to complete eating their desserts. In an interview on 8/21/24 at 1:24 PM, Dietary Aide 7 indicated residents should be served table by table. If residents arrive late, they should be worked in as soon as possible, before beginning service to an unserved table. In an interview on 8/21/24 at 1:27 PM, [NAME] 8 indicated trays are served on a first come, first serve basis. In an interview on 8/22/24 at 10:25 AM, the Director of Nursing indicated residents at a table should be served at the same time. She indicated any late arriving residents should be worked in as soon as possible rather than serving in order of arrival. In an interview on 8/23/24 at 9:21 AM, Resident 76 indicated she had bussed tables in the dining room to help the staff before. She indicated no training or oversight was provided. In the same interview, Resident 82 indicated residents bussing table in the dining room was not an unusual occurrence. She indicated residents frequently help when short staffing occurs. 1) Resident 49's record was reviewed on 8/23/24 at 1:01 PM. Diagnoses included major depressive disorder, unspecified dementia, moderate, with other behavioral disturbance, and generalized anxiety disorder. Resident 49's current quarterly, Minimum Data Set (MDS) dated [DATE] indicated their Basic Interview for Mental Status (BIMS) score was 8 (cognitively impaired). 2) Resident 76's record was reviewed on 8/23/24 at 1:40 PM. Diagnoses included major depressive disorder recurrent severe without psychotic features, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and dysphagia following cerebral infarction. Resident 76's current quarterly MDS dated [DATE] indicated indicated her Basic Interview for Mental Status score not available due to not being assessed. Resident 76's quarterly MDS dated [DATE] indicated her BIMS score was 15 (cognitively intact). 3 )Resident 77's record was reviewed on 8/23/24 at 10:15 AM. Diagnoses included hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left dominant side, unspecified psychosis not due to a substance or known psychological condition, and generalized anxiety disorder. Resident 77's current quarterly MDS dated [DATE] indicated her BIMS score was 15 (cognitively intact). 4) Resident 82's record was reviewed on 8/23/24 at 12:36 PM. Diagnoses included chronic kidney disease, stage 3, unspecified, generalized anxiety disorder, and essential hypertension. Resident 82's current quarterly MDS dated [DATE] indicated her BIMS score was 15 (cognitively intact). 5) Resident 100's record was reviewed on 8/23/24 at 12:42 PM. Diagnoses included unspecified fracture of shaft of right femur, subsequent encounter for closed fracture with routine healing, displaced fracture of body of scapula left shoulder, subsequent encounter for fracture with routine healing, multiple fractures of ribs, left side, subsequent encounter for fracture with routine healing. Resident 100's current Admission MDS dated [DATE] indicated his BIMS score was 14 (cognitively intact). A current policy titled SNF Meal Service and Distribution provided by the Administrator on 8/22/24 at 2:30 PM indicated meals should be distributed to residents promptly and the dining room should be cleaned after each meal. The policy did not indicate each meal should be served table by table. 3.1-3(a)

Based on observation, interview, and record review the facility failed to ensure pureed food was prepared to guideline specifications. 5 of 5 residents requiring pureed diets consumed food prepared by the dietary staff. (Resident 5, Resident 10, Resident 27, Resident 39, and Resident 68). In an observation followed by an interview, on 8/20/24 at 11:16AM, [NAME] 8 identified a pan of meat with charred spots, and sticking to wax paper as pork tenderloin. [NAME] 8 took 8 varied size pieces of the meat and put into the grinder adding 3 soup ladles of gravy. [NAME] 8 was shaking the grinder and then using a spatula to wipe the sides. [NAME] 8 added 1 additional ladle of gravy. There was no recipe visible. [NAME] 8 indicated she was unable to determine the measurement of soup ladle. [NAME] 8 asked [NAME] 7 if there was a recipe for the pork tenderloin puree. [NAME] 7 located the recipe book. The book did not include the recipe for tenderloin puree. The kitchen manager was surprised the recipe did not include puree. He indicated he would locate a recipe and bring it for review along with a policy later in the day. On 8/20/24 at 1:16PM, the Administrator provided the production recipe for pork tenderloin roasted pureed thick. Yield was 20 portions. [NAME] 8 was yielding 6 so she would have cut this and done 1/3. The recipe called for 3lbs and 12 ounces of roasted pork tenderloin, 1 1/3 cup beef base , 1 quart hot water, and 1/2 cup food thickener. [NAME] 8 used 8 breaded pork tenderloin patties (no weight was measured on the patties). The patties were not similar in style to the pork tenderloin being served to other residents. In lieu of hot water, beef base and thickener, [NAME] 8 used gravy. The gravy was not measured, and she did not use thickener, so the consistency of the puree was not uniform. 1) Resident 5's record was reviewed, on 8/20/24 at 9:16AM, diagnoses included respiratory disease, heart disease, dementia, and dysphagia. Resident 5 had an order for pureed/dysphagia thin consistency, dated 12/6/23. 2) Resident 10's record was reviewed, on 8/20/24 at 9:21AM, diagnoses included heart disease, lung diseases, dementia, and dysphagia. Resident 10's diet order was pureed/dysphagia, thin consistency, dated 12/30/23. 3) Resident 27's record was reviewed, on 8/23/24 at 9:26AM, diagnoses included stroke, diabetes, heart disease, dementia, and dysphagia. Resident 27's was ordered blenderized texture thin consistency, dated 6/8/23. 4) Resident 39's record was reviewed, on 8/23/24 at 9:52AM, diagnoses included Alzheimer's, adult failure to thrive, and dysphagia. Resident 39's diet order was blenderized texture, nectar thick consistency, dated 12/17/22. 5) Resident 68's record was reviewed, on 8/23/24 at 9:58AM, diagnoses included malnutrition, heart disease, dementia, and dysphagia. Resident 68 had an order pureed/dysphagia thin consistency diet, dated 10/30/23. A policy and procedure titled, Use of Recipes, dated April 2014 was received from the Administrator on 8/22/24 at 12:16PM. The policy indicated recipes were to be used when preparing menu items. 3.1-21(a)(3)

Based on interview and record review the facility failed to ensure formulation of an advanced directive after admission for 1 of 1 residents reviewed. (Resident 30) Findings include: Resident 30's record was reviewed on 8/21/24 at 9:40 AM. Diagnoses included respiratory failure, Parkinson's disease, and type 2 diabetes with chronic kidney disease. A review of Resident 30's current quarterly Minimum Data Set (MDS) indicated their Basic Interview for Mental Status (BIMS ) score was 14 (cognitively intact). A review of Resident 30's current care plan, dated 8/14/24, titled Resident and family have chosen a DNR order, indicated Resident 30 would not have life-saving measures performed, and all caregivers would be informed of code status. A review of physician orders dated 8/21/24 at 11:00 AM indicated Resident 30's DNR order was discontinued 8/14/24, and not reinstated until 8/21/24. A review of progress notes dated 8/20/24 indicated Resident 30 declined to decide an advanced directive status upon readmission from hospital on 8/19/24. In an interview on 8/21/24 at 10:30 AM, the Administrator indicated code status should be found in physician orders and care plan. If code status is not there then the resident would be assumed to be full code. In an interview on 8/21/24 at 12:45 PM, the DON (Director of Nursing) indicated the resident came back from the hospital on 8/19/24 and was unsure what code status he wanted. Advance Directive documents presented at 12:45 PM indicated Resident 30's code status was updated to DNR on 8/21/24 at 12:00 PM. A current policy dated 8/21/24 provided by the DON indicated the facility would determine whether the resident had executed advanced directives, and whether the resident would like a DNR order issued while in the facility. 3.1-4(d)

Based on interview, and record review the facility failed to ensure all Minimum Data Set (MDS) sections were completed for 2 of 32 residents reviewed (Resident 76, and Resident 66). Findings include: 1) Resident 76's record was reviewed on 8/23/24 at 1:40 PM. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, major depressive disorder, recurrent severe without psychotic features, and prediabetes. Resident 76's current quarterly MDS dated [DATE] indicated their Basic Interview for Mental Status (BIMS) score was not completed. Each question in the BIMS assessment was answered not assessed. In an interview on 8/26/24 at 8:30 AM, the Director of Therapy indicated the therapy department was responsible for the completion of the MDS section C for all MDS assessments for all residents. He indicated a problem with completion was identified and the department heads began reviewing MDS assessments in the morning meeting each day around two weeks ago. In an interview on 8/26/24 at 8:45 AM, the MDS Coordinator 6 indicated he was aware of several occurrences of Section C of the MDS not being completed or not be completed timely. He indicated this had been an issue for several months. He indicated the MDS department should receive completed MDS sections from all departments by the end of the business day on the Assessment Reference Date. 45243 2) Resident 66's record was reviewed on 8/20/24 at 11:04AM. Resident 66 was admitted on [DATE]. An admission MDS dated [DATE] did not have a BIMS score assessment. completed. In an interview on 8/21/24 at 1:35 PM, Resident 66 indicated he was able to carry on a conversation. Resident 66 was giving fact-based responses and was showing use of reasoning skills. Resident 66 recalled information given at the beginning of interview with ease and was able to explain and demonstrate his answers appropriately. A Performance Improvement Plan (PIP) from the facility regarding comprehensive assessment and timing provided by the MDS coordinator on 8/26/24 at 9:17AM, indicated the facility had a meeting on 5/16/24, 6/14/24, and 8/9/24. The target end date for the PIP was 8/17/2024. The last activity documented an intervention was discussed on 8/23/24, however, the intervention was not listed. TheResident Assessment Instrument (RAI) manual dated October 2023 indicated the following: CMS's RAI Version 3.0 Manual CH 3: MDS Items [C] Page C-1 SECTION C: COGNITIVE PATTERNS Intent: The items in this section are intended to determine the resident's attention, orientation and ability to register and recall new information and whether the resident has signs and symptoms of delirium. These items are crucial factors in many care-planning decisions. A current policy titled MDS Completion Guidelines dated 8/26/24 provided by MDS Coordinator 6 on 8/26/24 at 9:17 AM did not provide guidelines for completion of each MDS section. An undated document titled MDS Parts, provided by MDS Coordinator 6 on 8/26/24 at 9:17 AM indicated the therapy department was responsible for completing BIMS scoring for the MDS completion. A policy and procedure titled MDS Completion Guidelines dated April 2014, indicated .1. MDS Nurses are to complete every MDS within seven (7) days of the assessment date

Based on interview and record review the facility failed to identify and initiate plans to mitigate trauma informed care for 1 of 1 resident reviewed. (Resident 66) Resident 66's record review began on 8/20/24 at 11:04AM. Diagnoses included heart disease, depression, and Post Traumatic Stress Disorder (PTSD ). Resident 66's Trauma Screening Questionnaire dated 7/30/24, was not completed on admission. Resident 66 did not have a plan of care in place to minimize or alleviate triggers, no PTSD related triggers were identified. Resident 66 had a care plan related to alteration in amount of sleep secondary to insomnia. The insomnia was not identified as a sign or symptom of his PTSD. There were no progress notes to indicate family had collaborated to assist in identifying PTSD triggers. Prior to admission, Resident 66 lived at home with his wife. There were no progress notes to indicate counseling or talk therapy had been attempted. Resident 66's admission Minimum Data Set (MDS) dated [DATE] was not fully completed. Section C for BIMS (Brief Interview of Mental Status) indicated the resident had not been completely assessed. The assessment did not include assessment through staff interview. Section D for mood was not completed. Section I for Diagnosis did indicate depression nor PTSD. In an interview, on 08/21/24 at 01:35PM, Resident 66 talked about his time in the Vietnam war. He discussed his ongoing sickness from agent orange. He stated, my hands are useless, so am I. Resident 66 was crying yet easily consoled. Resident 66 expressed feelings of gratitude of the time spent with him. He indicated his wife would visit twice a week. Other than her visits, no one attempted to understand him. In an interview, on 8/21/24 at 2:18PM Social Services Director (SSD) 5 indicated she did not understand why Resident 66's BIMS score was not completed. She indicated therapy was responsible for Section C of MDS. She explained Resident 66 only triggered for sleep disturbance on the trauma assessment. She further explained the team felt by talking to Resident 66 further they may upset him, so they only care planned him for sleep disturbance. SSD 5 was unable to identify Resident 66's PTSD triggers. SSD 5 was unable to identify why the mood section D was not completed because SSD 5 was responsible for Section D. In an interview, on 08/22/24 at 10:26 AM, the Director of Nursing (DON) indicated Resident 66 would not talk to us about it. The management team had discussed the resident in behavior meeting on 8/22/24 and discussed a referral to the psychologist since he wasn't comfotable discussing the PTSD with staff. Resident 66 would not tell the facility what his PTSD triggers were. She indicated Resident 66 should have been care planned for the PTSD diagnosis and watched for any signs of triggers. The DON indicated she was unsure if the family had been contacted regarding the PTSD or any triggers they may have been aware of. A policy titled, Trauma-Informed Care, dated October 2022 was received 8/22/24 at 12:16PM by SSD 5. The policy indicated .trauma informed care in accordance with professional standards of practice and accounting for residents' preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident. To determine if the resident is currently experiencing trauma or is at risk the Trauma Screening Questioner will be completed on all resident at the time of admission and as needed during the stay. 1) Ensure that appropriate staff is trained to provide support to residents with a trauma related diagnosis .2) Trauma Screening will be completed by LSW (Licensed Social Worker) upon admission .3) The LSW to provide support and care plan interventions upon admission and throughout resident stay and educate other staff as needed .

Based on interview and record review, the facility failed to ensure pain management for 1 of 3 residents experiencing pain reviewed (Resident Q). Findings include: On 4/15/24 at 10:16 A.M., Resident Q was interviewed. She'd had a recent stay at the facility for rehabilitation services following a fracture due to a fall. During her stay, she experienced unrelieved pain. This led to her early discharge from the facility. She indicated she believed her pain worsened during her stay becasue she sat in a chair and on the toilet for long periods of time. This increased the pain in her hip and pelvis. Additionally, she alleged pain medications were not given timely and when administered, were ineffective in relieving the pain. She indicated she had entered the facility on 3/21/24, asked for prescribed pain medication but wasn't given anything until 3:30 a.m. on 3/22/24. She indicated this put her behind with pain management making it difficult to regain control of the pain. She initiated early discharge due to ineffective pain management. On 4/16/24 at 11:44 A.M., Resident Q's record was reviewed. Diagnoses included a fractured pelvis from a fall and required skilled therapy services. She had a diagnosis of chronic pain syndrome and was prescribed an anti-seizure medication used for chronic pain but was not on any routine opioid medications. A 5 day Medicare MDS (Minimum Data Set) assessment, dated 3/26/24, indicated the resident was cognitively intact. She was admitted for a short stay to complete therapy prior to returning to her home. There was no pain assessment completed on the MDS. A care plan, dated 3/21/24, indicated the resident had pain due to a fall. Interventions included: provide pain medications as ordered; monitor and record pain characteristics; monitor response to pain prevention/interventions; evaluate the effectiveness of pain interventions and review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results and impact on functional ability; and attempt non-pharmacological interventions for pain management as indicated/appropriate (distraction, repositioning, massage, cryotherapy, etc). A hospital note, dated 3/19/24 at 9:37 a.m., indicated the resident had been receiving Hydrocodone-Acetaminophen 5-325 mg (milligram) 2 tablets by mouth every 4 hours as needed for pain. A physician order, dated 3/20/24 (day prior to admission) was for Hydrocodone-Acetaminophen 5-325 mg 1 tablet by mouth every 8 hours as needed for pain. A MAR (Medication Administration Record) dated March 2024, indicated the resident had not received pain medication on 3/21/24. Hydrocodone-Acetaminophen 5-325 mg was administered on the following dates and times: -3/22/24: 3:41 a.m., 12 noon, and 8:17 p.m. There was no further pain medication administered until the following morning. The record didn't indicate any non-pharmacological interventions had been offered to the resident. -3/23/24: 7:27 a.m. and 3:26 p.m. There was no further pain medication administered until the following morning. The record didn't indicate any non-pharmacological interventions had been offered to the resident. -3/24/24: 2:58 a.m. and 11:51 a.m. for a pain level of 10 out of 10 (worst pain ever), and 8:37 p.m. for continued pain at a level 8 out of 10. The record didn't indicate any non-pharmacological interventions had been offered to the resident. -3/25/24: 4:42 a.m. for pain level of 6 out of 10, and 12:57 p.m. for continued pain level at 6. There was no further pain medication administered until the following morning. The record hadn't indicated if or what non-pharmacological interventions had been offered to the resident. -3/26/24: 2:02 a.m. for pain level of 5, and 11:06 a.m. for continued pain level of 7. The record didn't indicate any non-pharmacological interventions had been offered to the resident. A Physical Therapy- PT evaluation and Plan of Treatment form, dated 3/22/24 at 10:54 a.m., indicated the resident complained of pain at rest at a level 10 out of 10. The pain was in her left hip and was sharp. She indicated her pain level with movement was 5 out of 10. The pain was in her left hip and felt sharp. The pain limited the resident's activities. The pain was relieved with rest and pain medications but worsened with prolonged sitting, standing, or inactivity. Physical Therapy encounter notes indicated: -3/22/24 at 2:36 p.m., indicated the resident had been sitting up in her wheelchair and complained of left hip pain from sitting too long. The resident was provided with an ice bag to use on the left hip to alleviate pain. -3/23/24 at 3:24 p.m., indicated the resident reported she had received her pain medication later than she was supposed to and had sharper pain in her hip, in the morning, as a result. Occupational Therapy-OT evaluation and Plan of Treatment form, dated 3/22/24 at 2:10 p.m., indicated the resident was provided with a different wheelchair to decrease discomfort. She was offered ice to decrease pain but declined at the time. The nurse reported the resident had not yet been due for her pain pill while in session. She reported pain at rest and with movement, was a 7 out of 10, constant, throbbing, and located in her left pelvis. Her pain was relieved with pain medications. Occupational Therapy encounter notes indicated: -3/22/24 at 2:45 p.m., the resident complained of left pelvic pain. The nurse indicated the resident wasn't due for pain medications yet. The resident was offered ice which she declined. She was provided with a smaller wheelchair with a cushion becaue the wheelchair was too large for her and the cushion added additional pain relief. -3/25/24 at 3:09 p.m., indicated the therapist was notified the resident was discharging the following day. During the session, she reported pain in her left groin 6 out of 10 and indicated she had been overdue for her pain medications. The nurse administered them during the OT session. A nurse progress note, dated 3/24/24 at 3:46 p.m., indicated the NP (Nurse Practitioner) was notified of difficulty controlling the resident's pain with pain medication only given every 8 hours as needed. The NP replied she would address it in the morning because she had not yet met the resident. A physician progress note, dated 3/25/24 at 1:34 p.m., indicated the resident had been seen for a 2nd day follow up to her hospitalization . The note indicated the resident wanted to discharge as soon as possible. There was no documentation about the resident's pain and difficulty controlling with her current pain medications. There were no changes made to the plan of care to address timing of medications in relation to therapy, limitations set to limit her time up in a wheelchair, possible changes in pain medication, or additional pain medications added (such as Tylenol or topical pain medication). No new non-pharmacological interventions had been added to the care plan On 4/16/24 at 2:30 P.M., the Director of Nursing was interviewed. She indicated staff were to develop and implement a comprehensive pain management plan for residents experiencing pain, including use of non-pharmacological interventions in addition to pain medications. Pain medications were to be administered per physician orders. She indicated the facility did not use a comprehensive pain assessment form. On 4/16/24 at 1:20 P.M., a current copy of the facility policy, titled Pain Assessment and Management provided by the Administrator, indicated: 3. Pain management is a multidisciplinary care process that includes the following: Assessing the potential for pain; effectively recognizing the presence of pain; identifying characteristics of pain; addressing the underlying causes of the pain; developing and implementing approaches to pain; identifying and using specific strategies for different levels and sources of pain; monitoring effectiveness of interventions; and modifying approaches as necessary. Conduct a comprehensive pain assessment upon admission to the facility .and when there is onset of new or worsening pain .Assessing pain: 1. During the comprehensive pain assessment gather the following information .a. history of pain and it's treatment including pharmacological and non-pharmacological interventions; b. characteristics of pain: intensity, description of pain, pattern of pain, location and radiation of pain, frequency/timing/duration of pain .d. factors that precipitate or exacerbate pain. e. factors and strategies that reduce pain .Defining goals and appropriate interventions .Implementing pain management strategies: non-pharmacological interventions may be appropriate alone or in conjunction with medications .Monitoring and modifying approaches .Documentation: 1. Document the resident's reported level of pain with adequate detail This tag relates to Complaint IN00431781. 3.1-37(a)

Based on interview and record review, the facility failed to ensure 1 of 3 residents reviewed were free from a significant medication error. The error resulted in respiratory distress, need for emergent treatment and the potential for death (Resident D). The Immediate Jeopardy began on 1/11/23 when Resident D was administered 100 milligrams of Morphine by mouth, 20 times the amount of medication prescribed. The facility failed to assess and monitor the resident for side effects after identifying the medication error. This resulted in respiratory distress and need for emergent treatment. The Administrator was notified of the Immediate Jeopardy on February 8, 2023 at 4:09 P.M. The Immediate Jeopardy was removed, and the deficient practice corrected, on 1/27/23 when the facility implemented a systemic plan that included all nurses were in-serviced on safe medication administration, an initial audit of physician's orders for morphine sulfate, and completed medication administration competencies with nursing staff. The correction date was prior to the start of the survey and was therefore past noncompliance. Findings include: On 2/8/23 at 10:15 A.M., Resident D's record was reviewed. Diagnoses included insulin dependent diabetes, dementia, pressure ulcers, and peripheral vascular disease. The resident was receiving hospice services for end-of-life care and pain management. A physician order, dated 8/13/22, for Morphine Sulfate (Concentrate) Solution 20 milligrams per 1 milliliter (20 mg/ml); indicated to give 5 milligrams (mg) by mouth every 2 hours as needed for pain (0.25 ml). The order was discontinued on 1/11/23, a new order for Morphine Sulfate 20 mg/ml-give 0.5 ml (10 mg) every 2 hours as needed for pain and Morphine Sulfate 20 mg/ml-give 0.5 ml every 6 hours (routine) was written. A review of the Medication Administration Record (MAR) indicated to give Morphine Sulfate 20 mg/5 ml-give 5 ml by mouth every 2 hours as needed and Morphine Sulphate 20 mg/5 ml-give 5 ml by mouth every 6 hours (routine). A Controlled Substance Accountability Sheet for Morphine Sulfate 20 mg/ml: take (0.25 ml) (5 mg) by mouth every 2 hours as needed for pain, indicated Morphine Sulfate 0.25 ml had been signed out and administered as ordered, between the dates of 11/11/22 and 1/4/23. On 1/11/23 at 4:45 p.m., Morphine Sulfate 5 ml (milliliters) was signed out and administered to the resident. This would equal a dose of 100 mg, 20 times the dose prescribed. The MAR dated January 2023 indicated the resident received 100 mg of Morphine on 1/11/23 at 5 p.m. Progress notes indicated the following: -1/12/23 at 12:00 a.m., 2 nurses identified a medication error for the resident. The resident was assessed and responsible parties notified. The hospice nurse came in to assess the resident, the medication order was clarified and corrected with the hospice nurse. A verbal order was received to hold the 10:00 p.m. dose on 1/11/23 and reassess in the morning before administering the 5:00 a.m. dose on 1/12/23. -1/12/23 at 11:02 a.m., indicated the resident's son had been notified the resident had been given an incorrect Morphine dose the previous evening and now had a change in his condition prompting need for a dose of Narcan (medication used to treat opioid overdose). The resident had been assessed with a respiratory rate of 4 per minute (normal 16-20 breaths per minute) with periods of apnea (no breaths). He was started on oxygen at 4 liters per nasal cannula. There was no indication in the note a physician had been notified of the resident's low respiratory rate. -1/12/23 at 1:05 p.m., a respiratory note indicated the resident had an observed change in condition. The respiratory therapist (RT) had been asked by nursing to assess the resident. Upon assessment, his respirations were at 8 breaths per minute and his oxygen saturation was at 80% (normal oxygen saturation-greater than 90%). The resident was placed on 4 liters of oxygen via nasal cannula, his oxygen saturations increased to 93-96% and his heart rate was 117 beats per minute (normal-60-100 beats per minute). -1/12/23 at 1:17 p.m., the note indicated the resident had been unresponsive due to morphine overdose. His blood pressure (BP) was low at 80/40, pulse (P) elevated at 112, respirations (R) were 10 per minute and oxygen saturation was at 99% on oxygen at 4 liters per nasal cannula. At 10:46 a.m., the NP (Nurse Practitioner) was notified and order given to administer Narcan 0.4 mg/ml per intramuscular injection. This was administered into the left deltoid. At 10:50 a.m., the resident started responding and talking. His BP was 116/67, P: 107, and R: 15. At 12:07 p.m., the resident was unresponsive with a BP of 95/62, P: 106, R: 7 and oxygen saturation at 91%. The NP was notified and an order received for Narcan 0.4/0.1 ml nasal spray. This was administered at 12:17 p.m. At 12:25 p.m., the resident started to respond and talk. His BP was 113/68, P: 106, R: 15, and oxygen saturation was 94%. At 1:00 p.m., the resident was able to consume 240 ml of orange juice. In an interview on 2/8/23 at 2:47 P.M., the facility pharmacist indicated 100 mg of Morphine given to the resident would've caused lethargy, slowed respiratory rate, clammy skin, slurred speech, blurry vision and potentially, respiratory arrest. On 2/8/23 at 3:25 P.M., the RT was interviewed. She indicated on the morning of 1/12/23, she'd arrived at the facility between 6-6:30 a.m. A night nurse told her the resident had been given a high dose of morphine and wasn't responding. The RT went to Resident D's room to assess him, observed that he was unconscious and non-responsive. His respirations were shallow at 8 breaths per minute and his oxygen saturation on room air was 80%. She administered oxygen at 4 liters per minute per nasal cannula. She reported her concerns with the resident's change in condition to the oncoming shift nurses and the management team which included the Director of Nursing Services. On 2/8/23 at 4:00 P.M., the Administrator was interviewed. She indicated she was notified the evening of 1/11/23 when the medication error had been identified and staff had been instructed to monitor and document the resident's condition. A current facility policy, provided by the Administrator on 2/9/23 at 1:00 P.M., and titled Administering Medications, stated the following: Medications shall be administered in a safe and timely manner, as prescribed .3. Medications must be administered in accordance with the orders .7. The individual administering the medication shall check the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication The past noncompliance Immediate Jeopardy began on 1/11/23. The Immediate Jeopardy was removed, and the deficient practice corrected, on 1/27/23 when the facility implemented a systemic plan that included all nurses were in-serviced on safe medication administration, an initial audit of physician's orders for morphine sulfate, and completed medication administration competencies with nursing staff. The correction date was prior to the start of the survey and was therefore past noncompliance This Federal tag relates to Complaint IN00401079. 3.1-48(c)(2)

Based on interview and record review, the facility failed to ensure a medication was given per physician orders [REDACTED]. This deficit practice resulted in the resident being hospitalized . Findings include: On 8/8/19 at 11:26 [NAME]M., Resident D's record was reviewed. [DIAGNOSES REDACTED]. Prior to admission to the facility, the resident has been hospitalized multiple times for acute on chronic kidney failure and heart failure. A physician's orders [REDACTED]. A MAR (Medication Administration Record) for (MONTH) 2019, indicated the resident received Potassium Chloride ER 20 mEq tablets-2 tablets (40 mEq) daily at 8:00 a.m. on 7/20, 7/21, 7/22, and 7/23/19. A Lab Result Report, dated 7/23/19 at 9:20 a.m., indicated the resident's potassium blood level was 2.9 mmol/L (millimoles per liter). The reference range for a potassium blood level was 3.6 - 5.1 mmol/L. Resident D's potassium blood level was reported as low. 7/23/19 at 11:52 a.m., the NP (Nurse Practitioner) visited the resident and reviewed his abnormal potassium blood levels. The NP wrote an order for [REDACTED]. The (MONTH) 2019 MAR indicated [REDACTED]. The nurse offered it to him again, with the potassium tablets crushed and in applesauce and the resident agreed to take it at 12:32 a.m. (7/24/19). Resident D received a total of 160 mEq of Potassium ChlorideER on [DATE]. A Lab Result Report, dated 7/24/19 at 8:16 a.m., indicated Resident D's potassium blood level was 4.6 mmol/L which was within the reference range of 3.6 - 5.1 mmol/L. On 7/24/19 at 12:37 p.m., Resident D was visited by the NP for follow up to his labs and new complaints of abdominal pain. The resident complained of sharp lower abdominal pain. The NP progress note indicated to add [MEDICATION NAME] (stool softner) daily and continue to administer [MEDICATION NAME] as needed (for constipation). The resident was to have another potassium blood level checked on 7/26/19. The (MONTH) 2019 MAR indicated [REDACTED] 7/24/19, the resident was administered Potassium Chloride ER 20 mEq tablets-3 tablets (60 mEq) at 12:32 a.m. He was administered Potassium Chloride ER 20 mEq-2 tablets (40 mEq) by mouth every 6 hours at 5:00 a.m., 11:00 a.m., 5:00 p.m., and 11:00 p.m. for a total of 220 mEq of Potassium Chloride. 7/25/19, the resident was administered Potassium Chloride ER 20 mEq-2 tablets (40 mEq) by mouth every 6 hours at 5:00 a.m., 11:00 a.m., 5:00 p.m., and 11:00 p.m. for a total of 160 mEq of Potassium Chloride. 7/26/19 at 5:00 a.m., the resident received another dose of Potassium Chloride ER 20 mEq tablets-2 tablets (40 mEq) by mouth. A Lab Result, reported by phone from the lab to the DON (Director of Nursing) at 8:22 a.m., indicated Resident D's potassium blood level was at a Critical level of 7.5 mmol/L with a reference range of 3.6-5.1 mmol/L. A Change in Condition form, dated 7/26/19 at 10:10 a.m., indicated the NP had been notified of the resident's critical potassium blood level and orders were given to obtain a STAT EKG (electrocardiogram-measures the electrical activity of the heartbeat), chest x-ray, and give Sodium [MEDICATION NAME] Suspension 15 GM/60ML-15 grams by mouth STAT for [MEDICAL CONDITION]. On 7/26/19 at 11:06 a.m., Resident D was transferred by the EMS to the hospital where he was admitted for treatment of [REDACTED]. On 8/8/19 at 1:46 P.M., the DON was interviewed. During the interview, he indicated an investigation was immediately undertaken to determine the cause of the resident's [MEDICAL CONDITION]. Upon review of the physician orders [REDACTED]. He indicated the resident was to have received Potassium Chloride 20 mEq tablet-1 tablet at 11:00 a.m., 5:00 p.m., and 11:00 p.m. on 7/23/19 for a total of 60 mEq in addition to the 40 mEq that had already been administered at 8:00 a.m. that morning. Resident D was to have received a total of 100 mEq Potassium Chloride and then the order discontinued. The DON indicated the MAR indicated [REDACTED]. He indicated nursing staff were re-educated on entering orders into the electronic medical record. Additionally, all residents who were prescribed potassium supplements were reviewed for correct dosages and labs reviewed for normal reference ranges for potassium blood levels. On 8/8/19 at 2:23 P.M., LPN 5 (Licensed Practical Nurse) was interviewed. During the interview, she indicated she was not sure how 2 entries for Potassium Chloride had been ordered and put onto the MAR. She indicated she had been re-educated on transcribing orders into the electronic medical record. The facility implemented a new procedure for transcribing orders to prevent future medication errors which included 4 different checkpoints to be completed for each new medication order. On 8/8/19 at 3:00 P.M., [MEDICAL CONDITION] was retrieved from the Lippincott Advisor for nurses which indicated the following: [MEDICAL CONDITION] is excessive serum levels of the potassium ion. It may be induced by treatments for other disorders or medications. Decreased potassium excretion, such as with kidney dysfunction is a common cause. [MEDICAL CONDITION] may cause abdominal cramps, nausea and vomiting, muscle weakness, high heart rate, and [MEDICAL CONDITION] (death) with levels >7 mEq/L. This Federal tag relates to Complaint IN 270. 3.1-48(c)(2)

Based on record review and interview, the facility failed to provide documentation of increased supervision and increased toileting as recommended by therapy and to ensure alarms were in working condition at all times and functioning for 1 of 3 residents reviewed with falls in a sample of 3. (Resident #C) This resulted in a fall with a fracture. (Resident #C) Findings include: Resident #C's record was reviewed on 4/26/11 at 10:50 a.m. The record indicated Resident #C's [DIAGNOSES REDACTED]. The "Admission Assessment and Interim Care Plan," for Resident #C, dated 2/12/11, indicated Resident #C was admitted to the facility on [DATE] and was a high risk for falls and that a bed alarm was being utilized. The "Initial Plan of Care" for at risk for falls, dated 2/12/11, indicated Resident #C had a history of [REDACTED]. Interventions put in place at that time included: frequent monitoring, bed sensor alarm, night light, chair sensor alarm, call light within reach, and bed in low position. The computerized bowel and bladder detail report, dated 2/12/11, indicated Resident #C was toileted, checked and/or changed at 7:56 p.m. The medication administration record for March 2011, indicated dates of 2/13/11 for the initiation of the following: "...check alarm function every shift and chart in caretracker...sensor alarms to bed and wheelchair...." The "Initial Plan of Care" for at risk for falls, dated 2/12/11 and updated 2/27/11, indicated an order was placed to check the functioning of the alarm every shift. The computerized bowel and bladder detail report, dated 2/13/11, indicated Resident #C was toileted, checked and/or changed at 5:33 a.m., 12:16 p.m., 6:56 p.m., and 8:37 p.m. The computerized bowel and bladder detail report, dated 2/14/11, indicated Resident #C was toileted, checked and/or changed at 3:33 a.m., 1:41 p.m., and 9:43 p.m. The computerized bowel and bladder detail report, dated 2/15/11, indicated Resident #C was toileted, checked and/or changed at 4:26 a.m., 12:24 p.m., 1:45 p.m., and 9:54 p.m. The computerized bowel and bladder detail report, dated 2/16/11, indicated Resident #C was toileted, checked and/or changed at 1:13 a.m. and 2:03 p.m. The computerized bowel and bladder detail report, dated 2/17/11, indicated Resident #C was toileted, checked and/or changed at 3:13 a.m., 9:16 a.m., 12:25 p.m., 8:38 p.m. The occupation therapy log indicated the resident was in therapy from 9:00 a.m. until 10:05 a.m. even thought CNA charting indicated the resident was being toileted at 9:16 a.m. The computerized bowel and bladder detail report, dated 2/18/11, indicated Resident #C was toileted, checked and/or changed at 1:34 a.m., 1:56 a.m., 12:36 p.m., 8:40 p.m. The computerized bowel and bladder detail report, dated 2/19/11, indicated Resident #C was toileted, checked and/or changed at 12:37 a.m., 1:22 p.m., 4:16 p.m., and 9:35 p.m. The physical therapy log indicated the resident was in therapy from 3:55 p.m. until 4:55 p.m. even though CNA charting indicated the resident was being toileted at 4:16 p.m. A "Minimum Data Set (MDS) Assessment," dated 2/19/11, indicated Resident #C had a fall within the last month prior to admission and also had a fracture. The care areas triggered for the MDS included falls and indicated the following: "...resident has some cognitive deficits...required supervision to walk in room...required extensive assistance with toileting...not steady...at risk for falls due to hx (history) of falls...occasional urine incontinence, weakness and receives antidepressant medications...she requires assist with care and mobility and is receiving PT (physical therapy) and OT (occupational therapy)...has sensor alarms to bed and w/c (wheelchair) due to poor safety awareness... The computerized bowel and bladder detail report, dated 2/20/11, indicated Resident #C was toileted, checked and/or changed at 12:36 a.m. - 12:40 a.m., 2:49 a.m., 12:34 p.m., 9:11 p.m. The computerized bowel and bladder detail report, dated 2/21/11, indicated Resident #C was toileted, checked and/or changed at 4:03 a.m., 10:41 a.m., and 4:30 p.m. The physical therapy log indicated the resident was in therapy from 9:55 a.m. until 10:55 a.m. even though CNA charting listed the resident as having been toileted at 10:41 a.m. The computerized bowel and bladder detail report, dated 2/22/11, indicated Resident #C was toileted, checked and/or changed at 4:36 a.m., 5:15 a.m., 11:41 a.m., and 8:44 p.m. The computerized bowel and bladder detail report, dated 2/23/11, indicated Resident #C was toileted, checked and/or changed at 1:07 a.m., 10:38 a.m., 1:13 p.m., 3:24 p.m., 3:50 p.m., and 7:20 p.m. The computerized bowel and bladder detail report, dated 2/24/11, indicated Resident #C was toileted, checked and/or changed at 3:57 a.m., 12:49 p.m., and 9:26 p.m. The computerized bowel and bladder detail report, dated 2/25/11, indicated Resident #C was toileted, checked and/or changed at 2:10 a.m., 12:03 p.m., 1:38 p.m., and 4:05 p.m. The computerized bowel and bladder detail report, dated 2/26/11, indicated Resident #C was toileted, checked and/or changed at 3:57 a.m., 4:48 a.m., 1:30 p.m., and 9:09 p.m. The computerized bowel and bladder detail report, dated 2/27/11, indicated Resident #C was toileted, checked and/or changed at 4:21 a.m., 9:51 a.m., and 8:07 p.m. The "Skilled Daily Nurses Note," dated 2/27/11 at 6:30 p.m., indicated Resident #C was found lying beside her bed. Visitors to the facility noticed the resident and notified staff at the nurse's station. Few details were listed to the note but did include "...alarm cord possibly tripped...alarm was functioning earlier in shift...." The "Incident/Accident/Concern" staff statement form, dated 2/27/11 by LPN #2, indicated while she was at the nurse's station, an unidentified staff member notified her and another nurse that Resident #C was on the floor (at 6:30 p.m.). The unidentified staff member stated another resident's family member walked by Resident #C's room and saw her lying on the floor. The resident was lying on the floor by the bed with her wheelchair against the wall. The area was free of clutter, the call light was on the bed and the alarm was on the bed with the cord ripped from the devise. The resident stated she was trying to transfer herself and that she had to use the restroom. The Director of Nursing (DON) was interviewed on 4/27/11 at 11:20 a.m. The DON indicated she was unaware of who the unidentified staff members listed in the report were and was unable to confirm where the alarm box was placed on the bed, whether it was in reach or out of reach of the resident. The "Therapy Post Fall Assessment," dated 2/27/11, and completed by physical therapy and speech therapy. The assessment indicated the therapist was recommending for staff to periodically check to make sure the patients alarms were on and working properly and for the resident to be placed at the nurses station when up. Further recommendations include recommending nursing staff to check on the resident often for toileting as she has irritable bowel syndrome and needs to go often. Also recommended were reminders to use the call light. The computerized bowel and bladder detail report, dated 2/28/11, indicated Resident #C was toileted, checked and/or changed at 4:32 a.m., 10:09 a.m., 8:44 p.m. A care plan for "Risk for Falls," dated 2/28/11 for Resident #C, included, but was not limited to, 1/2 siderails for bed mobility, have commonly used articles within easy reach, have call bell within reach and reinforce need to call for assistance, resident to wear proper and non slip footwear, assess for pain and/or infection, assist with transfers and ambulation as needed, encourage resident to use handrails or assist devices properly, ensure environment free of clutter and well lit, evaluate effectiveness and side effects of psychotropic drugs with physician, fall risk assessment to be completed on admission/quarterly/or if change in condition, gait belt to be used for all transfers and ambulation, therapy to provide treatment as ordered. The care plan for incontinence, dated 2/28/11, indicated staff were to assist Resident #C with toileting upon arising, before meals, at bedtime and as needed (PRN). No further updates were noted. The computerized bowel and bladder detail report, dated 3/1/11, indicated Resident #C was toileted, checked and/or changed at 5:38 a.m., 12:18 p.m., and 8:10 p.m. The computerized bowel and bladder detail report, dated 3/2/11, indicated Resident #C was toileted, checked and/or changed at 3:59 a.m., 12:17 p.m., and 6:52 p.m. The computerized bowel and bladder detail report, dated 3/3/11, indicated Resident #C was toileted, checked and/or changed at 4:03 a.m., 12:29 p.m., and 8:33 p.m. The computerized bowel and bladder detail report, dated 3/4/11, indicated Resident #C was toileted, checked and/or changed at 2:19 a.m., 6:06 a.m., 12:21 p.m., and 9:10 p.m. The MDS, dated [DATE], indicated Resident #C required extensive assistance of one person for walking and toileting and that the resident was not steady with balance during transitions and walking. The computerized bowel and bladder detail report, dated 3/5/11, indicated Resident #C was toileted, checked and/or changed at 1:20 a.m., 5:41 a.m., 10:21 a.m., 12:58 p.m., and 4:58 p.m. The computerized bowel and bladder detail report, dated 3/6/11, indicated Resident #C was toileted, checked and/or changed at 3:49 a.m., 8:03 a.m., 2:11 p.m., and 8:51 p.m. The physical therapy log indicated Resident #C was in therapy from 2:05 p.m. until 2:55 p.m. even though the CNA charting indicated the resident was being toilet at 2:11 p.m. The computerized bowel and bladder detail report, dated 3/7/11, indicated Resident #C was toileted, checked and/or changed at 4:09 a.m., 10:29 a.m., and 8:14 p.m. The computerized bowel and bladder detail report, dated 3/8/11, indicated Resident #C was toileted, checked and/or changed at 4:13 a.m., 12:29 p.m., and 9:15 p.m. The computerized bowel and bladder detail report, dated 3/9/11, indicated Resident #C was toileted, checked and/or changed at 4:11 a.m., 4:44 a.m., 9:01 a.m., and 7:35 p.m. The computerized bowel and bladder detail report, dated 3/10/11, indicated Resident #C was toileted, checked and/or changed at 4:15 a.m., 12:47 p.m., and 7:47 p.m. The computerized bowel and bladder detail report, dated 3/11/11, indicated Resident #C was toileted, checked and/or changed at 3:59 a.m., 8:15 a.m., 9:16 a.m., 1:25 p.m., 3:20 p.m., and 8:00 p.m. The speech therapy log listed Resident #C as being in therapy from 3:10 p.m. until 3:55 p.m. even though the CNA documentation listed the resident as being toiled at 3:20 p.m. The "Skilled Daily Nurses Note," dated 3/11/11 at 5:30 a.m., indicated Resident #C's call light in reach but seldom uses. The note further indicated she sits at the side of the bed, setting of the alarm. The computerized bowel and bladder detail report, dated 3/12/11, indicated Resident #C was toileted, checked and/or changed at 4:01 a.m., 1:49 p.m., and 8:19 p.m. The computerized bowel and bladder detail report, dated 3/13/11, indicated Resident #C was toileted, checked and/or changed at 4:41 a.m., 1:54 p.m., and 8:38 p.m. The physical therapy log indicated the resident was in therapy from 1:05 p.m. until 2:05 p.m. even though CNA charting indicated the resident was being toileted at 1:54 p.m. The computerized bowel and bladder detail report, dated 3/14/11, indicated Resident #C was toileted, checked and/or changed at 3:49 a.m., 9:34 a.m., 1:22 p.m., and 8:21 p.m. The physical therapy log indicated the resident was in therapy from 9:15 a.m. until 10:15 a.m. even though the CNA charting listed the resident as being toiled at 9:34 a.m. The computerized bowel and bladder detail report, dated 3/15/11, indicated Resident #C was toileted, checked and/or changed at 5:03 a.m., 9:22 a.m., 12:29 p.m., and 8:25 p.m. The computerized bowel and bladder detail report, dated 3/16/11, indicated Resident #C was toileted, checked and/or changed at 12:48 a.m., 1:37 a.m., 5:09 a.m., 10:45 a.m., 1:46 p.m., and 9:44 p.m. The computerized bowel and bladder detail report, dated 3/17/11, indicated Resident #C was toileted, checked and/or changed at 12:30 a.m., 10:45 a.m., 1:39 p.m., and 8:38 p.m. The "Skilled Daily Nurses Note," dated 3/17/11 at 6:00 p.m. for Resident #C, indicated the resident was observed up and ambulating without assistance, alarm sounded and CNA instructed resident to call for help. The resident stated "know I should call, but I forgot." The note further indicated the alarm was functioning and the call light was within reach. The "Fall Risk Assessment," dated 3/18/11 and 3/22/11, indicated Resident #C was a high fall risk. The computerized bowel and bladder detail report, dated 3/18/11, indicated Resident #C was toileted, checked and/or changed at 4:18 a.m., 9:42 a.m., 1:07 p.m., and 8:33 p.m. The "Skilled Daily Nurses Note," dated 3/18/11 at 2400 (midnight) by LPN #3, indicated Resident #C was found on the floor of her room at 9:40 a.m., with the alarms in place and functioning. The note further indicated a hematoma (swelling) was noted to the resident's forehead. The note for 3:30 p.m., indicated a new order was obtained for the resident's medications to be changed. The "Incident/Accident/Concern" staff statement form, dated 3/18/11 by LPN #3, indicated at 9:40 a.m., the nurse was called to Resident #C's room by a CNA. The alarms were sounding and the resident was lying on her back with a hematoma noted to the right side of her forehead. The resident stated she was attempting to get into the closet. CNA #4, who was present on 3/18/11, was interviewed on 4/27/11 at 11:10 a.m. She indicated she did not write any statements for the fall investigation. She indicated she was not aware of any times the resident messed with the alarm box but she did indicate the resident did have some confusion. The Incident/Accident/Concern" staff statement form, dated 3/18/11 by CNA #6, indicated she was talking with CNA #4 when she turned to go down the hallway when she heard an alarm sounding. CNA #6 from walking down one end of the hall while CNA #4 was approaching from the other end of the hall towards Resident #C's room. CNA #4 was the first to arrive at the room so CNA #6 then went to get the nurse. The "Nursing Post Fall Assessment," dated 3/18/11 by LPN #3, indicated Resident #C had been trying to get into her closet prior to the fall. A progress note by the nurse practitioner, dated 3/18/11, indicated the resident was seen for a recent fall, unclear of how she fell . The note further noted a lump and bruise to Resident #C's right forehead due to fall. The "Therapy Post Fall Assessment," dated 3/18/11, indicated the therapist recommendations included to place the resident at the nurses station when up throughout the day. The note further indicated the resident had pressure alarms and staff were to provide frequent checks and reminders to use the call light for assistance. The computerized bowel and bladder detail report, dated 3/19/11, indicated Resident #C was toileted, checked and/or changed at 5:41 a.m., 9:37 a.m., 1:06 p.m., 8:42 p.m., and 11:59 p.m. The computerized bowel and bladder detail report, dated 3/20/11, indicated Resident #C was toileted, checked and/or changed at 2:02 a.m., 8:15 a.m., 1:40 p.m., 7:23 p.m., and 9:28 p.m. The speech therapy log listed Resident #C as being in therapy from 1:36 p.m. until 2:06 p.m. even the CNA documentation listed the resident as being toileted at 1:40 p.m. The "Skilled Daily Nurses Note," dated 3/20/11 at 12:30 a.m., indicated Resident #C was alert and oriented but forgetful. The resident was able to make needs known but forgets to use call light at times. Shown call light with each interaction. The computerized bowel and bladder detail report, dated 3/21/11, indicated Resident #C was toileted, checked and/or changed at 6:01 a.m., 8:27 a.m., 1:12 p.m., 9:08 p.m., and 11:40 p.m. The computerized bowel and bladder detail report, dated 3/22/11, indicated Resident #C was toileted, checked and/or changed at 12:32 a.m. The "Skilled Daily Nurses Note," dated 3/22/11 at 2:30 a.m. by LPN #5, indicated Resident #C was found lying in the hallway by her room after a nurse heard a thud. The resident indicated she was attempting to go to the bathroom. The note further indicated the resident was last toilet by the CNA at 1:30 a.m. and the alarm were functioning at that time. A hematoma (swelling) was noted to her left forehead along with a small laceration with bleeding. An x-ray report, dated 3/22/11, indicated Resident #C was evaluated for complaints of left leg pain after a fall. The results indicated a pubic fracture and suspicious left hip. An "Admit/Discharge" form provided by the DON on 4/26/11 at 10:20 a.m., indicated Resident #C was discharged from the facility on 3/22/11 to a local community hospital. The inservice for "Fall Prevention Guidelines" for 3/28/11 was provided by the DON on 4/27/11 at 2:10 p.m. The guidelines indicated "...use gait belts...make sure alarms are turned to the on position and functioning...make sure alarm wires are not showing...if resident messes with alarm move out of reach of resident...make sure the rooms are clutter free and well lit...do room rounds throughout your shift and take care of any fall hazards that are present...always make sure the resident has their call light within reach...make sure the resident has on non-skid footwear...make sure to toilet residents upon rising, before and after meals, at bedtime, and prn (as needed)...offer confused residents activities, snacks, reading materials, etc. to keep them busy...if confused residents are attempting to get up out of bed, do not leave tem unattended in their room, sit them close to nurses station so they can be closely watched...common extrinsic fall risk factors...room to far from nurses station...toileting needs of residents who need assist or incontinent residents...malfunctioning call system or alarms...fall risk prevention...reassessment with any acute illness, change in functional or cognitive status...documentation of specific interventions in interdisciplinary care plan...reassessment at regular intervals to determine if interventions are effective...team conference and root cause analysis of any falls, even non-injurious ones...." The most recent inservice prior to this for alarm management was dated 11/17/10 and 11/18/10. The current policy "Accident and Incidents - Investigating and Reporting," dated 2001, with a revision date of March 2004, was provided by the DON on 4/27/11 at 9:15 a.m. The policy indicated "...All accidents or incidents...must be investigated...the nurse supervisor/charge nurse and/or the department director or supervisor must conduct an immediate investigation of the accident or incident...the following data, as it may apply, must be included on the Accident Investigation Report Form...the name(s) of witnesses and their accounts of the accident or incident...." The undated manufacturers instruction for the pressure pad alarm, was provided by the DON on 4/27/11 at 9:15 a.m. The instructions indicated the following: "...place pad under shoulders to be alerted when resident sits up in bed...place pad under lower back/buttocks to be alerted when the resident vacates the bed...place monitor out of reach of the resident...make sure the resident cannot tamper with monitor or reach the 'reset' button...always check battery level before monitor is attached to patient...this product is not suitable for all individuals. Other devises may be required. This product is not a substitute for visual monitoring by caregiver. This device is to help augment caregivers comprehensive resident mobility management program. Test this device before each use...This device is not designed to replace good care giving practices including, but not limited to: a.) direct patient supervision b.) Adequate training of staff personnel for elopement c.) Testing of the system before each use...." The Physical Therapy Assistant #1 was interviewed on 4/27/11 at 10:30 a.m. During the interview, the Physical Therapy Assistant indicated the Resident #C's room was eighty (80) feet from the rehabilitation nurse's station and was 110 feet to the next closest nurse's station. During a confidential interview on 4/26/11 at 10:12 a.m., the interviewee indicated Resident #C was now in another nursing facility and that since the fall has been declining. The interviewee further indicated due to the resident's health, she was not a surgical candidate therefore her pelvic fractures were not repaired. This federal tag relates to complaint IN 731 3.1-45(a)(2)