Every finding on record at Kokomo Healthcare Center

Based on interview and record review, the facility failed to ensure the residents' right to a dignified existence and an environment which promoted their quality of life was maintained when a staff-to-staff altercation occurred between 2 of 2 staff members. (CNA 12 and CNA 13)Findings include:A police report, dated 7/14/26 at 10:27 p.m., indicated a battery occurred, on 7/14/26 at 10:04 p.m., between two employees. A police report, dated 7/14/26 at 11:14 p.m. by Officer 2, indicated he was dispatched to the facility in reference to a physical altercation between two employees which involved a stabbing. CNA 13 was standing in the hallway, and he observed hair on the ground near CNA 13. The officer asked CNA 13 if she had any weapons and she stated she had 2 pocketknives in her belongings. The officer went outside where CNA 12 was standing with Officer 3. CNA 12 stated her side was hurting and her chest was hurting from where she was stabbed with a fork. The officer observed the fresh scratches with blood which were consistent with a sharp object pressing or dragging against skin. CNA 13 stated during the altercation, CNA 12 was pulling her hair and would not let go. CNA 13 found a fork on the ground and pushed it into CNA 12's side. Officer 2 spoke with witnesses at the scene and multiple witnesses stated they observed the physical altercation but did not see how it started. They observed both parties on the ground with hair being pulled and other physical contact. CNA 13 was placed in double locked wrist restraints and removed from the facility. Both CNA 13 and CNA 12 were transported to jail and booked on a misdemeanor: class A for battery with bodily injury.A police report, dated 7/14/26 at 11:31 p.m. Officer 4, indicated a male, identified as Resident C, was standing in the hallway where the hair and fork were located. He asked Resident C what he had observed. Resident C indicated he heard yelling and pounding and observed two employees in a physical altercation. Resident C stated he observed CNA 12 grabbing hold of CNA 13's hair and throwing her against the wall. The resident stated this continued as he attempted to exit his room and separate the two. A facility witness statement, dated 7/14/26, indicated, at approximately 10:00 p.m., CNA 10 was taking old dinner trays to the dining room. When she came to the end of her hall, she heard a bunch of commotion coming from another hall. She looked and saw CNA 12 behind CNA 13 pulling her back and forth with her hair. A facility witness statement, not dated, indicated CNA 9 was going to empty the trash bins and saw CNA 12 walk up to CNA 13 and grab her hair and pull her to the floor. There was screaming and the residents started to gather in the hall. CNA 10 ran down the hall yelling at CNA 12 to let go of CNA 13. Resident C and RN 11 managed to separate them.A facility witness statement, dated 7/14/26, indicated CNA 8 reported she heard yelling all the way back in the other hall. She repeatedly heard someone say, Do not touch me. She thought residents could have been involved or in danger, so she immediately responded. When she arrived, she observed CNA 12 physically assaulting CNA 13. She was striking her face with her fist, pulling her hair, and took her down to the floor. The altercation was witnessed by several staff and residents. The altercation was beyond what staff could safely stop on their own and one resident was frightened by the incident and crying. The resident had grabbed CNA 8's hand and told her she was scared. Another resident was standing near the altercation which was a potential risk for injury. CNA 8 was concerned about the safety of both the staff involved and the residents. CNA 8 notified the police department.A facility witness statement, dated 7/15/26, indicated Registered Nurse (RN) 11 reported CNA 12 suddenly became very angry, yelled loudly that the evening shift aides were lazy, and she was tired of always having to clean up after them. CNA 13 heard CNA 12's comments, became upset, and started to verbally defend herself to CNA 12. RN 11 reported CNA 12 then walked up to CNA 13 and was face to face with her. RN 11 heard CNA 13 say, Go ahead and hit me, I know you want to. RN 11 immediately attempted to intervene and told the two CNAs to stop arguing. CNA 12 then began to yell at RN 11 about making sure her CNAs did what they were supposed to. CNA 13 then stated she was going to clock out and go home and had begun to walk away from the situation. CNA 13 walked down the hall when CNA 12 ran up behind her, grabbed her hair, pulled her down, and began hitting her with her fist repeatedly. LPN 7 from another hall came and was able to break up the physical altercation between the two staff members. Law enforcement showed up and both CNAs were escorted out of the building by officers. No residents were involved in the altercation, but several residents witnessed the incident.During an interview, on 8/18/26 at 11:22 a.m., Resident B indicated a few weeks ago he heard a loud commotion when he was in bed. It sounded like people were fighting. He was not scared but concerned. He later found out there were two CNAs fighting. During an interview, on 8/18/26 at 2:55 p.m., the Director of Nursing (DON) indicated staff called her when the incident happened and she told the staff to get the CNAs out of the building. The police were notified, came to the facility, and took the 2 employees to jail. They were terminated. It was all over something very minor as one employee was mad about the other employee not filling the ice chest. During an interview, on 8/19/26 at 12:01 p.m., the former Executive Director indicated the facility had cameras, but they did not record. The facility did away with the recording cameras after the building had received an Immediate Jeopardy (IJ) citation and now the cameras did not record. During an interview, on 8/19/26 at 12:30 p.m., CNA 9 indicated she heard commotion as she went up the hall and witnessed both CNAs outside room [ROOM NUMBER] and 210. CNA 12 yelled at CNA 13 to go ahead and hit her. CNA 12 walked up, grabbed CNA 13's hair, forced her to the ground, and started to punch her face. Resident C stepped in between the 2 CNAs. The CNAs hair and nails were all over the floor. CNA 8 called 911. Resident D came out of her room and witnessed the incident. Resident D was visibly upset and instructed the CNAs to take it outside. CNA 9 indicated she did not feel safe and felt the residents were not safe.During an interview, on 8/19/26 at 12:40 p.m., CNA 10 indicated she walked to the dining room, heard a lot of noise coming from the other hall, and saw CNA 12 and CNA 13 fighting. CNA 12 had CNA 13's head and was aggressively pulling on her hair while shaking her head back and forth. CNA 13 tried to get away. CNA 10 then ran back to tell the nurse on her hall.During an interview, on 8/20/26 at 10:39 a.m., CNA 8 indicated she no longer worked at the facility due to not feeling safe. On the night of the incident, she heard yelling, thought a resident could have been in trouble, and went to see what was going on. When she arrived at the hall, she saw CNA 13 physically assaulting CNA 12 by hitting her in the face several times, pulling her hair and they were on the floor. Several residents watched CNA 12 hitting and assaulting CNA 13. CNA 8 called 911. The staff and residents were scared while the altercation was going on.During an interview, on 8/20/26 at 4:13 p.m., the Director of Nursing (DON) indicated QMA 3 called her to inform her what happened. at the facility. She indicated CNA 8 said Resident D was upset, so a psychosocial evaluation was completed. The facility completed a psychosocial evaluation of the residents the CNAs indicated witnessed the incident and not every resident who resided in that hallway.During an interview, on 08/21/26 at 9:43 a.m., Resident F indicated CNA 13 was the one getting her hair pulled. He witnessed the incident and went back into his room. He did not want to have anything to do with it. Resident C was involved and observed the incident. During an interview, on 8/21/26 at 9:47 a.m., Resident J indicated the CNAs were fighting and yelling. She had bad vision and could not tell exactly what was happening but knew the 2 CNAs were fighting.During an interview, on 8/21/26 at 11:24 a.m., Qualified Medication Aide (QMA) 3 indicated CNA 9 informed her there was a fight between 2 CNAs. She then called the Director of Nursing.A facility document, titled Workplace Conduct and Employment Practices, indicated .We will not tolerate disrespectful, intimidating, threatening, or harassing behavior.This included but was not limited to: Workplace violence, including physical assault, threat of violence.Each of us has the right to work in an environment free of harassment, intimidation and workplace violence. Accordingly, we prohibit any behavior that creates an intimidating, hostile, or offensive work environment.If you observe or experience any form of harassment or violence, you should report the incident immediately. A current facility policy, titled Resident Rights, undated and received from the DON on 8/18/26 at 1:00 p.m., indicated .Dignity: a state worthy of honor or respect; includes but not limited to.providing safe and secure housing.It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents.Safety of residents.top priority of care.This citation relates to Intake 3106454.410 IAC (Indiana Administrative Code) 3.1-3(t)

Based on observation, interview and record review, the facility failed to ensure discontinued controlled substances were disposed of timely, controlled substances were accounted for while waiting to be disposed of, and to ensure an ordered medication was provided in a timely manner for 11 of 11 residents reviewed for pharmacy services. (Resident 61, 50, 6, 9, 32, 56, 7, 1, 20, 29, and 5) Findings include:1. During an observation and interview, on 9/5/25 at 11:59 a.m., the Director of Nursing (DON) indicated the discontinued controlled substances were kept in a locked box in her desk drawer in her office. The spare key to the desk was also in her office in a safe which could be accessed with a keypad. The DON took a key and unlocked the bottom drawer on the right side of the desk. The DON opened the drawer and removed a small teal colored box with a lock on the front. The locked box was opened and inside contained several narcotic cards wrapped with the narcotic reconciliation count sheets. There were seven (7) narcotic medication cards locked in the bottom drawer of the DON's desk in a small lock box. 1. The clinical record for Resident 61 was reviewed on 9/8/25 at 9:55 a.m. A physician's order, dated 7/31/25 and discontinued on 8/29/25, indicated to give oxycodone 10 milligrams (mg) every 4 hours for chronic pain. A record of disposal for controlled substances, dated 9/5/25, indicated 16 pills were destroyed on 9/5/25, 7 days after the medication was discontinued. 2. The clinical record for Resident 50 was reviewed on 9/8/25 at 9:39 a.m. A physician's order, dated 6/26/25 and discontinued on 8/14/25, indicated to give hydrocodone-acetaminophen 10-325 mg every 4 hours for pain. A record of disposal for controlled substances, dated 8/22/25, indicated 13 pills were destroyed on 8/22/25, 8 days after the medication was discontinued. 3. The clinical record for Resident 6 was reviewed on 9/4/25 at 9:13 a.m. A physician's order, dated 6/3/25 and discontinued on 8/13/25, indicated to give hydrocodone-acetaminophen 10-325 mg every 6 hours as needed for pain. A record of disposal for controlled substances, dated 8/22/25, indicated 14 pills were destroyed on 8/22/25, 9 days after the medication was discontinued. 4. The clinical record for Resident 9 was reviewed on 9/8/25 at 10:05 a.m. A physician's order, dated 4/17/25 and discontinued on 5/1/25, indicated to give hydrocodone-acetaminophen 5-325 mg every 6 hours as needed for hip pain for 14 days. A shift-change controlled substance inventory tracker dated 7/23/25-7/25/25, indicated a card of hydrocodone-acetaminophen was removed for destruction, on 7/23/25, 83 days after the medication was discontinued. The card was reported stolen by the facility, on 8/9/25, by a former employee while being stored in the Director of Nursing's locked desk waiting to be destroyed, 17 days after removal from the medication cart. 5. The clinical record for Resident 32 was reviewed on 9/8/25 at 10:07 a.m. A physician's order, dated 10/10/24, indicated to give tramadol 50 mg as needed for pain. A shift-change controlled substance inventory tracker dated 7/23/25-7/25/25, indicated a card of tramadol was removed for destruction on 7/23/25. The card was reported stolen by the facility, on 8/9/25, by a former employee while being stored in the Director of Nursing's locked desk waiting to be destroyed, 17 days after removal from the medication cart. 6. The clinical record for Resident 56 was reviewed on 9/8/25 at 10:10 a.m. A physician's order, dated 6/30/25 and discontinued on 7/22/25, indicated to give hydrocodone-acetaminophen 5-325 mg four (4) times a day for pain. A shift-change controlled substance inventory tracker dated 7/23/25-7/25/25, indicated a card of tramadol was removed for destruction on 7/24/25. The card was reported stolen by the facility, on 8/9/25, by a former employee while being stored in the Director of Nursing's locked desk waiting to be destroyed, 16 days after removal from the medication cart. 7. The clinical record for Resident 7 was reviewed on 9/4/25 at 11:56 a.m. a. A physician's order, dated 7/11/25 and discontinued 7/16/25, indicated to give Morphine Sulfate Extended Release (ER) 15 milligrams (mg) twice a day for pain. A controlled substance administration record indicated 29 tablets were destroyed in a RX destroyer, on 7/22/25, six (6) days after being discontinued. b. A physician's order, dated 6/24/25 and discontinued 7/2/25, indicated to apply one (1) fentanyl transdermal patch every 3 days for pain. A controlled substance administration record indicated five (5) patches were destroyed in a RX destroyer, on 7/22/25, 20 days after being discontinued. A controlled substance administration record indicated two (2) patches were destroyed in a RX destroyer, on 7/22/25, 20 days after being discontinued. c. A physician's order, dated 6/16/25 and discontinued 6/24/25, indicated to give morphine sulfate concentrate oral solution 100mg/5ml for pain. A controlled substance administration record indicated 29.75 ml were destroyed in a RX destroyer, on 6/30/25, 6 days after being discontinued. 8. The clinical record for Resident 1 was reviewed on 9/8/25 at 10:20 a.m. A physician's order, dated 5/21/25 and discontinued on 6/20/25, indicated to give hydrocodone-acetaminophen 10-325 mg every 6 hours as needed for pain for 30 days. A shift-change controlled substance inventory tracker dated 7/23/25-7/25/25, indicated one (1) narcotic card was removed from the medication cart, on 7/21/25, one (1) month after the medication was discontinued. A controlled drug destruction sheet, dated 7/22/25, indicated 24 pills were destroyed. 9. The clinical record for Resident 20 was reviewed on 9/8/25 at 10:25 a.m. A physician's order, dated 6/4/25 and discontinued on 7/10/25, indicated to give tramadol 50 mg every 6 hours for pain. A controlled drug destruction sheet, dated 7/22/25, indicated 18 pills were destroyed, 12 days after being discontinued. 10. The clinical record for Resident 29 was reviewed on 9/8/25 at 10:27 a.m. A physician's order, dated 2/27/25 and discontinued on 3/13/25, indicated to give lorazepam 0.5 mg every 12 hours as needed for anxiety for 14 days. A shift-change controlled substance inventory tracker dated 4/10/25-4/13/25, indicated the lorazepam card was removed from the medication cart, on 4/11/25, 29 days after the order was discontinued. A record of disposal for medications, dated 4/18/25, indicated 42 tablets of lorazepam 0.5 mg were destroyed, on 4/18/25, 7 days after removal from the medication cart. The previous record of disposal for medications was dated 4/4/25. 11. The clinical record for Resident 5 was reviewed on 9/4/25 at 9:30 a.m. The diagnoses included, but were not limited to, asthma, aneurysm of the carotid artery, chronic obstructive pulmonary disease (COPD), aortic valve stenosis, osteoporosis, hypothyroidism, anemia, and dependence on supplemental oxygen. A nursing progress note, dated 3/6/25, indicated Resident 5 was admitted to the hospital for COPD exacerbation and pulmonary effusion. A nursing progress note, dated 3/8/25, indicated Resident 5 returned to the facility from the hospital with new orders for prednisone and an antibiotic. A hospital Discharge summary, dated [DATE], indicated to administer prednisone 40 mg daily with breakfast for 3 days, then administer 20 mg daily with breakfast for 4 days, and to begin administering the medication on 3/8/25. A physician's order, dated 3/9/25, indicated to administer prednisone 40 mg in the morning for 3 days for inflammation. Medication administration notes, dated 3/9/25, 3/10/25, and 3/11/25, indicated the prednisone was on order from the pharmacy and was not given. There was no documentation the pharmacy was called for follow-up related to the medication not being delivered. During an interview, on 9/5/25 at 11:52 a.m., the Administrative Support nurse indicated the facility's policy was to remove discontinued controlled substances from the double locked medication carts and keep the narcotics in the Director of Nursing's office until they were destroyed by the DON and another nurse. The procedure of locking the medications in the DON's office was created to limit access of the discontinued medications by the staff nurses. It was to decrease the number of hands which touched the discontinued controlled substances. The facility did not immediately destroy the medications because of limited nurses available to witness the destruction with the DON and because the DON had so many duties which demanded her attention. The DON tried to destroy medications every Friday. The discontinued medications should be removed from the cart and destroyed as quickly as possible once the order was discontinued to prevent potential theft. The controlled substances were not counted while they were stored in the DON's office. Controlled substances should be counted and accounted for daily until destroyed. During an interview, on 9/5/2025 at 11:59 a.m., the DON indicated the discontinued controlled substances were stored in her office until the medication was destroyed. She pulled out the discontinued medications and would wait until the Unit Manager could destroy them with her. She preferred to destroy discontinued controlled substances with the Unit Manager, but any 2 nurses could destroy medication. The facility had decided this process would be the best and fewer people would handle the discontinued medication if it was not stored in the cart. When the medication was removed from the medication cart, the pills were placed with the narcotic count sheet and therefore the medications were not counted after they were removed from the cart. The medication should be counted daily to make sure they were monitored. The medication was placed in the lock box and not touched until she destroyed them. She had the key to the lock box and did not think about continuing to count the medications. The spare key to her desk and the locked drawer were kept in a safe locked with a keypad code in her office. During an interview, on 9/5/25 at 12:33 p.m., LPN 2 indicated when a resident was discharged , depending on their insurance type, the medication would go with the resident if it was an active order. If the medication was not sent home with the resident, the DON and the Unit Manager would come, take the medication out of the cart, and destroy them. If the medication was sent home with the residents, it was added to the discharge summary. During an interview, on 9/5/25 at 2:04 p.m., the Director of Nursing (DON) indicated the prednisone was on order at the pharmacy and was not received. The nurse practitioner reordered the medication on 3/13/25 and it was administered for four (4) days. During an interview, on 9/8/25 at 10:47 a.m., LPN 2 indicated the time of day the medication was ordered, determined when it would arrive from pharmacy. If it was early in the day, it would arrive in the night drop of medications. If it was a specialty medication, it could take longer. She did not know of a process to receive medications STAT (immediately) if they had not been delivered in a timely manner. A current facility policy, titled Medication Administration, undated and received from the DON on 9/4/25 at 3:30 p.m., indicated .Medications that are refused or withheld or not given will be documented .Critical medications that are refused .will be followed up with physician contact .Documentation of medication will be current for medication administration .Documentation of medications will follow accepted standards of nursing practice A current facility policy, titled Physician Orders, undated and received from the DON on 9/4/25 at 3:50 p.m., indicated .Place orders in electronic Medical Record .Contact pharmacy for changes .The nurse that takes the physician order will be responsible for executing the order or provide for the safe hand-off to the next nurse .Notifying attending or other providers as appropriate .Document contacts in the medical record A current facility policy, titled Chain of Custody for Controlled Substances, undated and received from the DON on 9/4/25 at 3:30 p.m., indicated .Two nurses will provide a count of controlled substances before placing in medication cart(s).Nurses will adjust the shift-to-shift count sheet to reflect addition of new medications.In the event a second nurse is unavailable, the nurse will secure the controlled substances in the double-locked drawer.When the second nurse is available or at the following shift change, two nurses will count and validate the delivery.Controlled substances are to be secured using the double lock method when not in the immediate possession of the nurse.Scheduled drugs require an inventory count sheet.Specific pharmacy delivered sheets are to be used, do not recreate.Doses must be accounted for at all times.two nurses will perform the Shift-to Shift Chain of Custody Count.One nurse from the off-going shift will count with the on-coming nurse.The medications will be secured using a double-lock system until a second nurse witness is available to witness the disposal.Controlled substance medication will be wasted in a drug disposal system) such as Drug Buster.The nurse will remove the medication from the cart in the presence of a second nurse.Both nurses will count and sign the disposition of the drug and count sheet for disposal.The destruction log and the drugs will be kept in separate areas to reduce theft of both items. 3.1-25(e)(2) 3.1-25(e)(3) 3.1-25(g)(2)

Based on observation, interview and record review, the facility failed to ensure discontinued controlled substances were free from theft of a former employee for 3 of 3 residents reviewed for misappropriation of property. (Resident 9, 32 and 56)Findings include: During an observation and interview, on 9/5/25 at 11:59 a.m., the Director of Nursing (DON) indicated the discontinued controlled substances were kept in a locked box in her desk drawer in her office. The spare key to the desk was also in her office in a safe which could be accessed with a keypad. The DON took a key and unlocked the bottom drawer on the right side of the desk. The DON opened the drawer and removed a small teal colored box with a lock on the front. The locked box was opened and inside contained several narcotic cards wrapped with the narcotic reconciliation count sheets. There were seven (7) narcotic medication cards locked in the bottom drawer of the DON's desk in a small lock box.A facility reported incident, dated 8/9/25 at 1:37 a.m., indicated the DON received a call from a staff member to inform her the former unit manager had entered the building and locked herself in the DON's office. Another staff member reported hearing the former unit manager going through drawers and papers from outside the door. When a staff member knocked on the door and encouraged the former unit manager to exit the office, she refused. The DON arrived at the building at 1:50 a.m., and the former unit manager had already left. Upon searching the office, the DON discovered three discontinued controlled substance prescriptions pending destruction missing from the double locked medication storage in the office.A facility witness statement, dated 8/9/25, indicated CNA 5 went into the hallway and heard rambling from the drawers outside the DON's office. They called the former unit manager, and she answered her phone and told them she was in her old office getting papers. CNA 5 witnessed the former unit manager in the mirror when she left the office.A facility witness statement, dated 8/9/25, indicated CNA 6 was taking a break around 1:05 a.m. She was outside for 1 to 2 minutes when a white car pulled into the parking lot. She called the staff inside to let them know someone entered the building. They called the former unit manager to see if it was her inside the DON's office. The former unit manager came out of the DON's office 30-40 minutes later.A facility witness statement, dated 8/9/25, indicated CNA 8 received a call from CNA 6. CNA 8 walked down the hall with another CNA, and they called the former unit manager's phone. The former unit manager told her she was in the DON's office and would not leave the office until everyone was out of the hallway. The former unit manager exited the DON's office and was witnessed in the mirror in the hallway.A facility witness statement, dated 8/9/25, indicated CNA 7 heard the door alarm sound and then instantly turn off. Shortly after, two co-workers came to ask her if she saw anyone come in the building. She heard a noise coming from the DON's office and witnessed the former unit manager in the mirror when she exited the building. A shift-change controlled substance inventory tracker indicated the following controlled substance cards and count sheets were missing from the DON's locked box after the incident:a. The clinical record for Resident 9 was reviewed on 9/8/25 at 10:05 a.m.A physician's order, dated 4/17/25 and discontinued on 5/1/25, indicated to give hydrocodone-acetaminophen 5-325 mg every 6 hours as needed for hip pain for 14 days. A shift-change controlled substance inventory tracker dated 7/23/25-7/25/25, indicated a card of hydrocodone-acetaminophen was removed for destruction on 7/23/25, 83 days after the medication was discontinued. The card was reported stolen by the facility on 8/9/25 by a former employee while being stored in the Director of Nursing's locked desk waiting to be destroyed, 17 days after removal from the medication cart.b. The clinical record for Resident 32 was reviewed on 9/8/25 at 10:07 a.m.A physician's order, dated 10/10/24, indicated to give tramadol 50 mg as needed for pain.A shift-change controlled substance inventory tracker dated 7/23/25-7/25/25, indicated a card of tramadol was removed for destruction on 7/23/25. The card was reported stolen by the facility on 8/9/25 by a former employee while being stored in the Director of Nursing's locked desk waiting to be destroyed, 17 days after removal from the medication cart.c. The clinical record for Resident 56 was reviewed on 9/8/25 at 10:10 a.m.A physician's order, dated 6/30/25 and discontinued on 7/22/25, indicated to give hydrocodone-acetaminophen 5-325 mg four (4) times a day for pain.A shift-change controlled substance inventory tracker dated 7/23/25-7/25/25, indicated a card of tramadol was removed for destruction on 7/24/25. The card was reported stolen by the facility on 8/9/25 by a former employee while being stored in the Director of Nursing's locked desk waiting to be destroyed, 16 days after removal from the medication cart.During an interview, on 9/4/25 at 11:03 a.m., the Administrative Support indicated the former unit manager took the narcotics out of the DON's drawer. The facility was not aware how the former unit manager entered the office. The former unit manager was let go in May and the pills were taken in August. The former unit manager was believed to have entered the back door and gone directly to the office.During an interview, on 9/4/25 at 2:44 p.m., the DON indicated she received a phone call at 1:30 a.m. and was told staff saw a suspicious person in the building. One of the staff said it was the former unit manager, and they would find out what was going on. The staff saw the former unit manager enter the DON's office, and noticed the door was locked. They heard what sounded like papers rustling and the staff told the former employee to come out of the office. The former unit manager told the staff she would not come out of the office until they left the hallway. The DON arrived shortly after the former employee exited the building. The police were called, a report was filed, and a warrant was placed for her arrest. The former unit manager shared an office with the DON and knew how to get into the safe hanging on the bathroom wall. There were multiple missing narcotics from the locked box which were for Resident 9, 32 and 56. During an interview, on 9/8/35 at 3:39 a.m., CNA 7 indicated a staff member saw someone come into the building using the door by the time clock. CNA 7 and another staff member jumped up and started to search all their residents' rooms. As they were walking around, they heard movement coming from their DON's office. The noise sounded like someone was moving papers around. CNA 6 called the former unit manager, and she told them she was in her old office getting papers. The former unit manager told CNA 6 she would not leave the office until everyone left the hall. They stood further down the hall and could see the former unit manager leaving the building in the mirror hanging up on the wall.During an interview, on 9/8/25 at 3:45 a.m., CNA 5 indicated CNA 6 was going out on break and saw an unknown car in the parking lot. CNA 6 saw someone enter the building and went to tell staff. They started to check on the residents and heard a sound coming from the DON's office. The noise sounded like someone moving papers. CNA 6 called the former unit manager and was told she would not leave the office until everyone was out of the hall. Staff were down the hall when the former unit manager exited the office and could see the former employee in the mirror hanging on the wall. During an interview, on 9/5/2025 at 11:59 a.m., the DON indicated the discontinued controlled substances were stored in her office until the medication was destroyed. She pulled out the discontinued medications and would wait until the Unit Manager could destroy them with her. She preferred to destroy discontinued controlled substances with the Unit Manager, but any 2 nurses could destroy medication. The facility had decided this process would be the best and fewer people would handle the discontinued medication if it was not stored in the cart. When the medication was removed from the medication cart, the pills were placed with the narcotic count sheet and therefore the medications were not counted after they were removed from the cart. The medication should be counted daily to make sure they were monitored. The medication was placed in the lock box and not touched until she destroyed them. She had the key to the lock box and did not think about continuing to count the medications. The spare key to her desk and the locked drawer were kept in a safe locked with a keypad code in her office.During an interview, on 9/5/25 at 11:52 a.m., the Administrative Support nurse indicated the facility's policy was to remove discontinued controlled substances from the double locked medication carts and keep the narcotics in the Director of Nursing's office until they were destroyed by the DON and another nurse. The procedure of locking the medications in the DON's office was created to limit access of the discontinued medications by the staff nurses. It was to decrease the number of hands which touched the discontinued controlled substances. The facility did not immediately destroy the medications because of limited nurses available to witness the destruction with the DON and because the DON had so many duties which demanded her attention. The DON tried to destroy medications every Friday. The discontinued medications should be removed from the cart and destroyed as quickly as possible once the order was discontinued to prevent potential theft. The controlled substances were not counted while they were stored in the DON's office. Controlled substances should be counted and accounted for daily until destroyed.During an interview, on 9/5/25 at 12:33 p.m., LPN 2 indicated when a resident was discharged , depending on their insurance type, the medication would go with the resident if it was an active order. If the medication was not sent home with the resident, the DON and the Unit Manager would come, take the medication out of the cart, and destroy them. If the medication was sent home with the residents, it was added to the discharge summary. A current facility policy, titled INDIANA Abuse & Neglect & Misappropriation of Property, undated and received from the ED at entrance on 9/2/25, indicated .Misappropriation of resident funds or property: In Indiana, the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's property or money without the resident's consent. Resident's property includes all residents' possessions, regardless of their apparent value since it may hold intrinsic value to the resident. This includes any medication dispensed in the name of a resident. This does not include medications from an EDK that have not been charged to the resident.It is the intent of this facility to prevent the abuse, mistreatment, or neglect of residents or the misappropriation of their property A current facility policy, titled Chain of Custody for Controlled Substances, undated and received from the DON on 9/4/25 at 3:30 p.m., indicated .Controlled substances are to be secured using the double lock method when not in the immediate possession of the nurse.Scheduled drugs require an inventory count sheet.Specific pharmacy delivered sheets are to be used, do not recreate.Doses must be accounted for at all times.two nurses will perform the Shift-to Shift Chain of Custody Count.One nurse from the off-going shift will count with the on-coming nurse.The medications will be secured using a double-lock system until a second nurse witness is available to witness the disposal.Controlled substance medication will be wasted in a drug disposal system such as Drug Buster.The nurse will remove the medication from the cart in the presence of a second nurse.Both nurses will count and sign the disposition of the drug and count sheet for disposal.The destruction log and the drugs will be kept in separate areas to reduce theft of both items.3.1-28(a)

Based on interview and record review, the facility failed to ensure the physician was notified of a resident's blood glucose readings according to the physician's order for 1 of 2 residents reviewed for quality of care. (Resident 31)Findings include: The clinical record for Resident 31 was reviewed on 9/4/25 at 9:39 a.m. The diagnoses included, but were not limited to, diabetes mellitus, hypertension, major depressive disorder, visual loss in both eyes, anxiety disorder, and chronic kidney disease.A care plan, dated 1/3/25, indicated Resident 31 had a diagnosis of diabetes mellitus. Interventions included, but were not limited to, obtain blood sugars according to the physician's order and report abnormal findings to the physician, resident, and the resident's representative. A physician's order, dated 1/6/25, indicated to check Resident 31's blood glucose twice a day and to notify the physician if the blood glucose reading was less than 70 or greater than 150. The Medication Administration Record (MAR), dated 7/1/25 through 7/31/25, indicated the following:a. On 7/2/25 at 9:00 a.m., the blood glucose reading was 168 and the physician was not notified.b. On 7/2/25 at 9:00 p.m., the blood glucose reading was 159 and the physician was not notified.c. On 7/3/25 at 9:00 a.m., the blood glucose reading was 160 and the physician was not notified.d. On 7/4/25 at 9:00 a.m., the blood glucose reading was 168 and the physician was not notified.e. On 7/10/25 at 9:00 p.m., the blood glucose reading was 162 and the physician was not notified.f. On 7/14/25 at 9:00 p.m., the blood glucose reading was 177 and the physician was not notified.g. On 7/30/25 at 9:00 a.m., the blood glucose reading was 158 and the physician was not notified. The MAR, dated 8/1/25 through 8/31/25, indicated the following:a. On 8/1/25 at 9:00 a.m., the blood glucose reading was 153 and the physician was not notified.b. On 8/2/25 at 9:00 p.m., the blood glucose reading was 185 and the physician was not notified.c. On 8/22/25 at 9:00 a.m., the blood glucose reading was 151 and the physician was not notified.d. On 8/25/25 at 9:00 a.m., the blood glucose reading was 158 and the physician was not notified.e. On 8/27/25 at 9:00 a.m., the blood glucose reading was 151 and the physician was not notified.f. On 8/29/25 at 9:00 a.m., the blood glucose reading was 153 and the physician was not notified.During an interview, on 9/4/25 at 2:48 p.m., the Support Administrator indicated there was no documentation the physician was notified of the blood glucose readings above 150. A current facility policy, titled Physicians Orders, undated and received from the DON on 9/4/25 at 3:50 p.m., indicated .to accurately document physician and provider orders as determined by the license's Scope of Practice.The nurse that takes the physician order will be responsible for executing the order or provide for the safe hand-off to the next nurse.The MAR/TAR should automatically be updated with the new orders if schedule has been assisted.Notify attending or other providers as appropriate.Document contacts in the medical record.3.1-37(a)

Based on interview and record review, the facility failed to ensure the ombudsman was notified of a resident's hospitalization and to document a bed hold policy was provided to the resident or resident's representative for 3 of 4 residents reviewed for transfer and discharge. (Resident 1, 20, and 65)Findings include:1. The clinical record for Resident 1 was reviewed on 9/4/25 at 9:00 a.m. The diagnoses included, but were not limited to, hypertensive heart disease with heart failure, stage 4 chronic kidney disease, and a history of a stroke. A nursing progress note, dated 6/3/25, indicated Resident 1 was found face down in front of her wheelchair. A physician's order was received to send her out to the emergency room. The June ombudsman notification log was reviewed, and Resident 1 was not listed on the June notification log. During an interview, on 9/5/25 at 11:00 a.m., the Social Services Director (SSD) indicated it was her responsibility to notify the ombudsman. She sent the notification on the first of the month for the prior month. If the residents' name was not listed, then the ombudsman was not notified. 2. The clinical record for Resident 20 was reviewed on 9/4/25 at 9:46 a.m. The diagnoses included, but were not limited to, hypertension, heart failure, and type 2 diabetes. A nursing progress note, dated 7/24/25, indicated a large amount of blood was found under Resident 20's leg in bed. The physician was called, and the resident was sent out to the hospital. There was no documentation in the electronic health record of a bed hold policy being provided to the resident or resident's representative at the time of transfer. A bed hold authorization form was provided for Resident 20 for the 7/24/25 hospitalization. The signature for the resident or resident's representative was blank, and nothing was marked related to the decision to hold or not hold the bed. During an interview, on 9/5/25 at 12:13 p.m., Licensed Practical Nurse (LPN) 2 indicated the bed hold information should be charted in the progress notes or could be scanned into the electronic health record. During an interview, on 9/5/25 at 1:50 p.m., the Director of Nursing (DON) indicated she did not send out the bed hold information when residents were transferred. The nurses on the floor might send it with the residents. 3. The clinical record for Resident 65 was reviewed on 9/8/25 at 9:30 a.m. The diagnoses included, but were not limited to, malnutrition, weakness, anxiety, chronic obstructive pulmonary disease, anemia, hypothyroid, tongue cancer, depression, dysphagia, psychoactive substance abuse, and gastrostomy status. A nursing progress note, dated 8/22/25, indicated the resident was sent to the emergency room for a decreased level of consciousness and low oxygen levels. A nursing progress note, dated 8/22/25, indicated the resident was admitted to the hospital for aspiration pneumonia. An acute transfer letter form was provided for Resident 65 for the 8/22/25 hospitalization. The signature for the resident was blank and there was a written statement which said the resident was unable to sign due to decreased responsiveness. There was no documentation in the electronic health record of a bed hold policy being provided to the resident or resident representative at the time of transfer or thereafter. A current facility policy, titled Transfer and Discharge, undated and received from the administrative support on 9/5/25 at 11:30 a.m., indicated .Emergency transfers/discharges .provide a notice of the residents bed hold policy to the resident and representative at the time of transfer, as possible, but not later than 24 hours of the transfer. Provide notice as soon as practicable to the residents and representatives. Social services director, or designee, shall provide notice of transfer to a representative of the state long-term care ombudsman via monthly list 3.1-12(a)(6)(A)(i) 3.1-12(a)(6)(A)(ii) 3.1-12(a)(6)(A)(iii) 3.1-12(a)(6)(A)(iv)

Based on observation, interview and record review, the facility failed to ensure the concrete in the outside patio was free of uneven areas for 3 of 3 residents and 1 of 1 family member who voiced concerns for the environment. (Resident 37, 44, 15 and 262) Finding includes: 1. During a resident council interview, on 10/10/24 at 2:08 p.m., Resident 37 indicated the patio area was a safety concern due to uneven concrete. Resident 37 and Resident 44 indicated other residents had tripped over the uneven concrete and Resident 15 tipped his wheelchair backwards and hit his head while trying to go over the uneven concrete. During an observation, on 10/10/24, the outdoor patio area had multiple areas of uneven concrete. 2. The clinical record for Resident 15 was reviewed on 10/11/24 at 12:06 p.m. The diagnoses included, but were not limited to, acquired absence of the right and left legs below the knee, nicotine dependence, chronic obstructive pulmonary disease, weakness, and anxiety disorder. A post fall evaluation, dated 8/19/24 at 12:37 a.m., indicated Resident 15 was outside smoking. As the resident was finished and going back inside, he tried to pop a wheelie over the small bump and fell backwards hitting his head on the concrete. An annual Minimum Data Set (MDS) assessment, dated 9/5/24, indicated Resident 15 used a manual wheelchair for mobility and required substantial/maximal assistance (helper did more than half the effort). 3. During an interview, on 10/11/24 at 12:06 p.m., Resident 262's daughter indicated her father's legs would sometimes drop off his foot pedals when his wheelchair went over the uneven concrete. The resident's wife indicated other residents had issues getting over the uneven concrete when they were propelling themselves in their wheelchairs. During an interview, on 10/11/24 at 12:12 p.m., a staff member indicated the residents would occasionally have trouble getting over the uneven concrete. During a facility tour, on 10/11/24 at 2:26 p.m., the Executive Director (ED) indicated the concrete was uneven in the patio area. At exit conference, the facility did not provide an environmental policy and indicated they followed the state regulations. 3.1-19(f)(5)

Based on observation, interview and record review, the facility failed to ensure the physician was notified before medications were given when a resident was suspected of being intoxicated from alcohol intake for 1 of 1 resident reviewed for quality of care. (Resident 53) Findings include: During an observation, on 10/7/24 at 3:01 p.m., a bruise was noted on the right side of Resident 53's face. During an interview, on 10/07/24 at 4:12 p.m., the resident indicated she fell and did not remember falling. The clinical record for Resident 53 was reviewed on 10/08/24 at 2:52 pm. The diagnoses included, but were not limited to, moderate protein calorie malnutrition, anemia, major depressive disorder, opioid abuse, alcohol abuse, and anxiety. A physician's order, dated 9/20/24, indicated to give temazepam (a medication used for insomnia) 30 mg (milligrams) at bedtime. A physician's order, dated 9/20/24, indicated to monitor for sedative and hypnotic side effects. The monitoring included, but were not limited to, sedation, drowsiness, increased falls, dizziness, weakness and hangover effect every shift related to hypnotic medication use. A medication administration record, dated 10/1/24 to 10/31/24, indicated the temazepam was administered at 9:36 p.m., on 10/6/24. A telehealth progress note, dated 10/6/24 at 10:38 p.m., indicated the resident had a fall. She was found on the floor with right cheek and eye edema. The resident appeared to be intoxicated. She was out on a leave of absence and when she returned to the facility, she was showing signs of intoxication. She struck her head when she fell . She refused to participate with neurologic checks. A progress note, dated 10/6/24 at 11:01 p.m., indicated the resident was found on the floor at approximately 10:00 p.m. She was alert and oriented. She had a bruise and edema on the left cheek and eye. The resident was not cooperative and refused neurological checks (tests to evaluate the nervous system). An order was obtained to send the resident to the emergency department for evaluation. An interdisciplinary team follow-up progress note, dated 10/7/24 at 1:15 p.m., indicated the resident had an unwitnessed fall upon her return to the facility from a leave of absence. The resident reported to the staff she fell out of bed. She was found by staff on the floor next to her bed. The root cause of the incident indicated when the resident returned from her leave of absence at approximately 9:30 p.m., the staff reported the resident smelled of alcohol and appeared intoxicated. The resident was uncooperative and was not allowing the staff to perform neurological checks after hitting her head during the fall. There was no documentation the physician was notified of the resident's suspected intoxication prior to administering the temazepam. During an interview, on 10/11/24 at 3:00 p.m., Director of Nursing indicated if a resident was intoxicated the medication should have been held. A current publication, titled Mobile PDR, indicated . increased central nervous system (CNS) and respiratory depressant effects may be seen when temazepam is used with alcohol .ethanol ingestion should be avoided during temazepam use .ethanol intoxication may increase the risk of serious CNS or respiratory depressant effects A current policy, titled Medication Administration, not dated and received from the Director of Nursing on 10/11/24 at 3:00 p.m., indicated .a resident centered, individualized approach to medication administration will be used for administering medications as possible .safety and avoiding adverse effects are considered a high priority for medication administration and may preclude some preferences A current policy, titled Resident Substance Abuse in Facility, not dated and received from the Director of Nursing on 10/11/24 at 3:00 p.m., indicated .being under the influence of illicit drugs or alcohol places the resident at risk for overdose, falls, and respiratory depression and places other residents at risk for injury by a resident under the influence of illicit or illegal drugs or alcohol .the facility will safeguard the resident under the influence of illicit or illegal drugs to the extent possible, as well as provide a safe environment for other residents, staff and visitors 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure there was an accurate physician's order for the use of oxygen, oxygen was set at the correct liter flow rate, the compressor was set at the correct rate and oxygen tubing was labeled and dated for 4 of 4 residents reviewed for oxygen. (Resident 118, 20, 23 and 43) Findings include: 1. During an observation, on 5/14/24 at 11:16 a.m., Resident 118's Easy Air compressor was set at 20 and the oxygen concentrator was set at 2 liters per minute for the trach stoma (opening). During an observation, on 5/16/24 at 11:07 a.m., the resident was sitting up in a chair in his room and the oxygen concentrator was set at 2 liters per minute. The resident did not have oxygen on his trach stoma. The clinical record for Resident 118 was reviewed on 5/15/24 at 12:22 p.m. The diagnoses included, but were not limited to, congestive heart failure, chronic obstructive pulmonary disease, and dependence on supplemental oxygen. A care plan, dated 5/8/24, indicated the resident had chronic obstructive pulmonary disease with shortness of breath while lying flat. The interventions included, but were not limited to, oxygen therapy as ordered. A physician's order, dated 5/14/24, indicated oxygen at 3 liters per minute by the stoma mask continuous with compression at 50%. During an interview, on 5/15/24 at 11:15 a.m., the outside oxygen company representative who set up the resident's oxygen to his trach stoma indicated the Easy air setting should be at 20 for pressure, 80 for humidity and the oxygen concentrator at 2 liters per minute. During an interview, on 5/16/24 at 11:09 a.m., LPN 2 indicated the resident's oxygen concentration should be set at 3 liters per minute for continuous use. She would need to look at the physician's order to see what the Easy air compressor should be set on. She was going to call the Director of Nursing (DON) because she did not know what the Easy air should be set at. During an observation and interview, on 5/16/24 at 11:12 a.m., the DON indicated the respiratory therapist from the oxygen supply company should have set up the Easy air compressor at the correct rate and it should not be changed. The DON set the Easy air on 50 and the concentrator at 3 liters per minute. During an interview, on 5/16/24 at 3:28 p.m., the Clinical Support Nurse indicated the physician's order for the Easy air compressor should have been written to set the machine at 20 and it would equal the 50%. The staff working should have known how to set the Easy air compressor by following the physician's order. The physician's order was not clear. 49891 2. During an observation, on 5/13/24 at 1:30 p.m., Resident 20 was wearing oxygen with an unlabeled nasal cannula tubing. During an observation, on 5/14/24 at 11:00 a.m., Resident 20 was wearing oxygen with an unlabeled nasal cannula tubing. The clinical record for Resident 20 was reviewed on 5/14/24 at 4:08 p.m. The diagnoses included, but were not limited to, multiple sclerosis, edema, chronic obstructive pulmonary disease, anemia, dependence on supplemental oxygen, anxiety, and other seasonal allergic rhinitis. A physician's order, dated 3/8/24, indicated to administer oxygen at 2 liters per minute via nasal cannula (NC) continuously every shift for chronic respiratory failure. A physician's order, dated 3/25/24, indicated to change oxygen tubing and humidifier every 7 days and as needed (prn) every night shift on Monday. During an interview, on 5/16/24 at 11:10 a.m., LPN 1 indicated the nurses would verify the flow rate with the physician's order and set the oxygen flow according to the order. She indicated the tubing was ordered to be changed every Monday on nightshift. 3. During an observation, on 5/13/24 at 12:30 p.m., Resident 23 was wearing oxygen at a flow rate of 3 liters per minute with unlabeled nasal cannula tubing. During an observation, on 5/14/24 at 10:46 a.m., Resident 23 was wearing oxygen at 2.5 liters per minute with unlabeled nasal cannula tubing. During an observation, on 5/15/24 at 10:50 a.m., the resident was wearing oxygen at 2.5 liters per minute with unlabeled nasal cannula tubing. The clinical record for Resident 23 was reviewed on 5/15/24 at 09:38 a.m. The diagnoses included, but were not limited to, moderate persistent asthma, aneurysm of carotid artery, nonrheumatic aortic valve stenosis, chronic obstructive pulmonary disease, hypothyroidism, and anemia. A physician's order, dated 9/27/23, indicated to administer oxygen at 2 liters per minute via nasal cannula continuously every shift. A physician's order, dated 3/25/24, indicated to change, initial, and date the cannula tubing every night shift on Monday. 4. During an observation, on 5/13/24 at 12:55 p.m., Resident 43 was wearing oxygen at 3 liters per minute with unlabeled nasal cannula tubing. During an observation, on 5/14/24 at 10:15 a.m., Resident 43 was wearing oxygen at 3 liters per minute with unlabeled nasal cannula tubing. The clinical record for Resident 43 was reviewed on 5/16/24 at 2:41p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, type 2 diabetes mellitus with diabetic autonomic polyneuropathy, tobacco use, difficulty in walking, weakness, anxiety disorder, anemia, bipolar disorder, and recurrent major depressive disorder. A physician's order, dated 4/29/24, indicated to administer oxygen at 2 liters per minute via nasal cannula continuously every shift. A physician's order, dated 3/25/24, indicated to change cannula tubing every night shift on Monday. During an interview, on 5/16/24 at 11:10 a.m., LPN 1 indicated the nurses verify the flow rate with the physician's order and set the oxygen flow according to the order. She indicated the tubing was ordered to be changed every Monday on nightshift. A current policy, titled Continuous Aerosol Therapy, no date and received from the Clinical Support Nurse on 5/16/24 at 2:19 p.m., indicated .A physician order/provider's order is required for aerosol therapy with or without oxygen .The order should include the mode of administration (mask, collar, face tent) .The frequency and the duration of the therapy .The percentage of oxygen. A current policy, titled Supplemental Oxygen using Nasal Cannula, no date and received from the Clinical Support Nurse on 5/15/24 at 11:45 a.m., indicated .The nurse or RT (respiratory therapist) will verify the oxygen order for route an LPM (liters per minute) delivery rate .The nurse of RT will set the delivery rate on the tank or concentrator as ordered by the physician .Nasal cannulas and tubing are changed weekly or when soiled and labeled with date opened A current policy, titled Oxygen-Medical Gas Use, no date and received from the Clinical Support Nurse on 5/15/24 at 11:45 a.m., indicated .Residents Receiving Oxygen .Will have a physician/provider's order for the oxygen including route of administration, liters per minute and frequency of use 3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure a prn (as needed) psychotropic medication was renewed after 14 days for 1 of 5 residents reviewed for unnecessary medications. (Residents 38) Finding includes: The clinical record for Resident 38 was reviewed on 5/15/24 at 3:45 p.m. The diagnoses included, but were not limited to, fracture of the second cervical vertebra, adjustment disorder with mixed anxiety and depressed mood, vascular dementia, and cognitive communication deficit. A care plan, dated 1/15/24, indicated the resident had a mood problem potential related to anxiety and depressed mood. The interventions included, but were not limited to, monitoring and recording mood to determine if problems seem to be related to external causes, medications, treatments, concern over diagnosis, and change in sleep patterns. A physician's order, dated 5/1/24, indicated to give lorazepam (an anxiety medication) concentrate 2 milligram(mg)/milliliter(ml) 0.5 ml by mouth every 4 hours prn (as needed). A Medication Administration Record (MAR) indicated the resident received the following: a. On 5/14/24 at 3:00 p.m., the resident received a prn lorazepam concentrate 2mg/ml b. On 5/15/24 at 8:00 p.m., the resident received a prn lorazepam concentrate 2mg/ml c. On 5/16/24 at 2:52 p.m., the resident received a prn lorazepam concentrate 2mg/ml During an interview, on 5/16/24 at 11:43 a.m., the Director of Nursing (DON) indicated a prn lorazepam order needed to have a 14 day stop date. The physician would need to reevaluate the resident's need for the antianxiety medication after 14 days. During an interview, on 5/17/24 at 9:07 a.m., the Clinical Support Nurse indicated if the resident had an order for prn lorazepam, the medication would need to have a stop date after 14 days. A current policy, titled Antipsychotic Second Clinical Review, no date and received by the Clinical Support Nurse on 5/17/24 at 9:28 a.m., indicated .Antipsychotic Medication Orders will .Require a clinical review by a supervisory level nurse .PRN or as needed use of antipsychotic medications is: Not to be used routinely due to increased risk for adverse events .Supported by documentation within the medical record .Limited to 14 days use and may not be continued/renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication .A face-to face assessment of the resident is required by the practitioner .Telephonic or verbal orders may not be provided .Documentation by the practitioner is required in the progress notes .If on-going a new order for the PRN antipsychotic is required to be written every 14 days with the prescriber assessment and documentation .The physician/provider makes the final determination regarding the use of the medication 3.1-48(b)(2)

Based on observation, interview and record review, the facility failed to ensure assessments were completed and physician's orders and consents were obtained prior to the use of side rails for 2 of 2 residents reviewed for accident hazards. (Resident 117 and 118) Findings include: 1. During an observation, on 5/13/24 at 1:07 p.m., Resident 117 had two upper side rails on her bed which were in the raised position. The clinical record for Resident 117 was reviewed on 5/14/24 at 4:06 p.m. The diagnoses included, but were not limited to, wedge compression fracture of the thoracic (T) spine at T 11 and T 12, generalized muscle weakness, and restless leg syndrome. A progress note, dated 5/3/24 at 1:49 p.m., indicated the resident was at the facility for rehabilitation services due to a spinal fixation at level T 12 due to a fall. The electronic record did not have a side rail assessment or consent. A physician's order, dated 5/15/24, indicated 1/4 side rails to the bed to promote independence with activities of daily living. The physician's order for the side rails was completed after the side rails were utilized. A care plan, dated 5/3/24 and revised on 5/16/24, indicated the resident had an activities of daily living self-care performance deficit related to the wedge compression fracture of the T 11 and T 12 vertebra. The interventions included, but were not limited to, 1/4 side rails which was added to the care plan on 5/16/24. During an interview, on 5/16/24 at 10:29 a.m., the Clinical Support Nurse indicated the side rail assessment was not completed until 5/15/24. The side rail informed consent was signed by the resident on 5/8/24 however there was no date by the resident's signature to show when the consent was signed. 2. During an observation, on 5/14/24 at 11:10 a.m., Resident 118 had two upper side rails on his bed with the left side rail in the raised position. The clinical record for Resident 118 was reviewed on 5/15/24 at 12:22 p.m. The diagnoses included, but were not limited to, a fracture of the shaft of the humerus of the right arm, congestive heart failure, and weakness. The electronic record did not include a side rail consent or assessment. A physician's order, dated 5/15/24, indicated 1/4 side rails to the bed to promote independence with activities of daily living. The physician order was obtained after the side rails were on the resident's bed. During an interview, on 5/16/24 at 10:30 p.m., the Clinical Support Nurse indicated the resident did not have a side rail assessment or consent completed until 5/15/24. The consent and assessment should have been completed when the side rails were applied. A current policy, titled Safe Use of Bed Rails, not dated and received from the Executive Director on 5/15/24 at 3:30 p.m., indicated .It is the policy of this facility to provide resident centered care that meets the safety, psychosocial, physical and emotional needs and concerns of the residents. The facility will assess the residents' cognition and therapeutic need of the bed rail to assist the resident in reaching their highest potential of independence. A physician order is required to implement the use of bed rails .Assessment of residents with bed rails include .Review of prior interventions and outcomes prior to the initiation of the bed rails .Consent .Disclosure of the needs, risk and benefits of use .Education provided to the resident or resident representative .Signed by the resident or, if applicable, the resident representative .Monitoring .Documentation .Physician order is required .Completion of Bed Safety Evaluation .Consent obtained for bed rail use .Education provided to the resident .Care Plan for the use/need for bed rails 3.1-45(a)(1)

Based on interview and record review, the facility failed to ensure a Qualified Medication Aide (QMA) asked for permission prior to giving as needed (PRN) medications to 2 of 3 residents reviewed for staff working outside their professional classification. (Residents B and C) Findings include: During an investigation regarding a missing card of narcotic medication, it was discovered a QMA was administering PRN pain medications without the permission of a licensed nurse. 1. During an interview with a confidential interviewee, the person indicated QMA 6 administered Resident B's Tramadol (a non-narcotic pain medication) without the permission of a licensed person. The record for Resident B was reviewed on 3/7/24 at 1:30 p.m. The diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction, anxiety disorder, hypertension, major depressive disorder, and chronic obstructive pulmonary disease. A nursing progress note, dated 12/22/23 at 6:18 a.m., indicated the resident received Tramadol 100 mg (milligrams) for pain. There was no documentation from a licensed person indicating QMA 6 had permission to give this medication. The narcotic sheet for Resident B was reviewed, and included, but were not limited to, the following entries: On 12/11/23 at 7:00 p.m., one Tramadol 100 mg tablet was given by QMA 6. There was no documentation from a licensed person indicating QMA 6 had permission to give this medication. On 12/17/23 at 9:00 a.m., one Tramadol 100 mg tablet was given by QMA 6. There was no documentation from a licensed person indicating QMA 6 had permission to give this medication. 2. During an interview with a confidential interviewee, the person indicated QMA 6 administered Resident C's Hydrocodone/APAP (Acetaminophen) (a narcotic pain medication) without the permission of a licensed person. The record for Resident C was reviewed on 3/7/24 at 1:45 p.m. The diagnoses included, but were not limited to, type II diabetes mellitus, hypertension, heart failure, peripheral vascular disease, and major depressive disorder. A nursing progress note, dated 11/29/23 at 7:35 a.m., indicated Hydrocodone-Acetaminophen 5-325 mg one tablet was given for pain by QMA 6. There was no documentation from a licensed person indicating QMA 6 had permission to give this medication. A nursing progress note, dated 12/6/23 at 7:47 a.m., indicated Hydrocodone-Acetaminophen 5-325 mg one tablet was given for pain by QMA 6. There was no documentation from a licensed person indicating QMA 6 had permission to give this medication. A nursing progress note, dated 12/17/23 at 8:59 a.m., indicated Hydrocodone-Acetaminophen 5-325 mg one tablet was given for pain by QMA 6. There was no documentation from a licensed person indicating QMA 6 had permission to give this medication. A nursing progress note, dated 12/22/23 at 6:52 a.m., indicated Hydrocodone-Acetaminophen 5-325 mg one tablet was given for pain by QMA 6. There was no documentation from a licensed person indicating QMA 6 had permission to give this medication. A nursing progress note, dated 1/14/24 at 12:57 p.m., indicated Hydrocodone-Acetaminophen 5-325 mg one tablet was given for pain by QMA 6. There was no documentation from a licensed person indicating QMA 6 had permission to give this medication. The narcotic sheet for Resident B was reviewed, and included, but were not limited to, the following entries: On 11/29/23 at 8:30 a.m., one Hydrocodone-Acetaminophen 5-325 mg tablet was given by QMA 6. There was no documentation from a licensed person indicating QMA 6 had permission to give this medication. On 11/29/23 at 1:30 p.m., one Hydrocodone-Acetaminophen 5-325 mg tablet was given by QMA 6. There was no documentation from a licensed person indicating QMA 6 had permission to give this medication. On 12/6/23 at 7:47 p.m., one Hydrocodone-Acetaminophen 5-325 mg tablet was given by QMA 6. There was no documentation from a licensed person indicating QMA 6 had permission to give this medication. On 12/11/23 at 8:00 p.m., one Hydrocodone-Acetaminophen 5-325 mg tablet was given by QMA 6. There was no documentation from a licensed person indicating QMA 6 had permission to give this medication. On 12/17/23 at 8:00 a.m., one Hydrocodone-Acetaminophen 5-325 mg tablet was given by QMA 6. There was no documentation from a licensed person indicating QMA 6 had permission to give this medication. On 12/22/23 at 8:00 a.m., one Hydrocodone-Acetaminophen 5-325 mg tablet was given by QMA 6. There was no documentation from a licensed person indicating QMA 6 had permission to give this medication. On 1/14/24 at 12:00 p.m., one Hydrocodone-Acetaminophen 5-325 mg tablet was given by QMA 6. There was no documentation from a licensed person indicating QMA 6 had permission to give this medication. During an interview, on 3/6/24 at 4:00 p.m., Resident C indicated she had asked for pain medication one time, but someone had signed her pain medication out 4 or 5 other times indicating they gave her pain medications, when she did not receive the pain medication. She did not know her name. She did not work in the hallway very often. During an interview, on 3/7/24 at 10:15 a.m., the Executive Director and the Director of Nursing were in attendance. The Executive Director and the Director of Nursing both indicated they did not know a licensed nurse had to give permission and sign after a QMA gave a PRN medication. This citation relates to Complaint IN00429433 3.1-14(i)

Based on interview and record review, the facility failed to follow their medication destruction and narcotic storage policy and procedure for 1 of 3 residents reviewed for pharmaceutical services. (Resident D) Finding includes: A document, titled Intake Information, dated 2/27/24, from the Indiana Department of Health indicated a concern was filed alleging a card of narcotic medication was missing after being removed from the medication cart by a staff member. The clinical record for Resident D was reviewed on 3/7/24 at 12:10 p.m. The diagnoses included, but were not limited to, protein-calorie malnutrition, anxiety disorder, depression, hypotension, chronic pain syndrome, and gastrostomy. The resident had an order, dated 1/11/24, for Hydrocodone-Acetaminophen (a narcotic medication) 10-325 mg (milligrams), give one tablet by mouth three times a day for pain. This medication was discontinued on 2/7/24. A narcotic count sheet indicated Hydrocodone/APAP (Acetaminophen) 10-325 mg give one tablet by mouth three times a day for pain. The sheet indicated there were 12 tablets left on the card on 2/8/24 at 8:00 p.m. At the bottom of the narcotic count sheet, the date of discontinuance was listed as 2/7/24 and the date of disposition was listed as 2/19/24. A narcotic card count sheet indicated, on 2/13/24, QMA 6 removed Resident D's Hydrocodone card and narcotic sheet from the cart. There was no verification of the removal of this narcotic medication by a second licensed person. The narcotic card count, on 2/13/24 at 6:00 a.m., was 26 narcotics. The narcotic card count, on 2/13/24 at 2:00 p.m., was 25 narcotics remaining. During an interview, on 3/6/24 at 10:09 a.m., the Executive Director (ED), Director of Nursing (DON) and [NAME] President of Clinical Operations (VPCO) were in attendance. The DON indicated QMA 6 (the scheduler) had removed a card of discontinued Hydrocodone pills from the Central hallway cart. She took them to her office and locked them up when she realized the DON and Unit Manager were in a meeting and were not able to destroy the medication at that time. The Scheduler was unaware she was not able to remove the medication as she did not know the correct procedure for the facility since she was new. She removed the narcotic sheet and the narcotics from the cart and could not place them back in the cart since she had removed them and signed them out of the cart as being removed already. She indicated the Unit Manager obtained the narcotic medication from QMA 6's office. The DON did not realize it at that time, so she went to her office to obtain the narcotics and they were gone, so she called the Scheduler looking for them. She learned the Unit Manager removed the narcotics from the scheduler's office and placed the medication in their office. The Unit Manager and DON destroyed the narcotic medication. During an interview, on 3/7/24 at 10:52 a.m., QMA 6 indicated she pulled out a card of discontinued Hydrocodone pills off the Central hallway medication cart, on 2/13/24, then went to the conference room to give them to the DON and Unit Manager to destroy. She seen they were in a meeting, so she stuck the card and sheet of discontinued narcotics in her binder and kept them with her all day until she left the facility, which was when she locked them in her office. She had stayed down in the North hallway most of the day doing her scheduling, so she always had her binder with her. Other staff members had a key to her office such as CNA 9, CNA 13, CNA 14, the Unit Manager, and the DON. The Unit Manager went into her office after she left and retrieved the narcotics and sheet from her binder, which were in a drawer. During a confidential interview, the person indicated the staff licensed personnel were not allowed to remove narcotic cards from the carts or destroy narcotic cards. The DON and Unit Manger destroyed the medications and either the DON or the Unit Manager would come to the medication cart to get the discontinued medication. If it was a narcotic, then the nurse on the cart had to co-sign with them, when they removed the card from the cart. A current policy, titled Storage of Controlled Substances, dated 9/2018 and provided by the ED on 3/6/24 at 12:00 p.m., indicated .Medications classified by the Drug Enforcement Administration (DEA) as controlled substances are subject to special handling, storage disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations .Schedule II through V medications and other medications subject to abuse or diversion are stored in either a permanently affixed, double locked compartment separate from all other medications or in accordance with state regulations. The access system to controlled medications is not the same as the access system for other medications (e.g., the key that opens the compartment is different from the key that opens the medication cart). If a key system is used, the medication nurse on duty maintains possession of the key to controlled substances, are kept by the Director of Nursing or designee .A controlled substance accountability record is prepared by the pharmacy/facility for all Schedule II, III, IV, and V medications, including those in the emergency supply .Controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are retained in the facility in a securely locked area with restricted access until destroyed in accordance with facility policy and state regulations. Accountability records for discontinued controlled substances are maintained with the unused supply until it is destroyed or disposed of, and then stored for five years or as required by applicable law or regulation A current policy, titled Discontinued Medications, dated 9/2018 and provided by the ED on 3/7/24 at 2:45 p.m., indicated .When medications are discontinued by the prescriber or the resident is discharged and medications are not sent with the resident, the medications are marked as discontinued and stored in a secure and separate area from the active medications until destroyed per facility policy or returned to the pharmacy when permissible by state regulations .The nurse documents the order to discontinue the medication in the resident's record .Medications are removed from the medication cart or active supply immediately upon receipt of an order to discontinue (to avoid inadvertent administration). 3. Medications awaiting disposal or return are stored in a locked, secure area designed for that purpose until destroyed or picked up by the pharmacy .Discontinued medications not returned to the pharmacy are destroyed in accordance with facility policy This citation relates to Complaint IN00429433. 3.1-25(n) 3.1-25(o)

Based on observation, interview and record review, the facility failed to ensure the ice scoop was stored in a container, the handwashing station had running water, and a trash can was available at the handwashing station. This deficient practice had the potential to affect 70 of 70 residents who received food from the kitchen. Findings include: During a tour of the kitchen, on 10/30/23 at 1:07 p.m., with the Dietary Manager (DM) the following was observed: 1. The handwashing station's sink did not have running water. The white plumbing pipe was sitting in the sink. 2. The ice scoop was sitting on a wire shelf with other supplies and not stored in a container. 3. The handwashing sink did not have a trash can. The staff were using the trash can for dirty linen. During an interview, on 10/30/23 at 1:10 p.m., the DM indicated the handwashing sink had not worked for a while. The staff were washing their hands in the sink by the dishwasher or the three-compartment sink. The handwashing sink should have been fixed and the staff should not use the sink which was used for dishwashing. During an interview, on 10/30/23 at 1:13 p.m., the DM indicated the ice scoop should be in a container and not sitting on the wire shelf with other items. The ice scoop would be considered dirty. During an interview, on 10/31/23 at 11:31 a.m., Cook 6 indicated the hands-free trash can was being used for soiled linen. The staff used the large trash can by the dishwasher. During an interview, on 10/31/23 at 11:33 a.m., the DM indicated she used her elbow to prop the lid up on the large trash can. There should be a hands-free trash can by the hand washing sink. During an interview, on 10/31/23 at 11:35 a.m., Cook 7 indicated she would wash her hands and use a paper towel to open the large trash can lid and place the towels in the large trash can. A current policy, titled Environment, revised on 9/2017 and received from the Administrator on 11/1/23 at 10:00 a.m., indicated .All food preparation areas, food services areas, and dining areas will be maintained in a clean and sanitary condition .The Dining Services Director will ensure that all employees are knowledgeable in the proper procedures for cleaning and sanitizing of all food service equipment and surfaces .All trash will be contained in covered, leak-proof containers that prevent cross contamination 3.1-21(i)(3)

Based on interview and record review, the facility failed to respond to concerns the resident council group brought up during their resident council meetings for 12 of 12 resident council meeting minutes reviewed. Finding includes: During a review of the resident council meeting minutes, on 10/5/23 at 3:00 p.m., the residents had brought up the following: a. New ideas for activities. b. A request to have more resident parties. c. Concerns with stained laundry. d. Concerns with call lights. e. Concerns with housekeeping taking trash. f. Maintenance concerns. The minutes did not indicate if the concerns brought up from the resident council group had been considered. The meeting minutes had a space, titled Old business, and this space was marked as NA (not applicable) or good follow up. The meeting minutes did not include if the department managers were notified of the concerns brought up by the resident council group and any resolution to the concerns. During a resident council meeting, on 11/1/23 at 3:11 p.m., the resident council group indicated there were concerns brought up at the resident council meetings although the concerns did not get addressed at times. During an interview, on 11/3/23 at 2:11 p.m., the Activity Director indicated she would write the resident council meeting notes. The Old Business section of the resident council meeting minutes was for recording if the residents had money problems. She did not put on the meeting minutes what happened the previous month at the resident council and what concerns or requests had been addressed. A current policy, titled Resident Rights, dated as revised on 6/21/2021 and received from the Clinical Support Nurse on 11/6/23 at 1:43 p.m., indicated .It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents .The purpose of this policy is to guide employees in the general principles of dignity and respect of caring for residents .Procedure .Form or Participate in Resident Groups .Residents have a right to form or participate in a resident group to discuss issues and concerns about the facilities policies and operations such as a resident council .The facility will provide meeting space and must listen to and act upon grievances and recommendations of the group A current policy, titled Resident Council, dated 4/22/21 and received from the Executive Director on 11/4/23 at 4:15 p.m., indicated .Duties of the Resident Council include .Helping identify concerns .Serving as a sounding board for new ideas .Document the Resident Council Meeting on the Resident Council Minutes Form. Any concerns voiced at the meeting should be documented on the Concern Form and distributed to the appropriate Department Head . 3.1-3(l)

Based on observation, interview, and record review, the facility failed to ensure there was enough staff to complete the electronic medication administration records for 2 of 2 residents reviewed for medication documentation (Residents 20 and 45), to ensure showers were completed for 2 of 2 residents reviewed for activities of daily living (Residents 8 and 20), to ensure the physician and family were notified of a fall for 1 of 3 residents reviewed for falls (Resident 64), and to ensure staff followed up on resident concerns for 12 of 12 resident council meeting minutes reviewed for sufficient staffing. Findings include: 1. A medication administration record for Resident 20, dated 9/1/23 to 9/30/23, indicated there were 12 areas of missing documentation of medications and treatments. A medication administration record for Resident 45, dated 9/1/23 to 9/30/23, indicated there were 13 areas of missing documentation of medications and treatments. A medication administration record for Resident 45, dated 10/1/23 to 10/31/23, indicated there were 4 areas of missing documentation of medications. 2. a. During an interview, on 10/30/23 at 3:42 p.m., Resident 20 indicated showers did not get completed when they should, and she would only get 4 or 5 showers a month. During an observation, on 10/30/23 at 3:53 p.m., the resident was in her room and there was a strong foul body odor noted in the room. During an observation, on 11/3/23 at 9:25 a.m., the resident was sitting up in her wheelchair. Her hair was combed although it was slightly oily and appeared like it had not been washed. The record for Resident 20 was reviewed on 10/31/23 at 4:39 p.m. Diagnoses included, but were not limited to multiple sclerosis, chronic obstructive pulmonary disease, major depressive disorder, Aspergers syndrome, generalized muscle weakness, neuromuscular dysfunction of the bladder, and dependence on supplemental oxygen. The shower sheets for the resident were reviewed and indicated the following: a. On 8/12/23, the resident did not receive her scheduled shower, so she was assisted to get a bed bath, on 8/13/23, since her family was coming to visit. b. On 10/16/23, the resident did not receive her scheduled shower, so she was assisted to get a bed bath, on 10/17/23. c. During the month of August 2023, 4 of the 7 showers documented were given during the day shift. d. During the month of September 2023, 4 of the 8 showers documented were given during the day shift. e. During the month of October 2023, all the showers documented were given during the day shift. 2. b. During an observation, on 10/30/23 at 2:37 p.m., Resident 8's hair appeared dirty. During an observation, on 11/1/23 at 3:50 p.m., the resident was laying her bed and her hair appeared dirty. During an observation, on 11/3/23 at 11:33 a.m., the resident was sitting, in the 400 Hall dining room, doing an activity. The resident's hair appeared greasy. The record for Resident 8 was reviewed on 11/1/23 at 3:25 p.m. Diagnoses included, but were not limited to, hypertension, heart failure, depression, and absence of the right eye. During an interview, on 10/30/23 at 2:37 p.m., the resident indicated she only had three showers in October. During an interview, on 10/31/23 at 10:08 a.m., CNA 8 indicated there were two CNAs covering the 400 Hall and was hard to complete their jobs. 3. During an interview, on 10/31/23 at 10:57 a.m., Resident 64's family member indicated they were not notified when the resident fell on [DATE]. The record for Resident 64 was reviewed on 11/1/23 at 11:39 a.m. Diagnoses included, but were not limited to, hypertension, depressive disorder, and dementia. A post fall evaluation, dated 10/28/23 at 6:00 p.m., indicated the fall was unwitnessed and the resident indicated he hit his head on the floor. The resident was not sent to the hospital and the physician or family was not notified. During an interview, on 11/2/23 at 3:15 p.m., the Corporate Support Nurse indicated they could not find any documentation the physician or resident's representative was called when the resident fell . She had asked the nurse why she did not chart or call the physician and the resident's representative and the nurse had indicated she was just too busy. 4. During a review of the resident council meeting minutes, on 10/5/23 at 3:00 p.m., the residents had brought up the following: a. New ideas for activities. b. A request to have more resident parties. c. Concerns with stained laundry. d. Concerns with call lights. e. Concerns with housekeeping taking trash. f. Maintenance concerns. The minutes did not indicate if the concerns brought up from the resident council group had been considered. The meeting minutes had a space, titled Old business, and this space was marked as NA (not applicable) or good follow up. The meeting minutes did not include if the department managers were notified of the concerns brought up by the resident council group and any resolution to the concerns. During a resident council meeting, on 11/1/23 at 3:11 p.m., the resident council group indicated there were concerns brought up at the resident council meetings although the concerns did not get addressed at times. During a resident council meeting, on 11/01/23 at 3:17 p.m., the resident council group indicated the staff have their cellular phones with them. The residents must interrupt the staffs cellular phone calls to get assistance. During an interview, on 11/03/23 at 2:10 p.m., QMA 10 indicated staffing was 2 CNAs and 1 QMA. The usual staffing was 2 CNAs and 2 nurses. QMA 10 indicated there was not enough staff with 2 CNAs and 1 QMA. The QMA had to come off the cart to help answer call lights and the residents would have to wait on their medications. QMA 10 indicated 3 CNAs would be better. During an interview, on 11/3/23 at 3:30 p.m., the Staffing Coordinator indicated if one unit needed more staffing than another she would staff accordingly. She indicated she staffed on what she was directed to do, and she was not aware of the facility assessment. The facility assessment was reviewed. The assessment did not indicate how many licensed staff members were needed per shift based on acuity. The facility assessment indicated to refer to the master schedule. A current document, titled Facility Assessment Tool for Kokomo, dated 10/1/22 to 9/30/23 and received from the Executive Director on 10/30/23, indicated .using a competency-based approach focuses on ensuring each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental and psychological well-being .facility has a master schedule for maintaining staffing levels .full time scheduler that monitors staffing and assists with staffing absences and open shift to maintain the staffing levels and addresses the fluctuation of census and acuity .the facility will staff at or above the minimum staffing requirement for the daily census to meet residents needs and determined by the facility assessment .facility has a clinical manager on call for weekends and evenings to monitor and address staffing needs .the IDT (interdisciplinary team) meets daily to review and discuss new admits, care needs, acuity .staffing is adjusted based on these factors .the staffing schedule daily with the administrator, DON (director of nursing), human resources manager and staffing coordinator to validate appropriate staffing numbers and identify the distribution of staff based on needs 3.1-17(a)

Based on observation, interview and record review, the facility failed to ensure toilet bowls and towel racks were clean, walls were free from marks, scratches, peeling wallpaper, gouges, and paint chips, rooms were free from dirty clothes and piles of clean clothes on the floor, toilet bolts were covered, and a dining plan was established when the dining room was closed for remodeling for 9 of 9 rooms and the main dining room observed for environment. (room [ROOM NUMBER], 204, 208, 215, 312, 414, 416, 424 and 425) Findings include: During a tour, beginning at 9:20 p.m., on 11/3/23, with the Administrator and the Maintenance Director, the following were observed: 1. room [ROOM NUMBER] had missing bolt covers on both sides of the toilet sticking up 2 or 3 inches. The toilet bowl had a brown ring in the bottom and the towel bar had dried scum. 2. room [ROOM NUMBER] had a bolt on the right side of the toilet sticking out about 3 inches and there was a round toilet seat on an oblong toilet. 3. room [ROOM NUMBER] had toilet bolts which were sticking up about 2 inches and were not covered. 4. room [ROOM NUMBER] had multiple cardboard boxes on the floor. 5. room [ROOM NUMBER] had chipped paint on the walls and an area of wallpaper peeling off near the ceiling. 6. room [ROOM NUMBER] had a large cardboard box on the floor, the wall behind the bed had gouges and approximately a 2 foot(ft) by 2 ft area with black scuff marks. 7. room [ROOM NUMBER] had a door with no trim. There were gouges on the wall with peeled off paint around the door and along bottom of the wall. There were a pair of dirty jeans, a plaid shirt, and a wet towel on the floor in the middle of the room and three stacks, approximately 2 foot tall, of clean clothes on the floor by the window. During an interview, on 10/31/23 at 10:10 a.m., the Social Service Director indicated in room [ROOM NUMBER] the dirty clothes should not be left on the floor and the piles of clothes should be put up in their drawers and not stacked on the floor. 8. room [ROOM NUMBER] had missing baseboard trim around the bottom of sink and under the sink was a white board placed against the left wall. 9. room [ROOM NUMBER] had a large area of paint peeled from behind the bed. 10. During an observation, on 10/30/23 at 1:00 p.m., the main dining room was located by the kitchen. The doors were closed, and a sign indicated the dining room was closed for remodeling. During an observation, on 10/31/23 at 12:00 p.m., the residents were painting in a room used for activities and dining located on the 400 Hall. During an observation, on 10/31/23 at 12:25 p.m., the lunch trays arrived on the 400 Hall. The residents continued to paint. A Certified Nursing Assistant (CNA) started to pass meal trays out to the residents and the Activities Director stopped the CNA. Painting supplies were covering all the tables and there was no place for the lunch trays. The Activities Director stopped the painting, and the residents were told to either go to their rooms or the 200 Hall dining room for lunch. During an observation, on 10/31/23 at 12:30 p.m., the 200 Hall dining room had nine residents sitting at six tables. There were three tables against the windows and three tables in the center of the room. Two vending machines were against the right wall and chairs were lined up against the left wall. The room was small and crowded with very little room to maneuver wheelchairs. During an interview, on 10/30/23 at 1:07 p.m., the Dietary Manager (DM) indicated the main dining room was closed for remodeling. The facility was using a room on the 400 Hall and the 200 Hall for dining. The DM did not know when the main dining room would be completed. During an interview, on 11/03/23 at 9:31 a.m., the Maintenance Director indicated they were working on the building. They purchased paint and putty to patch the walls and were working on the halls. During an interview, on 11/3/23 at 9:37 a.m., the Administrator indicated they were doing a large renovation project. They were painting and remodeling the main dining room. The boxes and clothes should not be on the floor, and they were having a hard time finding trim for the doors. The facility did not have an environmental policy. 3.1-19(f)(5)

Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment was coded correctly for a resident who had a Preadmission Screening and Resident Review (PASARR) Level II completed for 1 of 2 residents reviewed for PASARR. (Resident 63) Finding includes: The record for Resident 63 was reviewed on 11/3/23 at 2:54 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, schizoaffective disorder, and moderate protein-calorie malnutrition. A PASARR Level II, dated 2/9/23, indicated the resident had a serious mental illness due to the diagnoses of schizoaffective disorder and schizophrenia. This was considered a PASARR Level II condition. An annual MDS assessment, dated 5/17/23, indicated the resident did not have a PASARR Level II condition. During an interview, on 11/3/23 at 1:58 p.m., the MDS Coordinator indicated the resident did not have a PASARR Level II marked on the MDS assessment, dated 5/17/23. The resident did have a PASARR Level II, and this should have been marked on the MDS assessment. During an interview, on 11/6/23 at 4:55 p.m., the Clinical Support Nurse indicated the facility did not have an MDS policy and used the Resident Assessment Instrument (RAI) manual for MDS assessments. 3.1-31(d)(3)

Based on interview and record review, the facility failed to implement the Preadmission Screening and Resident Review (PASARR) Level II recommendations for 1 of 2 residents reviewed for PASARR. (Resident 63) Finding includes: During an interview, on 10/31/23 at 11:48 a.m., Resident 63 indicated he was working on his own arrangements to live somewhere else. He did not have a case manager and had signed up for the housing authority. He had applied for an apartment and the apartment complex needed more information. The record for Resident 63 was reviewed on 11/3/23 at 2:54 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, schizoaffective disorder, and moderate protein-calorie malnutrition. A care plan, dated 6/5/22, indicated the resident wanted to be discharged to home. The interventions included, but were not limited to, discuss with rehab any special equipment needs, provide education to the resident regarding obtaining equipment, and to notify the medical provider of discharge plans. The care plan did not include any case management services to explore community living. A PASARR Level II, dated 2/9/23, indicated the resident needed the following rehabilitative services: a. Supportive counseling from the nursing facility staff. b. Training in community living skills. c. Training in self-healthcare management. d. Training on activities of daily living skills. e. Case management to explore community living. f. Crisis intervention. g. Occupational therapy evaluation. h. Physical therapy evaluation. i. Family involvement in care. j. Medication review k. Individual mental health therapy. l. Psychiatric evaluation. The PASARR Level II indicated the reason for the psychiatric evaluation was to clarify the diagnosis and to recommend treatment. The case management was needed for discharge planning to make referrals to any services needed. The resident would benefit from training on health needs and daily care needs to be more successful in a community living setting. The PASARR Level II recommendations were not included in the resident's care plan. A PASARR Level II, dated 4/17/23, indicated the resident met PASARR criteria for mental illness based on the diagnosis of schizoaffective disorder and would need to be provided the following rehabilitative services by the facility: a. Supportive counseling from the nursing facility staff. b. Family involvement in care. c. Medication review. d. Individual mental health therapy. e. Outpatient mental health treatment services. f. Socialization/leisure/recreation activities. The care plan did not include any of the PASARR services to be provided. During an interview, on 11/1/23 at 11:29 a.m., the Social Services Director (SSD) indicated the resident was wanting to live on his own. He had applied to a local apartment complex. He did not have a case manager to assist with the applications even though the PASARR Level II indicated the resident needed a case manager to help him get alternative living arrangements. The SSD was not aware of the PASARR Level II recommendations. The resident had been at the facility for over one year and was still trying to make alternative living arrangements on his own. During an interview, on 11/3/23 at 1:58 p.m., the Minimum Data Set (MDS) Coordinator indicated the PASARR Level II was not included on the MDS assessment. Since the MDS assessment was not coded correctly, the PASARR Level II recommendations did not get added to the care plan. She thought the resident refused a psychiatric evaluation although she was not sure. During an interview, on 11/6/23 at 10:32 a.m., the Executive Director (ED) indicated there was no documentation in the Electronic Health Record (EHR) about the resident applying for alternate places to live. The care plan meeting notes did not include the resident was applying for alternate living arrangements or if the facility was assisting with the living arrangements. The resident had declined a psychiatric evaluation and was not receiving mental health services. There was no documentation in the EHR to show the resident refused the psychiatric services or if the services were offered. A current policy, titled Indiana PASSR, dated as reviewed 8/24/2020 and received from the Clinical Support Nurse on 11/6/23 at 4:15 p.m., indicated .The preadmission screening and resident review process, otherwise known as PASRR, is a federally mandated process to ensure nursing facility applicants and resident with serious mental illness and/or intellectual and development disabilities are identified and placed appropriately in the least restrictive setting. PASRR ensures that persons with disability are admitted or allowed to remain in a particular nursing facility only if they can be appropriately served in the facility. PASRR ensures that individuals are provided with the disability services they need, including rehabilitative and specialized services. The goal of PASRR activity is to optimize each individual's placement success, treatment success, and ultimately, the individual's quality of life .The PASARR Level II evaluation identifies rehabilitative or specialized services that an individual may require 3.1-16(d)(1)(B)

Based on interview and record review, the facility failed to report to the state agency a drug overdose which resulted in the use of Narcan (a medication used to treat narcotic overdose) and a hospitalization for 1 of 2 residents reviewed for behavioral health. (Resident C) Finding includes: The record for Resident C was reviewed on [DATE] at 10:23 a.m. Diagnoses included, but were not limited to, protein calorie malnutrition, anxiety disorder, a history of malignant neoplasm of the tongue, and chronic pain syndrome. A progress note, dated [DATE] at 10:33 a.m., indicated Resident C was found unresponsive by a staff member at 9:32 a.m., when the staff member entered the room to administer morning medications. Cardiopulmonary Resuscitation (CPR) was initiated, and Emergency Medical Services (EMS) arrived at 9:40 a.m. The resident was transported to the hospital at 9:56 a.m. A progress note, dated [DATE] at 11:40 a.m., indicated the resident was unresponsive and 911 was called. The EMS administered Narcan, and the resident was then responsive. The EMS found drug paraphernalia on the resident's bed after he was moved to the EMS gurney. The resident was transferred to the hospital by EMS. A hospital admission note, dated [DATE], indicated the resident had an opioid overdose. A crack pipe was found underneath the resident by the EMS. The resident tested positive for opiates, cocaine, and benzodiazepines. A hospital discharge summary, dated [DATE], indicated Resident C's admission diagnosis was an opioid overdose and the discharge diagnosis was an opioid overdose. The resident presented to the Emergency Department after he was found unresponsive with pinpoint pupils and had no pulse. He received brief CPR. He admitted to smoking cocaine about four times a week and he had inhaled heroin on the day of admission. A crack pipe was found at the skilled nursing facility and the resident was laying on it. There was not a facility reported incident (FRI) to the State Agency to include Resident C's overdose, drug possession, and hospitalization . During an interview, on [DATE] at 11:09 a.m., an anonymous staff indicated she was told to keep quiet about the resident's overdose. During an interview, on [DATE] at 11:36 a.m., the Executive Director (ED) indicated she was in the building, on [DATE], when Resident C was getting chest compressions. The emergency medical technicians arrived and found some questionable items in the resident's room. The police were called and found a glass pipe in the room. The resident had overdosed on crack cocaine and heroin. The facility was not aware of any substance abuse issues with the resident until he went to the hospital for the overdose. She was not aware the incident had to be reported to the state agency. During an interview, on [DATE] at 11:40 a.m., the Director of Nursing (DON) indicated she was not aware a resident's overdose needed reported to the state agency. During an interview, on [DATE] at 11:41 a.m., the Clinical Support Nurse indicated she was not aware a resident's overdose needed reported to the state agency. The facility had not provided a policy for reporting to the state agency by the time of exit. This Federal tag relates to Complaint IN00420789. 3XXX,d+[DATE](c)

Based on interview and record review, the facility failed to notify the physician and the resident's representative of a fall for 1 of 1 resident reviewed for notification. (Resident 64) Finding includes: During an interview, on 10/31/23 at 10:57 a.m., Resident 64's family member indicated they were not notified when the resident fell on [DATE]. The record for Resident 64 was reviewed on 11/1/23 at 11:39 a.m. Diagnoses included, but were not limited to, hypertension, depressive disorder, and dementia. A post fall evaluation, dated 10/28/23 at 6:00 p.m., indicated the fall was unwitnessed and the resident indicated he hit his head on the floor. The resident was not sent to the hospital and the physician or family was not notified. A progress note, dated 10/30/23 at 10:48 a.m., indicated the Nurse Practitioner was notified two days after the fall. A late entry progress note, dated 10/30/2023 at 12:54 p.m., indicated Resident 64 was found on the floor at the end of his bed. The resident indicated he did not hit his head and there were no injuries. An IDT (interdisciplinary team) fall note, dated 10/30/23 at 11:03 a.m., indicated the resident was in the wrong wheelchair at dinner and did not have anti-lock brakes. During an interview, on 11/2/23 at 3:15 p.m., the Corporate Support Nurse indicated they could not find any documentation the physician or resident's representative was called when the resident fell . A late entry note was charted, on 10/30/23, for the fall on 10/28/23. She had asked the nurse why she did not chart or call the physician and the resident's representative and the nurse had indicated she was just too busy. A current policy, titled Fall Prevention and Management, dated as revised 6/1/22 and received from the Clinical Support Nurse on 11/6/23 at 1:42 p.m., indicated .It is the policy of this facility to provide resident centered care that meets the psychosocial, physical, and emotional needs, concerns of the residents .Fall prevention and management is the process of identifying risk factors that can minimize the potential for falls and also a process to manage a resident's care if a fall occurs .The family and physician should then be notified with the information obtained. Document all interventions and family/physician notification A current policy, titled Notification of Change in Condition, not dated and received from the Clinical Support Nurse on 11/6/23 at 1:42 p.m., indicated .It is the policy of this facility to provide resident centered care that meets the psychosocial, physical, and emotional needs, concerns of the residents .The purpose of this policy is to provide guidance for notification made to residents, resident representatives, and authorized family members for resident changes in condition. Changes may include but are not limited to accidents, incidents, transfers, changes in overall health status, significant medical changes .The attending practitioner is promptly notified of significant changes in condition .When a change in condition is noted, the nursing staff will contact the resident representative 3.1-5(a)(1)

Based on interview and record review, the facility failed to ensure staff assessed and notified the physician of a resident who experienced a change in condition timely and failed to initiate cardiopulmonary resuscitation (CPR) when a resident went unresponsive for 1 of 3 residents reviewed for death. (Resident B) The immediate jeopardy began on [DATE], when Resident B had a change of condition which was not assessed by the licensed nurse on duty. Resident B was later found unresponsive, and the licensed nurse failed to start CPR and notify the physician of the death. The Executive Director (ED) and Regional Nurse Consultant (RNC) were notified of the immediate jeopardy on [DATE] at 2:20 p.m. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Finding includes: An Indiana State Department of Health incident report, dated [DATE] at 6:39 p.m., indicated staff notified the Registered Nurse (RN) of a resident, who was a full code, of the resident's change in condition. The RN determined respirations had ceased and notified the family, the resident was deceased . The record for Resident B was reviewed on [DATE] at 11:32 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident B's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident's cognition was moderately impaired. A progress note, dated [DATE] at 7:45 a.m., indicated Resident B had expired. His family member wanted to see the resident before the funeral home came to pick him up. A progress note, dated [DATE] at 8:25 a.m., indicated the funeral home arrived to pick up the resident. The last progress note, prior to [DATE], was on [DATE]. There were no other progress notes to address the resident's change of condition, his code status, the nurse's assessment of the resident, or pertaining to initiated CPR. A care plan, dated [DATE], indicated Resident B had a CPR code status. The goals indicated the resident would be cared for with respect and dignity and will be comfortable during the end-of-life process and the resident's code status would be honored. The resident requested to be full code. (CPR to be performed if required) A facility Investigation Planning Tool, dated [DATE] at 7:08 a.m., indicated staff notified RN 1 a resident, who was a full code, had a change in condition. RN 1 determined respirations had ceased and notified the family the resident was deceased . On [DATE], at 7:08 a.m., the Activities Director reported, to the Executive Director, Resident B had passed away and CPR had not been initiated. A Witness Statement from RN 1, dated [DATE], indicated QMA (Qualified Medication Aide) 3 came to his unit at 2:00 a.m., and asked him to come check on Resident B because he was throwing up. RN 1 could not leave his unit at that time. RN 1 indicated around 5:00 a.m., QMA 2 came to his unit and told him Resident B had passed away. He checked the chart, saw the resident was a full code so he notified the family he did not do compressions. A Witness Statement from QMA 2, dated [DATE], indicated around midnight to 1:00 a.m., it was reported to her Resident B was throwing up. She sent QMA 3 to go get RN 1, but he did not come. QMA 2 called down the unit RN 1 was on but there was no answer. She texted CNA (Certified Nurse Aide) 4 and CNA 5 and requested them to send RN 1 to her unit. Around 5:00 a.m., QMA 3 and CNA 6 reported to her Resident B was not responding or moving. She went to get RN 1, who returned to the unit with her, and he indicated there was no point in attempting CPR as the resident was already dead. A Witness Statement from QMA 3, dated [DATE], indicated Resident B started calling out around 2:00 a.m., she went to his room, and he was vomiting up dark emesis. She notified QMA 2 and then went to locate RN 1. She seen RN 1 in the hallway and attempted to wave him down. He continued to walk away from her, so she walked all the way to his unit. She asked RN 1 to come to her unit to check Resident B. RN 1 indicated this was normal for Resident B and he would come when he had time. He never came. QMA 2 tried to call RN 1's unit, and no one answered. She watched QMA 2 text the CNAs on RN 1's unit and they replied they were not near RN 1 at that time. QMA 3 indicated around 4:00 a.m., her and CNA 6 completed bed checks and found Resident B not moving or answering his name. His skin was colorless, and he had no pulse when she checked his wrist. He was not warm. She told QMA 2, who went and got RN 1. When RN 1 arrived, he indicated the resident had already passed and there was nothing he could do. A Witness Statement from CNA 4, dated [DATE], indicated she saw a text message from QMA 2 requesting to send RN 1 to her unit, but she did not see the message until QMA 2 came to her unit maybe 15 to 30 minutes later to inform RN 1 the resident had passed away. A Witness Statement from CNA 6, dated [DATE], indicated during her rounds, Resident B had vomited on himself, and she cleaned him up. Around 2:00 a.m., the resident was calling out from his room saying he was going to get sick. QMA 3 went to the resident's room and took him a basin. She went on break and when she returned QMA 3 was attempting to get RN 1 to come to their unit. When he did not come, QMA 2 attempted to call his unit, but no one answered. She went into Resident B's room at 3:45 a.m., and he was calm in his bed. She went back to his room around 4:30 a.m., with QMA 3, to complete bed checks and the resident was not responding and was not warm. She told QMA 2, who went to get RN 1. Ten to fifteen minutes later, RN 1 arrived at the unit, went to the resident's doorway. He did not attempt to get vitals and indicated the resident was already gone and there was nothing he could do. During an interview, on [DATE] at 10:10 a.m., the Regional Nurse Consultant (RNC) indicated RN 1 was terminated for failure to provide CPR and failure to notify a physician prior to the resident's death about a change in condition and his death. Resident B passed away, sometime between 4:30 a.m. and 5:00 a.m., but she was not sure of the exact time. There was one licensed nurse in the building at the time. He was working on another unit and a QMA 2 was working the unit Resident B was located on. The resident had a change of condition around 2:00 a.m., which included diarrhea, abdominal pain, and emesis. QMA 2 notified RN 1 of the resident's condition and asked him to assess the resident. There were two CNAs working with RN 1 on his unit. RN 1 indicated both CNAs were on break, and he could not leave his unit at the time. RN 1 indicated he forgot to go assess the resident when the CNAs returned. The RNC indicated QMA 2 indicated to her, she had notified RN 1 numerous times about the resident's condition and during one of the last times RN 1 responded with not my patient, not my problem. The other CNAs and QMAs in the building did not notify the Director of Nursing (DON) or call 911 to get help for the resident. The resident was a full code. QMA 2 indicated to the RNC, after she notified RN 1, Resident B was not breathing, RN 1 stood at the resident's door and indicated the resident looked dead. He did not go into the resident's room or check for a heartbeat. An attempt was made to call RN 1, on [DATE] at 1:05 p.m. and 8:58 p.m., with no answer. A voicemail message was left to return the call. No call was returned. During an interview, on [DATE] at 2:05 p.m., QMA 7 indicated when she arrived at the facility for her shift, on [DATE], QMA 2 told her Resident B had passed away. QMA 2 told her, Resident B had been vomiting since about 2:00 a.m. to 2:30 a.m. QMA 2 indicated the resident had asked to go to the hospital. When she asked QMA 2, why she did not send him to the hospital, QMA 2 indicated she did not know why she did not send him. QMA 7 arrived to work at 5:55 a.m., and RN 1 brought her the burial paperwork for the funeral home. During a phone interview, on [DATE] at 9:04 p.m., QMA 3 indicated, on the night of [DATE] into the morning of [DATE], Resident B was not assigned to her, but she and CNA 6 worked together to complete their two-person bed checks. Somewhere between 2:00 a.m. and 2:45 a.m., she heard the resident calling out in a confused manner. CNA 6 had told her the resident had just vomited and RN 1 (who had been the only licensed nurse in the facility since 6:00 p.m.) had been told earlier he was throwing up. When she went into the resident's room to check on him, she observed he had been vomiting what looked like dark red blood. She went to get CNA 6 to assist her with cleaning him up. She also notified QMA 2, and she came into the room to look at him, but she did not take a set of vital signs. QMA 2 observed the vomit. At that time, Resident B indicated he wanted to go to the hospital to get some help. QMA 2 asked her to go tell RN 1 to come look at Resident B, as she had tried to call his unit to inform him of the resident's condition and no one was answering the phone. Sometime between 2:45 a.m. and 3:10 a.m., she went and informed RN 1, Resident B was throwing up what looked like dark blood, and he was requesting to go to the hospital to get some help. RN 1 indicated he would be down there. She called QMA 2 to let her know RN 1 would be down to check the resident, then she was going on break. When she came back from break, she started completing her bed checks. She told CNA 6 they needed to do Resident B's bed check, since he was the last resident to do a bed check on. To her knowledge, no staff member had gone back into the resident's room to check on him after she and CNA 6 cleaned him up earlier between 2:00 a.m. to 2:45 a.m. At approximately 4:30 a.m., she and CNA 6 went into the resident's room to do his bed check and they observed the resident had passed away. He was not breathing and when she felt for a pulse on his wrist, there was none. She did not remember his skin being cool or cold when she touched his wrist. He had his basin with a medium amount of dark blood in it and in his mouth had pure blood with blood clots with blood coming out the side of his mouth. During a phone interview, on [DATE] at 11:29 p.m., CNA 6 indicated on [DATE] she was the CNA assigned to care for Resident B. Earlier in the shift, approximately between 7:00 p.m. to 8:00 p.m., the resident was throwing up dark colored emesis with undigested food particles and she cleaned him up. She notified QMA 9 the resident vomited at that time. QMA 9 told her she had informed RN 1 about the resident vomiting. Sometime between 1:30 a.m. and 2:00 a.m., the resident was calling out he was going to get sick, so QMA 3 went into his room and gave him a basin. CNA 6 went to break and when she returned QMA 3 was talking to RN 1 about the resident's change in condition and asked him to come check on the resident. Around 4:30 a.m., she and QMA 3 went to Resident B's room to do his bed check and they observed he had passed away. He was not breathing. He did not respond to his name. He was not warm to the touch when she touched him. He had what looked like blood coming out the side of his mouth with a medium amount of blood inside his mouth with blood clots. They notified QMA 2, the resident had passed away and she went and got RN 1. When he came to the room, he stood at the door and did not say one word. During a phone interview, on [DATE] at 11:55 p.m., QMA 2 indicated she worked on Resident B's Hall on [DATE] at 10:00 p.m. to [DATE] at 6:00 a.m. CNA 6 mentioned to her Resident B had vomited on the second shift and QMA 9 had told RN 1 about him vomiting. The resident vomited dark colored emesis, between 12:00 a.m. to 1:00 a.m., and he did not look good at that time. He was responsive, able to talk and did not complain of any pain. He asked to go to the hospital at that time. Between 2:00 a.m. and 2:45 a.m., CNA 6 and QMA 3 did a bed check on him and he had thrown up the dark colored emesis again. He requested to go to the hospital to get some help. She attempted to call RN 1, but no one answered the phone. She asked QMA 3 to go tell RN 1 about the change in condition with the resident and he needed to come to check the resident. She called RN 1's unit a few times and even texted both the aides on his unit to ask them to tell RN 1 to come see Resident B, but no one responded to her texts, or answered the phone. At approximately 4:30 a.m., they found Resident B had passed away. She went and got RN 1 and told him the resident had passed away. RN 1 only looked into Resident B's room; he did not enter the room. She told RN 1 the resident was a full code and he mumbled something she could not understand. He then called the family to notify them he was deceased . During an interview, on [DATE] at 2:55 p.m., the ED (Executive Director) indicated she was not made aware of Resident B's death until the Activities Director called her on [DATE] at 7:08 a.m. The facility staff on duty during the night shift, on [DATE], did not notify her or the DON (Director of Nursing) of Resident B's change of condition; RN 1's lack of providing the care to the resident; 911 not being called for the resident to be sent out to the hospital, when he asked to go to the hospital; or of the resident's death. During an interview, on [DATE] at 4:22 p.m., QMA 9 indicated the resident had not had any problems with emesis or complaints of abdominal pain on her shift until 9:30 p.m. At that time, the resident's wound to his backside was bleeding and his dressing needed changed. He had a small amount of clear colored emesis and he complained of his stomach hurting. He had a bowel movement which was loose. She informed RN 1 of the situation with the vomiting, bowel movement and the complaints of abdominal pain. She had asked him to come down to the resident's room to look at him and to change his dressing for her. Since she was a QMA, she was not allowed to change those types of dressings. He told her No, he did not have time to change the dressing. She asked him again to come change the resident's dressing due to the amount of bleeding and the resident was not feeling good and he told her No. She placed an extra-large brief under the residents bottom due to the dressing was bloody and needed to be changed. She passed the information regarding the dressing, the emesis, and the complaints of his stomach hurting onto the next QMA. During an interview, on [DATE] at 5:17 p.m., the Activities Director indicated she was informed by two of the day shift CNAs, of the resident's passing after she entered the facility on [DATE] at 7:00 a.m. She wanted to make sure the ED had been notified so she called her and informed her of the resident's passing. The ED had not been called and informed of the resident's death until the Activities Director called her. A current facility policy, titled Initiate CPR, dated effective [DATE] and received from the Regional Nursing Consultant on [DATE] at 11:28 a.m., indicated .Code Status: the recorded, expressed wishes of the resident/patient indicating procedures to be performed or not performed in the event of cardiac or respiratory activities cease. Every resident has a code status-if not indicated otherwise, a full code will be performed in the event of respiratory/cardiac cessation. CPR: Cardio-Pulmonary Resuscitation includes external heart massage using chest compressions and clearing of the airway including oxygen delivery in an effort to restore or maintain cardiopulmonary function until a higher level of care is accessed .It is the policy of this facility to promote resident centered care by respecting resident's right to formulate an advanced directive including to initiate CPR by trained staff if requested and indicated following The American Heart Association Guidelines (AHA) .2) The facility will maintain and train staff on a communication method that will quickly alert staff as to the code status of a resident in the event heart or respirations cease. 3) Residents found unresponsive, not breathing or without a pulse, will have staff immediately locate the Code Status and communicate this to the team. 4) If CPR is indicated, staff will begin CPR and call [DATE] A current facility policy, titled Death Pronouncement, dated as revised on [DATE] and received from the Regional Nursing Consultant on [DATE] at 11:28 a.m., indicated .Nurses within the facility may report signs and symptoms to the physician but it is not within the scope of practice for a nurse to pronounce death or sign documents that note death has occurred. The nurse will report absence of vital signs and provide other clinical findings .A Nurse may accept telephone pronouncement of death from a qualified physician after reporting assessment of absence of blood pressure, absence of breathing, and absence of heartbeat as evidenced by absence of an apical pulse .Documentation Requirements: a. The cessation of respiration and heartbeat must be assessed by the nurse and fully documented in the medical record. b. Documentation will reflect that physician/other pronounced the resident deceased . c. After the physician makes pronouncement of death, obtain an order to release the body. d. Make notifications to family, resident representative and coroner, as applicable. i. A licensed nurse may accept telephone order from the physician to release the body to the funeral home A current facility policy, titled Physician-Order-for-Scope-of-Treatment, dated effective [DATE] and received from the Regional Nursing Consultant on [DATE] at 11:28 a.m., indicated .A full-code status alerts the staff that in the event that respirations cease and/or the resident does not have a pulse (pulselessness), the staff will initiate CPR including calling [DATE], begin chest compressions, provide oral suctioning as appropriate, implement the use of a bag-valve mask for supplying oxygen, and employ the use of an AED if available to provide a cardiac shock as indicated by the AED. Upon arrival, the emergency transport staff may provide additional interventions and facility will hand off to the emergency care team The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility completed the following: The Regional Nursing Consultant and Director of Nursing completed education for all licensed nurses, CNAs and QMAs on general code status, MD notification, chain of command/escalation process and change of conditions, with emphasis on initiating CPR as soon as the code status would be identified as full code, CPR or attempt resuscitation. The facility completed Code Blue Drill assessments. The facility conducted audits of all resident's code status and licensed staff response to change of conditions. This Federal tag relates to Complaint IN 653. 3.,d+[DATE](a)

Based on observation, interview and record review, the facility failed to provide adequate supervision for a resident who required assistance of two staff with activities of daily living (ADL's) for 1 of 1 resident reviewed for accidents. (Resident 6) Resident 6 while receiving care from one CNA, fell from the bed and sustained significant injury requiring transport to the emergency room . Finding includes: During an interview, on 04/01/2022 at 10:03 a.m., Resident 6 was observed to be in bed with an oversized mattress. The bed was in the high position, with the top of the mattress to the floor estimated to have been 3 1/2 feet. The resident had an above the knee amputation to the left lower extremity and limited use of his left arm and hand. Resident 6 indicated he had sustained a fall from his bed in January 2022 when a CNA (certified nursing assistant) was assisting him with incontinent care. He stated he rolled over too far and fell out of bed and on to the floor. The resident indicated his head hit the frame of his over-the-bed table and he sustained a laceration near his left eye which caused him to be hospitalized . Resident 6 indicated there was blood everywhere. The record for Resident 6 was reviewed on 04/01/2022 at 2:19 p.m. Diagnoses included, but were not limited to, cerebral infarction (stroke), [CONDITION(S)], hypertension, anxiety disorder, and [CONDITION(S)] (paralysis of one side of the body) and [CONDITION(S)] (weakness to one side of the body). A progress note, dated 01/21/2022 at 3:13 p.m., indicated .called to room by (name of CNA) that resident had thrown himself out of bed. upon entering the room i seen him on the floor there was blood on floor he was screaming to get him up. writer told him to lay still and went to get help aide stayed in room with resident. writer called 911 .resident would not stop yelling unable find out if he was in pain or had other injuries. ambulance arrived resident lifted to gurney with assist of 5. his left eye was cut and bleeding. resident out to hospital A progress note from the nurse practitioner (NP), dated 01/21/2022 at 3:39 p.m., indicated informed by nurse that resident fell in his room The note further indicated He stated that he fell and hit his head on the metal part of the side table causing a laceration above the eye by the left eyebrow. A Post Fall Evaluation, dated 01/21/2022 at 4:41 p.m., indicated Resident 6 sustained a fall from bed which caused a laceration to the left eye area and the resident was transferred to the emergency room . The evaluation indicated the fall was witnessed by a CNA. The evaluation indicated the resident was non-ambulatory and total mechanical lift for transfers The resident was described to have been in bed at the time of the fall with the bed in high position. A review of Resident 6's current MDS (minimum data set) assessment, dated 12/30/2021, section G indicated the resident required extensive assistance of two + persons for bed mobility (how resident moves to and from lying position, turns side to side and positions body while in bed) and was totally dependent with assistance of two + persons for transfers. During an interview, on 04/05/2022 at 4:31 p.m., the Director of Nursing (DON) indicated when the CNA was cleaning the resident's bottom, the resident made a sudden jump and threw himself out of bed. The DON indicated she was not in the room when the event occurred and was called to the room after the fall. During an interview, on 04/05/2022 at 5:16 p.m., the DON indicated she had no further information to provide regarding the fall and investigation of Resident 6. The CNA assisting the resident at the time of the fall was not present in the facility at the time of the survey. Attempts were made to contact the CNA documented to have been in the room with the resident at time of the resident's fall, however those attempts were unsuccessful. A current facility policy, titled Accident/Incident: Occurrence Report, dated as last revised on 10/17/2013 and received on 04/01/2022 at 3:49 p.m., indicated .A report will be completed on every accident and/or incident that involves a resident. To keep the Medical Director aware of all incidents and to monitor safety in the center .All staff assigned to the area are required to complete a witness (non-witness) statement .Occurrence follow-up report to be completed including evaluate causative factors and all appropriate actions are to care planned and implemented 3.1-45(a)

Based on interview and record review, the facility failed to identify a significant weight loss, notify the physician of the weight loss and implement interventions to prevent further weight loss for 1 of 3 residents reviewed for nutrition (Resident D). Resident D had a 12.73% weight loss in less than 80 days. Finding includes: During an interview, while on the initial tour starting at 11:21 a.m. on 12/13/21, Resident D indicated he just didn't have an appetite although the food was not bad. The record for Resident D was reviewed on 12/13/21 at 2:47 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's order, dated 9/13/21, indicated a regular diet, regular texture and regular consistency. A care plan, dated 10/5/21, indicated the resident was at risk for nutritional problems. The interventions included, but were not limited to, notify the medical provider and resident representative of unplanned weight changes. The current Minimum Data Set (MDS) assessment, completed on 10/11/21, indicated the resident's weight was 165 pounds and the resident had not had a weight loss of 5% or more in the last month or 10% or more in the last 6 months. The resident required oversight, encouragement or cueing with eating and one person physical assist. The resident had the following weights: 1. On September 15, 2021, the weight was 170 pounds. 2. On September 29, 2021, the weight was 165 pounds. 3. On October 12, 2021, the weight was 150.4 pounds which was an 8.85% weight loss from 9/29/21. 4. On November 19, 2021, the weight was 146 pounds which was an 11.52% weight loss from 9/29/21. 5. December 10, 2021, the weight was 144 pounds which was a 12.73% weight loss from 9/29/21. The documentation did not include a reweight on 10/12/21 when the weight loss was greater than 5 pounds. The progress notes between 10/12/21 and 12/10/21 did not include the weight loss, notification to physician or any nutrition notes. The physician orders did not include any new dietary interventions after 10/12/21 when the significant weight loss occurred. The care plan did not include any new interventions since 10/5/21. During an interview, on 12/14/21 at 3:59 p.m., the Director of Nursing (DON) indicated she did not look at the weight loss until 12/13/21 and called the corporate dietician. The dietician would do a full assessment on 12/14/21 since one had not been completed for the significant weight loss from 10/12/21. The alert triggered in the computer by the significant weight loss on 10/12/21 had been cleared by a staff nurse manager. The staff nurse manager did not notify anyone of the significant weight loss and the nutrition at risk (NAR) team did not follow up. The next weight entered on 11/19/21 did not show as a significant weight loss from the weight on 10/12/21 so the computer system did not show another weight loss alert. Since the computer did not trigger another weight loss alert, the NAR team was not notified. The nurse practitioner was notified of the significant weight loss on 12/13/21 and ordered labs to be completed. The progress notes, nutrition notes and dietician notes for the months of October, November and December 2021 had been requested and none of the notes included the significant weight loss from 10/12/21. A current facility policy, titled Resident Height and Weight, revised on 7/16/21 and received from the DON on 12/14/21 at 3:24 p.m., indicated .Accurate weight .Unless a compelling reason exists, obtain weight in the morning before meals and post voiding to obtain the most accurate body weight .Document the weight, the scale and any unusual events associated with obtaining the weight in EHR[electronic health record] .Compare weight to previous weight obtained. If a variance of 5 pounds or more is noted, reweigh residents to verify weight .Weigh the resident within 24 hours of admission .Obtain weekly weights times 4 weeks [x 4 weeks] for baseline .Stable residents will be weighed monthly thereafter, unless physician or diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .Update Interdisciplinary Care Plan as needed Documentation .In EHR .24 Hour Report Record .Reweight Parameters .A plus/minus of 5 pounds of weight in one week will result in .Reweight within 24 hours .Validation with nurse for accurate weight .Notify IDT team/doctor/family, if indicated .Weight loss concerns will be discussed at the weekly clinical meetings This Federal Tag relates to Complaint IN 712. 3.1-46(a)(1)

Based on interview and record review, the facility failed to ensure a resident was free from physical abuse when a resident with known aggressive behaviors (Resident B) had a verbal and physical altercation with another resident (Resident C) for 2 of 3 residents reviewed for abuse. Resident C had to be evaluated in the emergency room (ER) after the physical altercation. The Immediate Jeopardy began on September 18, 2021 when Resident B verbally and physically attacked Resident C. Resident C was assessed and noted with right eye swelling, petechiae (a small red or purple spot caused by bleeding into the skin) by the hairline and an abrasion to the right elbow and the left ankle. The resident complained of pain and double vision. Resident C indicated she feared for her life. Resident B was known to have verbal and physical aggressive behaviors. The Executive Director (ED), Interim Director of Nurses (DON) and Regional Director of Clinical Operations (RDOC) were notified of the immediate jeopardy at 2:21 p.m., on 10/06/21. The immediate jeopardy was removed on 10/07/21, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include 1. The record for Resident B was reviewed on 10/4/21 at 3:31 p.m. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident B's progress notes indicated: On 9/6/21 at 1:21 p.m., the resident refused assessment related to his G-tube being flushed. He would not let his stomach be seen. The resident was scheduled for [CONDITION(S)] and refused for his family member to transport him stating I'm in pain and my b**** are on fire, I want to go to the hospital. The MD (Medical Director) was notified and indicated to transfer the resident to the ED (Emergency Department) for evaluation. The resident started yelling your crazy, get out of my room the ride is 1,067 dollars and I'm not going to the hospital. His family member was present and the resident would not agree to go to the hospital or [CONDITION(S)]. On 9/6/21 at 3:29 p.m., the resident refused all care and would not let the nurse do an assessment or check his G-tube. The resident yelled out and stated get the f*** out of my room you're not looking at me. On 9/6/21 at 5:50 p.m., staff answered the resident's call light and the resident immediately began yelling get the h*** out of my room. I don't want you in here. Get out. Staff left the room and the resident turned his call light back on. He had been very loud and disruptive to others on this hall. On 9/7/21 at 6:53 a.m., the resident was yelling and verbally aggressive toward the staff. He was asked to go to his room in a nice, calm manner. He said in a loud voice I do not have to listen to you. I am my own boss. Staff asked him to go to his room, he paced to the north door side entrance by therapy and back. The CNA asked the resident to go to his room and the resident replied he didn't have to listen to a n*****. When he went to his room, he came out of the room and told two female residents to stop looking at him, slammed his door and went into his room. On 9/7/21 at 2:21 p.m., the resident's family was called and was at the facility but were not effective in de-escalating the resident's behavior or agitation. He stayed in his room and calmed himself. Staff used interventions in place such as ensuring his safety and ceasing interaction. On 9/7/21 at 2:25 p.m., Social Services followed up in regards to the behaviors on 9/6/21 at 3:29 p.m. and 5:50 p.m., when the resident was yelling and cursing at staff and refusing care. The staff attempted to explain care and the resident continued to yell at staff to get out of his room. Staff ceased interaction and the resident calmed. On 9/7/21 3:29 p.m., Resident B was shouting in the hallway, pacing rapidly and yelling at everyone get out of my way. He was verbally abusive to staff, refused any interventions, finally went into his room and slammed the door. Earlier in the day, the resident was in the administration office and refused to leave. He stood and stared at people going past his room. He was non-compliant with instruction. On 9/9/21, the resident was seen by the Nurse Practitioner for aggression: verbal per staff reports and indicated to start [MEDICATION(S)] DR (delayed release) 125 mg (milligram) twice a day for mood stabilization. Staff reported the patient was irritable and at times verbally aggressive with staff and residents. On 9/13/21 at 6:01 p.m., the resident was sent to the hospital per the DON (Director of Nursing) and MD for lower abdominal pain. The resident did not get his [CONDITION(S)] completed because he refused to wear a mask. He refused vital signs to be taken and refused Tylenol for pain. On 9/15/21 at 7:32 a.m., the resident refused to have his blood pressure taken three times. Resident became very irritated. On 9/16/21 at 10:23 p.m., the resident asked the staff for a hug. Staff gave the resident a hug and he proceeded to grab the staff's bottom, kiss her on the cheek and attempted a second time. Staff pulled away and indicated it was inappropriate. The resident continued to ask her to come to his room. Staff notified the ED (Executive Director) and the resident was escorted off the hall. On 9/17/21 at 1:29 p.m., the resident's family came to the facility to take the resident to [CONDITION(S)], after several attempts, the resident continued to refuse to comply. The resident refused to have [CONDITION(S)] done today. POA (Power of Attorney) aware. ADON (Assistant Director of Nursing), ED and MD aware. On 9/18/21 at 8:26 a.m., Resident B was involved in a verbal altercation with a female peer. As staff were intervening, the resident made physical contact with the female peer and with staff. The resident was immediately placed on 1:1 and redirected away from the situation. MD notified. KOPD (Kokomo Police Department) was notified and responded to the facility. KOPD took the resident to the hospital for evaluation/emergency detention. His family was notified. Then ED and DON were notified. The resident refused assessment at the time of the incident but verbal assessment revealed no injuries or signs/symptoms of pain. 2. The record for Resident C was reviewed on 10/4/21 at 2:51 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS (Minimum Data Set) assessment, dated 9/20/21, indicated Resident C's BIMS (Brief Interview for Mental Status) was scored at 15 which indicated the resident was cognitively intact. Section G for Functional Status indicated for transfers (how the resident moved between surfaces) the resident was an extensive assist of one person. She used a wheelchair. A review of Resident C's progress notes indicated: On 9/18/21 at 8:12 a.m., Resident C was involved in a verbal altercation with a male peer. The male peer made physical contact with the resident resulting in Resident C landing on the floor. Resident C was assessed and noted with right eye swelling, petechiae by the hairline and an abrasion to the right elbow and the left ankle. The resident complained of pain and double vision. The MD was notified and an order to send the resident to the ER for evaluation was ordered. On 9/18/21 at 1:05 p.m., Resident C returned from the ER with an ace bandage on her right wrist. An order to follow up with ortho was put in the EMR (Electronic Medical Record) to schedule on Monday due to the office was closed today. On 9/18/21 at 4:06 p.m., a new area abrasion was noted to the left outer ankle. On 9/20/21 at 11:06 a.m., the X-ray from the ER visit showed no acute fracture. A letter from the Deputy Prosecuting Attorney, dated 9/29/2021, indicated the office filed charges against Resident B. It was their desire to ensure the full impact of the offense on Resident B was brought to the attention of the Court. The letter was the first communication to emphasize they would vigorously protect Resident C's rights as a victim at all stages of the proceeding of the case. A review of the facility's written staff statements indicated: QMA 3 indicated, on 9/18/21 at approximately 6:30 a.m., she was walking down the hall to the south unit when she heard a page for a nurse to south. When she entered onto the unit the other staff told her Resident B threw Resident C out of her wheelchair, punched her in the head and was kicking her. Resident C was on the ground and Resident B was in the dining room. As Resident B proceeded to walk off the unit, he picked up the narcotic book and threw it at QMA 3. He then kicked CNA 1 in the back and threw the wet floor sign at her. At approximately, 7:00 a.m., he came down to the south unit again. He stood at the nurses station and asked QMA 3 do you want some. QMA 3 politely said please go back to your hall. He said f*** you and charged at QMA 3. He ran and picked up a spray bottle and was going to throw it so QMA 3 took off running. Then he went and ran towards CNA 4. CNA 1 indicated, on 9/18/21 at approximately 6:30 a.m., she was walking past the south hall and heard Resident B yelling and screaming at another resident (Resident C). At that point, she found out Resident B threw Resident C out of her wheelchair and was beating her up. He started to come back at Resident C once she was back in her wheelchair and was heading down the hall. CNA 1 stepped in between them because Resident B was trying to kick and attack Resident C again. She stood in the middle of the residents to help avoid further incident. Resident B then kicked CNA 1 in her back and threw a wet floor sign at her. He then proceeded to go down the hall back to his room while continuing to yell and threaten Resident C's life with knives. CNA 1 then told Resident C to go to her room for safety. CNA 2 indicated, on 9/18/21 at 6:30 a.m., she did 1:1 observation with Resident B at this point. He was in his room yelling and pacing. Then he came out of his room and was headed toward the south hall to the nursing station. He starting yelling, screaming and ran toward the CNAs behind the desk. He picked up a bottle and tried to throw it but they had all moved away. He then headed back to the north hall and was yelling in his room until he was escorted out of the building by the police. During an interview, on 10/5/21 at 1:40 p.m., the ED indicated the staff on the unit was QMA 3 who witnessed the altercation. The Regional Nurse Consultant completed the documentation in the progress notes based on QMA 3's statement. The Regional Nurse Consultant was not in the building when the event happened. The altercation occurred on the south unit at the nurses station. During an interview, on 10/5/21 at 2:29 p.m., Resident C indicated Resident B came down to the south hall a lot. He did not belong on the south hall. He lived on the central hall. He came to the south hall and was yelling. He had been coming to the south hall and was yelling the whole week. The rest of the residents were asking who was yelling? and they did not like it. Residents need their rest. Resident C went out to the hallway and he was at the end of the medical cart at the nurses station. Resident C asked Resident B if he could please tone the yelling down. He cussed Resident C out, called her a f****ing b**** and hit her in her ear. He grabbed her head band and yanked her out of her wheelchair. When she went on the floor, she hurt her right hand and wrist. He hit her in the head and kicked her in the right side and back. Then he tried to choke her. She had to put her thumb in his neck because he was on the floor grabbing hold of her. He hit her in her head while she was on the floor. He came back at her 3 or 4 times. CNA 1 drug him off of her. Resident C indicated she was afraid for her life. She thought he was going to kill her. He came back later and Resident C was back in her room, he said where is that f****ing b**** I am going to kill her. He had come down before on the south unit, after midnight and would yell a lot of times. It was worse on September 18th. Some of the staff would not do anything about his yelling. She did not know if he was yelling at staff or a resident but he was disturbing the peace. She had not had any trouble with him before. During an interview, on 10/5/2021 2:56 p.m., the Social Service Director (SSD) indicated she spoke with Resident C and she was pretty upset. Resident C indicated to her Resident B grabbed her, threw her out of her wheelchair, hit and kicked her and threatened to kill her. Resident C was terrified and begged her not to let him come back. She indicated the situation was awful, the staff had to pull Resident B off of Resident C. Resident B's behaviors were agitation, quick to yell at staff and irritability. He was one if you approached him, you needed to give him options, if he felt like staff made a decision for him it would agitate him. His family would increase his behaviors. She would hear him get agitated. She did not hear him in the hallways yelling but would see him in his room clenching his fists. Most of his behaviors were in the evenings, he would go to the other units, get close to the staff and be very demanding and yell. During an interview, on 10/5/21 at 3:25 p.m., CNA 4 indicated she was on the south hall with CNA 5. The QMA was late and was not there yet. Resident B kept coming to the south unit and was upset over a remote control. He wanted it fixed. He was mad about it. CNA 4 and 5 tried to redirect him but it was not working. He came back and Resident C asked Resident B if he would quiet it down because she was trying to sleep. Resident C said he was disturbing everyone. Resident C was not loud, she was talking in a normal tone and asked Resident B to be quiet. He pulled her out of the wheelchair, hit her in the side of the head, grabbed her head and pulled her out of the wheelchair. He called her a f****ing b****. CNA 4 was behind the nurses desk and this occurred right outside the nurses station on the south hall. Only CNA 4 and 5 were there. Right after it happened, QMA 3 rounded the corner and the other girls were coming. He kicked one of the staff in the back and threw a floor sign at her. They had to get him to his room. CNA 4 indicated she was in shock and did not know what to do. She grabbed Resident C and pulled her away. Resident B and Resident C were on the floor, close to the tv room, in the doorway. She pushed Resident B off of Resident C and grabbed Resident C because he would not let go of her. He did not hit CNA 4. CNA 5 called for help in the intercom and then another staff member came around the corner to assist. Everyone else started coming down to the south hall. CNA 4 indicated she was scheduled for the day shift. The midnight shift QMA left before she arrived for the day shift. She quit. Resident B would come to the unit a lot in the mornings or during the night shift. He would roam the building when he was agitated. CNA 4 indicated she had worked on all three different shifts before and he was down on the south hall many times and sometimes he would be yelling. Most of the residents were annoyed by his yelling. They would be upset because he would wake them up in the middle of the night yelling. CNA 4 indicated she was afraid of him because she had seen him attack her coworkers. He chased her around the unit after the incident with Resident C. He did not try to go in the residents' rooms. He was just chasing CNA 4 and QMA 3. He was saying to QMA 3 b**** you want a piece of me and called her a n*****. He chased CNA 4 and QMA 3 and CNA 4 indicated they went into the locked linen room to get away from him. After the incident, Resident C complained her eyes hurt, she had a headache and blurred vision. She had a red arm, he had dragged her arm and her arm was red from hitting the floor. During an interview, on 10/5/21 at 3:36 p.m., QMA 3 indicated she arrived on the unit when the altercation with Resident B and C had ended. When she went around the corner, CNA 4 and 5 were breaking the altercation up. Resident C was on the ground and Resident B was in the doorway. Resident B stomped off and threw the narcotic book at QMA 3. He kicked CNA 1 in the back. During an interview, on 10/5/21 at 3:56 p.m., CNA 5 indicated she was working the day shift, it was before 6:30. CNA 5 and CNA 4 were at the nurses station getting started for the day. Resident B kept coming to the south hall talking about a remote. He was talking loudly. He was asked to go back to his room and talk to his nurse. He wanted the police called over a remote. He was angry. He just kept walking back and forth. He would leave then come back and holler more. CNA 4 indicated she asked him to talk to his nurse. He got more angry. Resident C came out and asked him to calm down since he had been screaming for the 4th day in a row. Other residents were hollering from their room for him to be quiet. He grabbed Resident C out of her wheelchair and started hitting and kicking her. She called on the intercom for help. Resident B had a good grip on Resident C. She paged all nursing staff to the south hall. Resident B kept coming back to attack her. He kicked her in the head. Then QMA 3 came around the corner. Resident B said something to QMA 3, she asked him to go back to his hall. He grabbed the narcotic book off the med cart and threw it at QMA 3. She heard shouting and heard a commotion. Staff took Resident C back to her room. Resident B went back to his room and you could still hear him hollering. Staff had tried to call the ED and she did not answer. Staff was able to contact the unit manager and the unit manager indicated she was coming into the facility and to put him on 1:1. Resident B came back to the south hall, looked at QMA 3 and said you want a piece of me went behind the nurses station and charged at QMA 3. CNA 5 indicated she called the police from the linen closet she was in with CNA 4 because Resident B was out of control. It was not long before the unit manager arrived at the facility. Then the police arrived. A lot of residents were afraid of him. She worked PRN (as needed) and did not work a lot so this was her first encounter with him. Residents had told her before Resident B hollered a lot. CNA 5 indicated she was afraid of Resident B because she did not have training on how to deal with that type of aggression. Resident B was running full force and kicking. She heard other staff say they were afraid of him because the smallest things would set him off. She felt like it could have been prevented because the facility was not the proper place for him. She did not know if they were trying to place him somewhere else. During an interview, on 10/6/21 at 11:41 a.m., CNA 1 indicated on 9/18/21, she was coming inside the building after taking the trash out and she saw Resident B walking away and then he was coming back for Resident C again. She did not witness any of the altercation as it had already ended. She saw Resident B going after Resident C so she stepped in the middle to make sure he did not get to Resident C. CNA 1 indicated Resident B kicked her in the back and threw a wet floor signs at her. He then proceeded to walk away, she followed him and closed all the resident doors to make sure he did not go anywhere. She observed Resident C's face was red, her arm was red, you could tell someone had touched her. Resident B was amped up by the time she came into work that morning. He was screaming and threatening people. This was an every day thing for him. The CNAs did not like to be in his room by themselves. Resident B was strong. The behaviors were an every day thing for Resident B. A lot of the residents seemed afraid of him. When Resident B was in the hallway, it was scary to walk by him. Everybody was on edge when he was out and about in the hallways and raging in his violence. Resident B would walk all units and yell. He would scream in residents faces and threaten them. He also would go to the nurses station and threaten staff and talk about killing the residents and the staff. During an interview, on 10/6/21 on 12:11 p.m., CNA 2 indicated on 9/18/21, she was working from 6 a.m. to 2 p.m. When she came in, Resident B was by the entrance doors in the front lobby. Then the next time she saw him was after the altercation, he was back in his room so she was doing the 1:1 with him. While on 1:1, he left his room and walked to the south hall again and chased one of the staff behind the nurses' station. She indicated she was following him when he was chasing the staff on the south hall and tried to talk him into going back to his room but there was no reasoning with him. Resident B went behind the nurses' station and started yelling and screaming at the QMA/nurse and then he tried to throw a bottle at her. When he went to throw it, he stumbled and the QMA/nurse was gone. She took off down the hall so he could not throw it at her. He then went back to his room, CNA 2 followed him and then the police showed up. During an interview, on 10/6/21 at 2:09 p.m., Resident G who also resided on the same unit as Resident B, indicated Resident B followed her all the time and yelled at her. She indicated he would ask her why the other residents did not like him and she told him it was because of how he acted. He hurt the staff before. She indicated she told the staff she was afraid the next person to get hurt would be a patient. She carried her scissors with her because she did not feel safe as he always went after women. She tried to avoid him. He would go to other halls and yell, it made her cringe when he would start yelling. He did this every day. A current policy, titled INDIANA Abuse & Neglect & Misappropriation of Property revised on 5/14/2020 and received from the DON on 10/4/21 at 2:50 p.m., indicated, .It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents .It is the intent of this facility to prevent the abuse, mistreatment, or neglect of residents .In the event the alleged abuse involves a resident-to-resident altercation, the residents will be placed in separate areas by the staff and the appropriate physical assessments will be completed on each resident .Aggressive residents may be placed in a quiet are to reduce stimulation The Immediate Jeopardy that began on 9/18/21 was removed on 10/7/21 when the facility completed the following: The ED and DON completed education for all staff on Indiana Abuse & Neglect & Misappropriation policy, Resident Rights policy and behavior de-escalation process, management and notification. The facility completed interviews for all residents who could be interviewed and head to toe assessments for residents to determine if they felt safe at the facility and determine if any other abuse had occurred. There were no additional findings during the interviews and assessments. An audit was conducted on all residents for signs of aggressive behaviors and no other residents were identified. This Federal Tag relates to Complaint IN 003. 3.1-27(a)(1)

Based on interview and record review, the facility failed to ensure a resident with a mild intellectual disability and an impulse disorder was free from abuse when the resident and a staff member had a verbal and physical altercation for 1 of 3 residents reviewed for abuse (Resident B and LPN 1). The immediate jeopardy began on August 17, 2021, when Resident B and LPN 1 had a verbal and physical altercation. LPN 1 continued to follow, instigate, and taunt the resident after the resident attempted to remove himself from the situation on two separate occasions. The Executive Director (ED), Director of Nurses (DON) and Regional Director of Clinical Services (RDOC) were notified of the immediate jeopardy at 4:42 p.m., on 9/02/21. The immediate jeopardy was removed on 9/03/21 but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: An Indiana Department of Health incident report indicated, on 8/18/21, staff reported to the Executive Director (ED) there had been a staff to resident physical altercation. The record for Resident B was reviewed on 9/1/21 at 2:10 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A PASRR Level II, dated 7/1/21, indicated the resident had past behaviors of hitting other residents or staff and a history of attempting to end his life. The resident would need to have rehabilitative services including a behaviorally based treatment plan. The behaviorally based treatment plan was to help the staff know how to best support and manage the resident's symptoms. The progress notes for Resident B were reviewed and indicated the following: On 6/29/21 at 2:23 p.m., a CNA entered the resident's room after lunch to pick up his lunch tray. The resident jumped up out of bed and hit the CNA while yelling and screaming. The CNA left room and the building due to it was the end of her shift. The resident was talked to about his behavior, and it would not be tolerated. The resident was left in his room to de-escalate. No further issues were noted. On 7/23/21 at 10:38 p.m., Resident B went to the nurses' station and accused the staff of arguing over a phone. There was not an argument. The CNA just said oh its my phone when asked about it. Resident B became abusive, yelling at staff and shouting. When he was told to go back to his room, he became violent and threw a cup at the CNA and hit her in the arm. He was told this was uncalled for, there was no need to throw things at anyone and to go back to bed and watch TV or something to calm down. The resident went back to bed. On 7/26/21 at 9:07 a.m., the MD (Medical Director) and Family were notified of the resident's behaviors. On 7/31/21 at 8:13 p.m., Resident B was vocal, angry, and asked for his medications. When the nurse asked if he was going to take them when she brought them down this time, the resident stated in a loud voice no and refused them once again. A CNA entered the resident's room to answer his light, he shouted at her and made an aggressive move towards her. She left the room. He later came out into the hallway and wanted to shout at her then hauled back with a fist and hit the CNA in the face, in front of an alert and oriented witness. The Director of Nursing (DON) and MD were called. The nurse spoke with the resident's sister, she was aware of resident's behaviors and indicated he had been a resident of the State hospital before. She would like him sent there or a local inpatient mental health center before anyone else was hurt. The resident was placed on 1:1. On 7/31/21 at 9:12 p.m., the resident was sent to the hospital and report was called. The resident was to be [NAME] (Emergency Detention Order) when he arrived at the hospital. On 8/1/21 at 12:44 a.m., Resident B returned to the facility at 12:30 a.m. On 8/6/21 at 10:41 a.m., an Interdisciplinary (IDT) note indicated the resident was upset over medications and made contact with a closed hand to a female staff member once in the jaw and once in the neck. A behavior care plan was update on 8/3/21. On 8/16/21 at 7:00 a.m., Resident B was at the nurses' station yelling at staff. He grabbed trash bags and tried to hit a CNA with the trash bags. The nurse grabbed the trash bags, and he pushed the nurse into the wall. The CNA tried to intervene, and the resident kicked her twice in the stomach. He was swinging his fists and hit the nurse over and over in her left lower back with a closed fist. The MD, ED, and family were notified. On 8/17/21 at 6:48 p.m., a nurse went to the head of the hall to explain to Resident B, he needed to go back to his room. The resident was yelling and refused to return to his room. He swung at the nurse and hit her in the jaw with his fist. He was just down on the other hall and was in an argument with staff and hit a staff member down there. A Psychiatry progress note, dated 8/19/21, indicated Resident B appeared upset and anxious but was not displaying any physical or verbal aggression. He repeatedly talked of fighting with a nurse. He also stated, he guessed he was not supposed to touch her, and she was not supposed to touch him. He claimed the police were protecting him because he did not lie. He kept saying he was being protected. He denied depression and anxiety but did appear anxious as he talked of the altercation between himself and the nurse. The resident has psychiatric conditions of Impulse Disorder, Anxiety disorder but also intellectual disabilities. He was unable to correctly list the year, month, or location. A review of the facility timeline of events which occurred on 8/17/21 indicated the following: On 8/17/21 at 5:56 p.m., Resident B walked down the hallway and stopped right before the nurses' station. He spoke to CNA 2 behind the desk. He proceeded to walk towards the nurses' station. LPN 1 met him and began pointing at him. She pulled the meal cart to block his path. Resident B shoved LPN 1. LPN 1 pushed Resident B back. They began rolling on the floor and off the view of the cameras. Resident B got up, LPN 1 grabbed his sleeve and pushed him down the hallway. He entered the North dining room. LPN 1 followed him. There was no camera view in the dining room. On 8/17/21 at 5:58 p.m., Resident B came out of the dining room and LPN 1 followed. Resident B walked around the nurses' station towards the therapy door. LPN 1 threw keys and other unknown belongings on the nurses' cart and proceeded to follow Resident B down the hall. On 8/17/21 at 5:59 p.m., Resident B was seen walking from the therapy door towards the nurses' station. LPN 1 was following closely behind him. There was a gap in the camera footage. On 8/17/21 at 6:10 p.m., Resident B walked into the dining room. LPN 1 followed. The resident sat in a chair and LPN 1 was bent down over him speaking. On 8/17/21 at 6:11 p.m., QMA 3 entered the camera view and appeared to talk to LPN 1 as LPN 1 was holding the resident by his head/hair. The scuffle was still continuing. On 8/17/21 at 6:12 p.m., Resident B left the dining room and walked towards the lobby. LPN 1 followed. QMA 3 was seen running to the west hallway to grab LPN 4. On 8/17/21 at 6:13 p.m., Resident B was sitting in lobby chair by the time clock. LPN 1 was bent down speaking to him. On 8/17/21 at 6:14 p.m., LPN 1 walked away. Resident B got up and walked towards the west hall where he was met by LPN 4 and QMA 3. On 8/17/21 at 6:15 p.m., LPN 1 was seen back on the North unit. Resident B and LPN 4 appeared to be speaking at the end of the West Hall and Resident B hit LPN 4. On 8/18/21 at 4:00 p.m., QMA 3 approached the ED and stated she needed to discuss an emergency with her. QMA 3 indicated the incident from 8/17/21 was not reported correctly. QMA 3 indicated she came in from the employee smoking door and saw LPN 1 chasing Resident B down the hall into the dining room. QMA 3 immediately went into the dining room and witnessed LPN 1 grabbing Resident B by his hair, face and was hitting him in the chest. QMA 3 indicated she attempted to intervene, but LPN 1 would not listen. QMA 3 immediately went to the West unit to grab another nurse. During an interview, on 9/22/21 at 10:55 a.m., the ED indicated the initial call she received indicated Resident B had been physical with staff. On 8/18/21, QMA 3 told the ED the altercation was between the resident and LPN 1. The ED further indicated during a review of the camera footage, on 8/17/21 at 5:51 p.m., LPN 1 and Resident B were seen on the ground from the waist down. Their faces could not be seen but they could be seen falling to the ground. Resident B had been physical with staff in the past. On 8/17/21, Resident B was observed walking toward the nurses' station, he stopped and talked to CNA 2. LPN 1 was seen pointing to the other end of the hallway. There was a food cart near her, she moved the food cart so there was nothing between LPN 1 and Resident B. Resident B was very close to LPN 1 however was not touching her. He walked to the right of her, she pulled the meal cart over so he could not walk that direction. He tried to go to the left of her and she took a step so he could not go that direction. Resident B then pushed LPN 1 and LPN 1 pushed him back with her hands on his chest. This was when they went to the floor. Resident B stood up, LPN 1 stood up and she pushed his back with her hands. They then went to the North dining room and was off camera. Resident B came out of the dining room and LPN 1 followed him. When Resident B went to the Main dining room he sat down in a chair to the right of the TV. LPN 1 entered the room and leaned over the resident making hand movements. LPN 1 then grabbed the top of his head. The back of the resident's chair was facing the camera, so she was able to see LPN 1's hand on his head and his head leaning to the side. Resident B then kicked towards LPN 1 and LPN 1 pushed his chair into the couch. Resident B then got up and went toward the lobby and sat in a chair on the right. LPN 1 entered the lobby and was seen with her hands moving and hovering over the resident. She then leaves the view of the camera. Resident B had a BIMS (Brief Interview for Mental Status) of 10. He had a mild intellectual disability. During an interview, on 9/2/21 at 1:52 p.m., QMA 3 indicated she had seen LPN 1 and Resident B coming down the hallway. They were both screaming. They went to the main dining room. He was sitting down, and LPN 1 was screaming at him, he had hit her the day before. He was trying to get away and she kept following him. QMA 3 was scared she would be hit by Resident B or LPN 1. When LPN 1 followed him to the lobby, she went to get the closest nurse on another hall. She did not see LPN 1 hit the resident, but she did grab his hair and was holding him by his hair. LPN 1 swung at him, but she could not tell if she made contact. She tried to tell LPN 1 to walk away but she would not listen. She thought it would be best to get help. A current facility policy, titled Indiana Abuse & Neglect & Misappropriation of Property, dated as revised 5/14/20 and received from the acting Director of Nursing at the entrance conference, indicated .Definitions: Abuse/Battery: Indiana defines abuse/battery as a person who knowingly or intentionally touches another person in a rude, insolent or angry manner or in a rude, insolent or angry manner places bodily fluid or waste on another person. Abuse: I Indiana, the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Willful: In Indiana, the individual's action was deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm .Endangered Adult: In Indiana, an endangered adult is one who meets the following criteria for an individual who: 1) is over [AGE] years of age, 2) is incapable by reason of mental illness, intellectual disability, dementia, habitual drunkenness, excessive drug user or other physical or mental incapacity .Physical Abuse: In Indiana, is defined as a willful act against a resident by another resident, staff, or other individuals. Examples: hitting, beating, slapping, punching, shoving, spitting, striking with an object, pulling/twisting, squeezing, pinching, scratching, tripping, biting, burning, using overly hot/cold water, and/or improper use of restraints .Policy .It is the intent of this facility to prevent the abuse, mistreatment, or neglect of residents or the misappropriation of their property, corporal punishment and/or involuntary seclusion and to provide guidance to direct staff to manage any concerns or allegations of abuse, neglect or misappropriation of their property The immediate jeopardy, that began on 8/17/21, was removed on 9/3/21/21, when the facility completed the following: the ED and DON completed education for all staff on Indiana Abuse & Neglect & Misappropriation policy and Resident Rights policy. The facility completed interviews for all residents who could be interviewed and head to toe assessments for residents to determine if they felt safe at the facility and determine if any other abuse had occurred. There were no additional findings during the interviews and assessments. An audit was conducted on all residents who exhibited behaviors and the behavior monitoring and care plans were updated as needed. This Federal Tag relates to Complaint IN 994. 3.1-27(a)(1)

Based on observation, interview and record review, the facility failed to remove a resident [MEDICATION NAME] medication per physician orders [REDACTED]. (Resident B) Resident B was hospitalized with potential drug overdose and administered [MEDICATION NAME] (a medication to reverse overdose) Findings include: The clinical record for Resident B was reviewed on 1/25/2018 at 1:25 p.m. [DIAGNOSES REDACTED]. Resident Hospital records, dated 1/3/2018, indicated the resident was admitted to the emergency room (ER) with [DIAGNOSES REDACTED]. The resident was found unresponsive at her nursing home facility and 2 [MEDICATION NAME]es were removed from resident. The resident was given [MEDICATION NAME]. The resident responded to the [MEDICATION NAME] and began to improve. A nursing progress note, dated 1/3/2018, indicated the resident was found in her room at the facility with blowing respirations and foaming at the mouth. The resident did not respond to verbal stimulation. Sternal rub attempted with some response from the resident. The resident vital signs were blood pressure 86/53 , pulse 129 and respirations were 22. The resident was on 4 liters of oxygen per nasal cannula. All limbs were flaccid. The resident sent to the ER for evaluation and treatment. Physician order, dated 3/31/2017, indicated apply [MEDICATION NAME] 72 hour 12MCG/ HR (microgram/hour) [MEDICATION NAME] every 72 hours for severe pain. The Medication Administration Records (MARS) indicated the resident received the [MEDICATION NAME] on 12/30/2017 and on 1/2/2018. The record did not indicated any patches were removed. During an interview, on 1/19/2018 at 11:25 a.m., with LPN 5, she indicated prior to placing a [MEDICATION NAME] on a resident you must first look for the old patch and remove from the resident. If no patch was found then the Director of Nursing is to be notified and the residents physician. The physician must order the patch placement. She indicated staff now document on the MARS the removal of the patch and the application of the new patch. During an interview, on 1/19/2018 at 3:25 p.m., with the Director of Nursing (DON), she indicated staff were inserviced to remove any [MEDICATION NAME]es from a resident prior to the application of a new patch after this event. She indicated she was not aware the resident had 2 patches on her until the hospital reported it to the facility. An incident report was filed with ISDH (Indiana State Department of Health) and investigation began at the facility. An incident report was filed on 1/5/2018 when the facility was notified by the hospital of the resident having 2 patches found on her body in the ER. The resident had been admitted to the hospital. Record review and inservices were completed and MARS were changed to include documentation of removal of medication patch and administration. Incident report was filed with the Indiana State Department of Health. A current pharmacy procedure titled [MEDICATION NAME] Patch Formulations not dated, provided by the Director of Nursing on 1/ 8 at 1:10 p.m., indicated, .Change patch at the same time of day every 3 days (72hours); remove any patches in use prior to application of a new patch The Past Noncompliance began on 1/3/2018 and was corrected on 1/12/2018. The facility immediately imitated their investigation and reported to ISDH. Other residents and employees were interviewed regarding medication patch placement and removal. The facility implemented new procedures including check list for the removal and placement of medication patches on the Medication Administration Record [REDACTED]. The facility completed the investigation. Inservices to all staff who administer medication patches to residents was completed on 1/5/2018 and are ongoing with new staff orientation. The correction date was prior to the start of the survey and was therefore Past Noncompliance. This Federal tag relates to Complains IN 931. 3.1-48(c)(2)

Based on interview and record review, the facility failed to ensure a resident's admission medication Physician orders [REDACTED]. unable to breathe on her own). Finding includes: During an interview on 12/7/17 at 5:37 p.m., the DNS (Director of Nursing Services) indicated Resident F was sent to the hospital recently related to her blood sugar dropped low and she was found unconscious and foaming at the mouth. She indicated she was given a [MEDICATION NAME] injection twice and glucogel sublingually (medication placed under the tongue, so the resident could absorb the medication from the blood vessels under the tongue.) She indicated she was admitted to the hospital in the ICU (Intensive Care Unit) related to her Physician had indicated she had aspirated the foam from her mouth. During an interview on 12/8/17 at 11:50 a.m., a family member indicated Resident F had been at the facility for 2 days when she was found in her room unconscious. She indicated the resident was receiving four oral hypoglycemics in the morning and two insulins in the evening and these medications were not what her family member normally took at home. She indicated she had talked to the facility regarding the medications her loved one was prescribed when she was admitted into the facility. After the resident was admitted to the facility, the family member obtained a list of her medications from the facility and she realized the medications, which was ordered for her at the facility upon admission were not medications she had taken at home prior to her admission to the facility. She indicated to the facility she wanted to know where the medication orders came from, but no one at the facility could provide answers for her. During an interview on 12/8/17 at 12:55 p.m., Resident F indicated she was not taking four oral (by mouth) medications for her diabetes prior to admission to the facility. She indicated she took [MEDICATION NAME] (a medication used orally to lower the blood sugar in a type 2 diabetic) 1000 mg (milligrams) by mouth twice a day, but the Physician discontinued that medication while she was at home and started her on [MEDICATION NAME] (a medication used orally to lower the blood sugar in type 2 diabetics). The record review for Resident F was completed on 12/8/17 at 4:15 p.m. [DIAGNOSES REDACTED]. A document titled ED (Emergency Department) Provider Notes from (Name of Hospital) dated 10/30/17, indicated the resident went to the ED from home and contained the following, .First Contact: 10/30/17 at 1705 (5:05 p.m.) .Prior to Admission medications: [REDACTED]. Analog ([MEDICATION NAME] Subq (Subcutaneously) Inject 26 units into the skin at bedtime. Insulin (sic) Asp PRT/Insulin [MEDICATION NAME] ([MEDICATION NAME] Mix 70-30 [MEDICATION NAME] Subq) Inject into the skin Three times a day. Per sliding scale with meals .[MEDICATION NAME] 1000 mg by mouth 2 (two) times daily with meals A document titled ED Provider Notes from (Name of Hospital) dated 10/31/17 at 1:01 p.m., indicated the resident went to the ED from home and contained the following, First Contact: 10/31/17 at 1301 (1:01 p.m.) .Current Discharge Medication List: (THESE medications have not been reviewed): [MEDICATION NAME] Sub q Inject 26 units into the skin at bedtime .[MEDICATION NAME] 1000 mg, Take 1000 mg by mouth 2 (two) times daily with meals . [MEDICATION NAME] Mix 70-30 [MEDICATION NAME] Subq Inject into the skin Three times a day sliding scale with meals A document titled Facsimile Transmission Cover Sheet from (Name of Hospital) dated 10/31/17 at 2:43 p.m., to the facility admissions coordinator for review for admission to the facility. The document indicated Incomplete H & P on the form and contained the following, (Name of Hospital) Emergency Department Date of visit: 10/31/17 .Medication List: These Medications have not been Reviewed: Actos 30 mg .[MEDICATION NAME] (a medication taken by mouth to lower the blood sugar in a type 2 diabetic) .[MEDICATION NAME] 25 mg, [MEDICATION NAME] (a medication used as an injectable medication to lower the blood sugar for a diabetic) Inject 26 units into the skin at bedtime .[MEDICATION NAME] 1000 mg Take 1000 mg by mouth 2 (two) times daily with meals .[MEDICATION NAME] Mix 70-30 [MEDICATION NAME] (a medication used as an injectable medication to lower the blood sugar in a diabetic) sub q (subcutaneously) (under the skin) Inject into the skin Three times a day. Per sliding scale with meals . Notice: This list has 2 medication(s) that are the same as other medications prescribed for you. Read the directions carefully, and ask your doctor or other care provider to review them with you A document titled Medication Review Report dated 11/1/17 through 12/31/17, included, but was not limited to, these physician's orders [REDACTED].>10/31/17--Actos tablet 30 mg give one tablet by mouth in the morning for diabetes mellitus. 10/31/17--[MEDICATION NAME] 1 mg Give 1 tablet by mouth in the morning for diabetes mellitus. 10/31/7--[MEDICATION NAME] Solution 100 unit/ml (milliliters) Inject 26 unit Subcutaneously one time a day for diabetes mellitus. 10/31/17--[MEDICATION NAME] HCL give one tablet by mouth twice daily for diabetes mellitus. 10/31/17--[MEDICATION NAME] 25 mg give one tablet by mouth once a day for diabetes mellitus 11/1/17--Tradenta 5 mg give one tablet by mouth daily for diabetes mellitus 11/1/17--Accu checks before meals for diabetes 11/2/17--Blood glucose test before meals and at HS. 11/2/17--[DIAGNOSES REDACTED] Protocol: Continue to check blood glucose every 15 minutes, until blood sugar is over 70 mg/dl (milligrams/deciliter) as needed for [DIAGNOSES REDACTED] If blood sugar continues to fall after 15 minutes or continues to be below 70 mg/dl after 30 minutes, call Physician. The progress notes indicated the following information: On 11/2/17 at 8:02 a.m., Blood sugar was a 65 when checked. (Name of doctor) notified and advised resident was just starting to eat breakfast. Advised make sure resident eats and call if she is low at lunch. On 11/3/17 at 8:29 a.m., CNA came to nurse to inform her that patient was foaming from her mouth. Nurse noted foaming and unresponsive to sternal rub or verbal stimulation. Management notified, pt (patient) suctioned, 911 called, family notified, BS 17 . [MEDICATION NAME] given, BS 14. Glucose gel placed under tongue. Another [MEDICATION NAME] administered arrived. 911 arrived, pt taken to (Name of Hospital). On 11/3/17 at 9:30 a.m., Spoke with (Name of Physician) related to residents blood sugars . asked him about how her blood sugars were down and we discussed her blood sugars again from last evening through this morning, he stated the nurse on evenings had called about the blood sugars. He stated they would be looking at her diabetic medications An Electronic Medication Administration Record [REDACTED]. There was no documentation found in Resident F's record to indicate the resident's Physician was notified of the 38 mg/dl blood sugar. A document titled Transfer/Discharge Report from the facility when she was sent out, indicated the following medications were the residents current medications with a start date of 11/1/17: [MEDICATION NAME] Solution 100 unit/ml Inject 26 units Subcutaneously one time a day for Diabetes Mellitus Actos Tablet 30 mg give one tablet by mouth in the morning for Diabetes Mellitus [MEDICATION NAME] 1 mg give one tablet my mouth one time daily for Diabetes Mellitus [MEDICATION NAME] Tablet 25 mg give give one tablet by mouth one time a day for Diabetes Mellitus [MEDICATION NAME] HCL 1000 mg give one tablet by mouth two times a day for Diabetes Mellitus. A Physician's progress note dated 11/3/17, indicated the chief complaint/reason for the visit was readmission. History of present illness indicated the resident was admitted to (Name of Hospital) for acute mental status change due to [DIAGNOSES REDACTED] with a fasting blood sugar of 16. She was admitted to the ICU and was intubated (an artificial breathing tube was inserted in the resident's throat to assist her with breathing) for airway protection. The resident was treated for [REDACTED]. During an interview on 12/11/17 at 10:10 a.m., the DNS indicated Resident F was found unconscious and frothing at the mouth when her breakfast tray was picked up that morning. The DNS indicated Resident F had to be Okay when her breakfast tray was delivered, at approximately 8:00 a.m., because whoever delivered her tray would have gotten the nurse if she wasn't. During an interview on 12/11/17 at 10:25 a.m., CNA 4 indicated she was working the South unit on 11/3/17. At 6:40 a.m., she made rounds on her residents checking and changing the incontinent residents that particular day. She indicated Resident F was talking and acting normal when she checked her at 6:40 a.m. CNA 4 went to the dining room to assist residents who needed fed. Approximately 8:20 a.m., CNA 4 indicated she had seen Resident F was not eating her breakfast tray, so she went to check on her and she found her with her breakfast tray untouched in front of her and she was unconscious with froth coming out the side of her mouth. She ran and got LPN 5. During an interview on 12/11/17 at 10:35 a.m., LPN 5 indicated she called a Code Blue and grabbed the crash cart and she started the Code Blue. She indicated Resident F was unconscious, had a large amount of froth running out the side of her mouth. She set up the suction machine off the crash cart and suctioned the resident. The resident's fasting blood sugar was taken with a result of 17 mg/dl. LPN 5 administered a dose of [MEDICATION NAME] IM (Intramuscularly). The resident's blood sugar fell to 14 mg/dl after the [MEDICATION NAME] injection. 911 was notified. When the paramedics arrived, they took over the care of the resident. During an interview on 12/11/17 at 1:20 p.m., the DNS indicated Resident F did not have a discharge summary sent with her when she was admitted to the facility the first time on 10/31/17. She indicated the nursing staff who admitted her used the ER record which looked like the discharge summary, but it did not have the accurate discharge medications on it. She indicated she had talked to the resident's Physician on the evening of 11/2/17 regarding her blood sugars being low and he requested she obtain the resident's Discharge Summary from the hospital for her last admission when he realized Resident F was on four oral hypoglycemic and two insulin medications. She indicated the resident's blood sugar dropped in the 60's the previous evening. She was given a peanut butter sandwich and glass of juice, then she was better. This Federal tag relates to Complains IN 306. 3.1-37(a)

Based on interview and record review, the facility failed to ensure pressure ulcers were assessed accurately, prevention interventions were implemented for know risk, physician orders [REDACTED]. Findings include: Resident C's record was reviewed on 12/12/16 at 9:26 a.m. [DIAGNOSES REDACTED]. Slough (Necrotic or avascular in the process of separating from viable tissue. Usually soft, moist, and light in color and may be stringy) or eschar (Thick, leathery necrotic or dying tissue, frequently black or brown in color) may be present on some parts of the ulcer bed. It often included undermining (Destruction of the tissue or ulceration, which extended under the skin edges, so the pressure ulcer was larger at the base of the wound than at the skin surface) and tunneling (Passageway of tissue destruction under the skin surface, with an opening at the skin level from the edge of the wound), [MEDICAL CONDITION] arthritis, acute [MEDICAL CONDITION] with [MEDICAL CONDITIONS] without current pathological fracture, contractures, and left [MEDICAL CONDITION] and necrotic left femur. Resident C's MDS (Minimum Data Set) discharge assessment dated [DATE], indicated she had a Stage I or higher pressure ulcer. She had one or more unhealed Stage I or higher Pressure ulcer. She had two Stage II pressure ulcers. The resident had a care plan dated 6/17/16, which addressed the problem she had an actual pressure ulcer related to decreased mobility. Interventions included, but were not limited to, 6/17/16--Administer treatments as ordered and monitor for effectiveness, Assess/record/monitor wound healing weekly. measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress a. The resident had the following Physician orders: 6/19/16--Pressure boot to the right ankle when in bed-start date 6/19/16. 7/18/16--Ankle--Discontinue the Santyl (a medication used to debride or remove the dead tissue from wounds) then apply Borderfoam dressing only daily and as needed. A document titled Weekly Pressure Ulcer .Report dated 6/17/16 at 2:38 p.m., indicated the resident had a newly acquired pressure ulcer to the right outer ankle, which measured 0.8 x 0.8 x 0.1 cm and was a Stage II. The date of the initial observation of the wound was 6/17/16. The stage/depth of the ulcer was a #2, which was Partial thickness skin loss involving epidermis &/or dermis. The necrotic tissue type was a #4, which was Adherent, soft black eschar and the amount was a #5, which was 75% to 100% of wound covered. IDT review of new wound to right outer ankle. Resident has area related to crossing her ankles in bed. Intervention in place to cushion this area and relieve pressure A document titled Weekly Pressure Ulcer .Report dated 6/24/16 at 11:35 a.m., indicated the pressure ulcer to the right outer ankle was not new. It measured 0.6 x 0.3 x 0.1 cm and was a Stage II. The date of the initial observation the pressure ulcer was 6/10/16. The stage /depth was a #1, which was Non-blanchable [DIAGNOSES REDACTED] &/or intact skin. The necrotic tissue type was a #5, which was Firmly adherent, soft, black eschar. and the amount was a #5. IDT weekly review of wound to right outer ankle .Pillows still applied to provide cushioning, and this seems to be working A document titled Weekly Pressure Ulcer .Report dated 7/1/16 at 10:56 a.m., indicated the pressure ulcer to the right outer ankle was not new. The stage was a Stage II and measured 0.5 x 0.3 x 0.1 cm. The stage/depth of the wound was a #1. There was no necrotic tissue present to the wound bed. IDT weekly review of wound to right outer ankle. Wound remains intact with visible covering of wound. Cushioning between legs in place to alleviate pressure A document titled Weekly Pressure Ulcer .Report dated 7/8/16 at 10:08 a.m., indicated the pressure ulcer to the right outer ankle was not a new. The stage was a Stage II and measured 1.0 x 0.8 x 0 cm. The stage/depth of the wound was a #2. The necrotic tissue type was a #4 and the amount was a #3, which was 25% to 50% of wound covered. IDT weekly review of ongoing pressure area. Area has shown no sign of change in the last week. NP (Nurse Practitioner) aware and will receive new order for treatment to be changed. Recommend to apply Santyl for debridement. A document titled Weekly Pressure Ulcer .Report dated 7/15/16 at 10:11 a.m., indicated the pressure ulcer to the right outer ankle was not new. The stage was a Stage II and measured 1.1 x 1.1 x 0.1 cm. The stage/depth was a #2. There was no necrotic tissue visible. IDT weekly review of ongoing pressure area. Wound was debrided last week using Santyl and appears without Eschar this week No prevention interventions were found documented in the resident's record prior to the development of this pressure ulcer on 6/17/16. No other pressure ulcer wound assessments were found in the resident's record after 7/15/16, of this pressure ulcer and she discharged on [DATE]. b. The resident had the following Physician orders: 6/10/16--Cipro (an antibiotic medication) 500 mg (milligrams) give one table by mouth twice a day for an infection until 6/22/16. 6/10/16--[MEDICATION NAME] 100 mg give one capsule by mouth twice a day for infection until 6/22/16. 6/13/16--Culture the coccyx wound please. Health Status Note dated 6/10/16 at 7:26 a.m., indicated .Resident is currently taking two separate antibiotics to treat the infection to her sacrum A document titled Patient Nursing Evaluation Part I dated 6/10/16 at 10:15 p.m., indicated the resident had a pressure area on her sacrum, which was a Stage IV and measured 1.0 x 1.0 x 6.0 cm (centimeters). Braden Scale for Predicting Pressure Score Risk Risk Score was 17, which indicated she was at risk for developing pressure ulcers. A document titled Skin Inspection Anatomy Diagram dated 6/11/16 at 6:15 p.m., indicated the resident had a non-pressure ulcer present. The site of the ulcer was the coccyx, the type was pressure and the measurements were 1.0 x 1.0 x 6.0 cm. The stage of the ulcer was Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink ulcer bed without slough. It may present as an intact or open/ruptured serum billed blister). There were no other sites or types of wounds. The comments section indicated Pressure Ulcer (s) identified: Weekly Pressure Ulcer .report initiated . signed by LPN #11 on 6/17/16. A Nurse Practitioner progress note dated 6/13/16, indicated .Physical Exam .She does have a small open area to her coccyx that measures about the size of a number 2 pencil unsharpened with tunneling of roughly 6 inches noted .Plan: Impression: Plan: We will culture the wound .Further medical intervention will be dictated as needed . 6/16/16--Chief Complaint: New Admission . The patient was evaluated on 6/7/16 for increasing left hip pain. It was felt that the patient has a severe aseptic necrosis of left femur .She also has a sacral decub in the low back area. There is concern of the wound tunneling . Systemic Review: Skin: The patient does have sacral decub in the low back area Physical Examination: The patient does have a 1.5 x 1.5 cm open wound in the sacral area. There is concern of wound tunneling . Impression: Recommendation: We will need to have wound care look at the sacral decub ulcer as well. The patient is currently on [MEDICATION NAME] and doxy until 6/22/16 for possible infection in the sacral decub area. The antibiotic was started by the orthopedic service. Otherwise medications will be continued as same A culture result indicated the Sacral wound culture had a Sample integrity issue. The culture was collected on 6/13/16 at 3:15 a.m. The laboratory received the specimen on 6/14/16 at 12:08 p.m., and the results were reported to the facility on [DATE] at 4:16 p.m. Culture Wound-Result-pending Status-pending Gram Stain-Result-pending Status-pending Sample Integrity Issue: Test Name-Result- wound culture Status-final Problem-Result-Sample Integrity Status-final Resolution: Status-Final Will recollect per nurse Nicole Lab will redraw (Date): Result-Called Status-Final There was no other culture result found in the resident's record for the Sacral pressure ulcer wound. Health Status Note dated 6/14/16 at 5:50 a.m., indicated .Resident continues on ATB's (antibiotics) x (times) 2 for wounds. [MEDICAL CONDITION] to BLE. Red petechie rash noted to blat (bilateral) feet and ankles An eMar-Electonic Medication Administration Note dated 6/15/16 at 1:51 p.m., indicated Culture Coccyx Wound one time only related to PRESSURE ULCER OF SACRAL REGION STAGE 4 . or 1 day no culture sticks available called lab to bring more. There were no further progress notes found indicating why the culture was not re-collected. During an interview on 12/14/16 at 3:05 p.m., the Director of Nursing provided a copy of the wound culture report of the resident's Sacral wound from the laboratory and indicated she could not find any other wound culture results, which indicated the culture was re-collected. She indicated she had a call out to the laboratory and she would provide more information if it became available. At the end of the Exit Conference on 12/14/16, the Director of Nursing had not provided any further laboratory results, which indicated the culture test was completed. c. A document titled Weekly Pressure Ulcer .Report dated 6/17/16 at 2:42 p.m., indicated this was a newly acquired pressure ulcer to the left inner ankle, which was a Stage I (Intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching and the color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler compared to the adjacent skin.) and measured 0.3 x 0.3 x 0 cm. The date of the initial observation of the ulcer was 6/17/16. The stage/depth was a #1, which was Non-blanchable [DIAGNOSES REDACTED] &/or intact skin. IDT review of new Stage I area to left inner ankle. Wound is not open at this time. Patient has pillow to provide cushioning and relieve pressure A document titled Weekly Pressure Ulcer .Report dated 6/24/16 at 11:39 a.m., indicated the resident did not have a new pressure ulcer to the left inner ankle. It was a Stage I and measured 0.1 x 0.2 x 0.1 cm. The stage/depth was a #1. IDT weekly review of wound to left outer ankle. Wound continues to be intact at this time. Pillow still applied to provide cushion A document titled Weekly Pressure Ulcer .Report dated 7/1/16 at 10:59 a.m., indicated this pressure ulcer to the left inner ankle was not a new. The stage was a Stage I and measured 0.2 x 0.2 x 0.1 cm. The stage/depth was a #1. IDT weekly review of wound to left inner ankle. Wound continues to remain closed A document titled Weekly Pressure Ulcer .Report dated 7/8/16 at 10:11 a.m., indicated the pressure ulcer to the left inner ankle was not a new. The stage was a Stage II and measured 0.8 x 0.7 x 0 cm. The stage had not changed since the last evaluation. The stage/depth was #2, which was Partial thickness skin loss involving epidermis &/or dermis. The necrotic tissue type was a #4, which was Adherent soft, black eschar. and the amount was a #3, which was 25% to 50% of wound covered. IDT weekly review of wound to left inner ankle. This area has gotten bigger over the last week. NP is aware, and new intervention will obtained. Wound has Eschar covering, will recommend Santyl. Also addition of padded boots to relieve pressure to these areas A document titled Weekly Pressure Ulcer .Report dated 7/15/16 at 11:44 a.m., indicated the pressure ulcer to the left inner ankle was not a new. The stage was a Stage II and measured 1.0 x 0.8 x 0.1 cm. The stage has not changed since the last evaluation. The stage/depth was a #2. There was no necrotic tissue visible. IDT weekly review of wound to left inner ankle. Santyl use for previous week has appropriately debrided wound bed, and wound now presents with good viable underlying tissue No prevention interventions were found documented in the resident's record prior to the development of this pressure ulcer on 6/17/16. No other pressure ulcer wound assessments were found in the resident's record after 7/15/16, of this pressure ulcer and she discharged on [DATE]. d. A document titled Weekly Pressure Ulcer .Report dated 7/15/16 at 11:48 a.m indicated the pressure ulcer was newly acquired to the right inferior foot and was a Stage II and measured 0.4 x 0.3 x 0.1 cm. The date of the initial pressure ulcer observation was 7/14/16. The stage/depth was a #2, which was Partial thickness skin loss involving epidermis &/or dermis. Granulation tissue was #2, which was Skin intact or partial thickness wound. Epithelization was #1, which was 100% wound covered, surface intact. IDT review of new wound to right inferior foot. Wound is on pad of foot proximal to the great toe. This is a very small open area with no drainage at this time. NP made aware and order obtained to place bordered foam on wound No other pressure ulcer wound assessments were found in the resident's record after 7/15/16, of this pressure ulcer and she discharged on [DATE]. e. A document titled Weekly Pressure Ulcer .Report dated 7/15/16 at 11:52 a.m., indicated there was a newly acquired pressure ulcer to the left outer ankle, which measured 0.3 x 0.1 x 0 cm and was a Stage II. The date of the initial observation of the pressure ulcer was 7/14/16. The stage/depth was #1, which was Non-blanchable [DIAGNOSES REDACTED] &/or intact skin. IDT review of new wound to left outer ankle. This is a very superficial area No other pressure ulcer wound assessments were found in the resident's record after 7/15/16, of this pressure ulcer and she discharged on [DATE]. During an interview on 12/14/16 at 2:15 p.m., the Executive Director indicated RN #12 was the unit manager and the wound nurse and he was employed at the facility from April 20, 2015 to August 11, 2016. She indicated he would have been the person who assessed and measured Resident C's wounds during the time frame she was admitted to the facility. During an interview on 12/14/16 at 3:24 p.m., RN #12 indicated Resident C had the sacrum wound and the ankle wounds while he was employed at the facility. She had a surgery performed to remove the Sacral ulcer and repair the area with a flap. She was admitted with the Sacrum pressure ulcer and she was very particular about how she laid because of the wound on her sacrum. She would only lay the way she wanted to lay to keep pressure off the sacrum wound. He indicated Resident C preferred to lay with her legs close together and her ankles crossed over each other. Initially there was nothing between the ankles to relieve the pressure when they were crossed. He indicated she probably acquired the pressure ulcers on her ankles due to a lack of padding between her ankles until the staff found the wounds, then pillows were used to pad between her ankles to relieve the pressure. He indicated there was a black eschar over the right ankle pressure ulcer when it was found and he could not see the wound bed. He indicated he was not a wound specialist and everything he learned about wounds he learned on his own by attending seminars. He indicated there should have been wound assessment documentation up until the resident was released of all her pressure ulcers, so if the assessments were not in the computer, then he did not know what happened to his measurements. The American Medical Director Association 2008 pressure ulcer definition indicated: .Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough at be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV: Full thicknes loss with exposed bone, tendon, or muscle. Slough or eschar may be present or some parts of the ulcer bed. Often includes undermining and tunneling A current policy titled NCD (Nursing Center Division) Prevention and treatment of [REDACTED]. Procedure: 1 .c. Pressure ulcer and other wound and skin related interventions are created in collaboration with the interdisciplinary team and implemented in order to identify, prevent or reduce the risk of acquiring pressure and/or non-pressure related wounds or skin issues: 2. treatment of [REDACTED]. This Federal tag relates to Complaint IN 529. 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview and record review, the facility failed to follow physician's order regarding monitoring a resident following a non-responsive episode and providing IV fluid therapy after a non-responsive episode for 1 of 7 residents reviewed for following physician's orders in a sample of 9. (Resident F) This deficient practice resulted in immediate jeopardy. The immediate Jeopardy began on [DATE] when the facility failed to follow physician orders to assess and monitor vital signs of for Resident F after the resident became non-responsive and failed to ensure intravenous fluids were provided timely. The resident's condition deteriorated resulting in the need for CPR and transfer to the hospital. The Administrator and Director of Nursing were notified on [DATE] at 11:15 a.m. The immediate jeopardy was removed on [DATE], but non compliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings Include: 1.) Resident F's closed clinical record was reviewed [DATE] at 2:45 p.m. Resident F's [DIAGNOSES REDACTED]. Resident F had an order for [REDACTED]. Resident F had an [DATE], 2:00 p.m., "Resident Progress Note" late entry for 12:00 p.m. (noon) which indicated the Resident had been up in his wheelchair and had become unresponsive to voice and touch. His pupils were dilated and sluggish. His vital signs were: temperature 98.6, blood pressure ,[DATE], heart rate 90, irregular pulse-weak, respirations ,[DATE], lungs course rattle noted when laid flat. Nonbreather (facial mask means to administer oxygen) on at 10 liters for 10 minutes to increase oxygen saturation. Oxygen saturation at 91%. Resident F had an [DATE], 12:45 p.m., "SBAR-(a tool used by nursing to notify physicians of resident condition change) Physician/NP/PA Communication and Progress Note For New Symptoms, Signs, and Other Changes in Condition" which indicated the following: "Recommended IV fluids Monitor vital signs and observe Change in current orders hold BP (blood pressure) medications Resident F had a [DATE], Physician's order for: 1.) ,[DATE] normal saline at 50 ccs an hour for 12 hours of intravenous therapy. 2.) Hold blood pressure medication for 24 hours 3.) Nonrebreather oxygen administration, keep saturations greater than 90%. These orders were consistent with the 12:45 p.m., SBAR-physician notification notes. Following the [DATE], 12:00 p.m. note, the clinical record lacked any documentation of monitoring vital signs up to and including his 6:25 p.m. discharge via 911. An [DATE], 6:10 p.m., Resident Progress Note indicated the CNA (certified nursing assistant) called the writer to the room concerning the inability to obtain blood pressure. The oxygen saturation level was ,[DATE]%. The resident was cold to the touch. The nurse was unable to obtain a pulse. Pulse oxymeter had pulse of 32. Respirations were 6 per minute. Doctor's office notified and an order was given to send the resident out to the hospital. When the nurse returned to the room, the resident had no pulse and not respirations CPR (cardio- [MEDICAL CONDITION] resuscitation) was started and 911 called. An [DATE], 6:25 p.m., Resident Progress Note indicated EMTs arrived and took over CPR. During a [DATE], 8:15 a.m. interview, the Director of Nursing indicated Resident F died on [DATE]. On [DATE] at 8:10 a.m., the Director of Nursing and Administrator provided one set of vital signs from the Nursing 24 hour report sheet, which was identified as not being a part of the clinical record. The vital signs lacked a time taken and indicated only [DATE] evening. The vital signs were as follows: Blood pressure ,[DATE], heart rate 84, respirations 22, temperature 98.4, oxygen saturation ,[DATE]%. This information was not signed. During a [DATE] at 8:10 a.m. interview, The Director of Nursing indicated the facility did not have any additional documentation regarding the monitoring of Resident F's [DATE] condition during the period of time from 12:00 p.m. to 6:25 p.m. She indicated the SBAR-physician notification tool was not a part of the resident's clinical record but could be added if chosen to be. She indicated she believed the resident had been assessed during this period, but had no means to identify if the resident remained the same or his condition deteriorated during the time. The immediate jeopardy that began on [DATE] was removed on [DATE] at 2:30 p.m., when the facility a.) evaluated all residents for the need for services following a significant change of condition. b.) educated all licensed nursing personal regarding the assessment of residents with a significant change of condition, the provision of monitoring of residents with changes in condition and following physician's orders c.) educated all Certified Nursing Aides regarding the notification of the charge nurse regarding the change of condition of any resident, but the noncompliance remained at the lower scope and severity level of isolated potential for more than minimal harm that is not immediate jeopardy because sufficient time had not elapsed to allow the facility to monitor their quality assurance for monitoring residents with a significant change of condition and following physician's orders following a significant change in condition. This Federal tag related to complaint number IN 116. 3XXX,[DATE](g)(2)

Based on interview and record review, the facility failed to ensure a resident who required IV fluids and ongoing monitoring of vital signs and condition received said services in order to determine the resident's need for altered care and services including emergency services in order to prevent further decline for 1 of 7 residents reviewed for quality of care in a sample of 7. (Resident F) This deficient practice resulted in immediate jeopardy. This deficient practice resulted in Resident F's death. The immediate Jeopardy began on [DATE] when the facility failed to thoroughly assess and monitor vital signs of Resident F after the resident became non-responsive and failed to ensure intravenous fluids were provided timely. The resident's condition deteriorated resulting in the need for CPR and transfer to the hospital. The Administrator and Director of Nursing were notified on [DATE] at 11:15 a.m. The immediate jeopardy was removed on [DATE], but non compliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings Include: 1.) Resident F's closed clinical record was reviewed [DATE] at 2:45 p.m. Resident F's [DIAGNOSES REDACTED]. Resident F had an order for [REDACTED]. Resident F had an [DATE], 2:00 p.m., "Resident Progress Note" late entry for 12:00 p.m. (noon) which indicated the Resident had been up in his wheelchair and had become unresponsive to voice and touch. His pupils were dilated and sluggish. His vital signs were: temperature 98.6, blood pressure ,[DATE], heart rate 90, irregular pulse-weak, respirations ,[DATE], lungs course rattle noted when laid flat. Nonbreather (facial mask means to administer oxygen) on at 10 liters for 10 minutes to increase oxygen saturation. Oxygen saturation at 91%. Resident F had an [DATE], 12:45 p.m., "SBAR-(a tool used by nursing to notify physicians of resident condition change) Physician/NP/PA Communication and Progress Note For New Symptoms, Signs, and Other Changes in Condition" which indicated the following: "The symptoms/sign/change I'm calling about is (change) of condition, (change) in mental status This started 12 noon This has gotten worse... lethargic... Recommended IV fluids Monitor vital signs and observe Change in current orders hold BP (blood pressure) medications Reported to (name) NP (nurse practitioner). ... (no time listed) several attempts made @ IV access, (by facility staff) unsuccessful. Added to this same tool was a 3:00 p.m. note which indicated called (name) @ IV Access, (a interventions therapy service agency) arrival pending." Resident F had a [DATE], physician's orders [REDACTED]. 1.) ,[DATE] normal saline at 50 ccs an hour for 12 hours of intravenous therapy. 2.) Hold blood pressure medication for 24 hours 3.) Nonrebreather oxygen administration, keep saturations greater than 90%. These orders were consistent with the 12:45 p.m., SBAR-physician notification notes. Resident F's clinical record contained a total of five entries regarding the resident condition following the [DATE], 2:00 p.m. entry. The record lacked documentation of any complete vital signs assessment from 12:00 p.m. through and including 6:25 p.m., when the resident coded and was sent to the hospital via EMT. Resident progress notes were as follows. a.) [DATE], 4:00 p.m. (4 hours following onset of condition change) indicated "Res (Resident) lethargic, check O2 (oxygen) sat 90%. Unresponsive to voice, responsive to touch..." The entry lacked a complete thorough assessment of the resident's condition and lacked a vital signs assessment of the resident. The entry did not address the inability to provide IV therapy nor was there an assessment of the lack of IV fluids on the resident's condition. b.) [DATE], 5:30 p.m. (1 and ,[DATE] hours following the above entry) which indicated the resident continues to be lethargic and unresponsive to voice, the oxygen saturation was ,[DATE]% with oxygen being administered at 10 liters. The nurse had spoken to IV Access and a nurse was in route to insert a midline intravenous port. The entry lacked a complete and thorough assessment of the resident's condition, lacked a vital sign assessment of the resident and did not assess the resident's condition with the delay of IV fluid therapy. c.) [DATE], 6:10 p.m., (40 minutes following the above entry) indicated the CNA (certified nursing assistant) called the writer to the room concerning the inability to obtain blood pressure. The oxygen saturation level was ,[DATE]%. The resident was cold to the touch. The nurse was unable to obtain a pulse. Pulse oxymeter had pulse of 32. Respirations were 6 per minute. Doctor's office notified and an order was given to send the resident out to the hospital. When the nurse returned to the room, the resident had no pulse and not respirations CPR (cardio- [MEDICAL CONDITION] resuscitation) was started and 911 called. d.) [DATE], 6:20 p.m. (4 hours and 20 minutes after the 2:00 p.m. proceeding entry).-This entry was made by the nurse who came to place the IV midline for hydration therapy. "...Resident's condition deteriorated after being placed in bed. Nurse talked (with) dtr (daughter) resident to be sent out." e.) [DATE], 6:25 p.m., EMTs arrived and took over CPR. During a [DATE], 8:15 a.m., interview the Director of Nursing indicated Resident F died on [DATE]. On [DATE] at 8:10 a.m., the Director of Nursing and Administrator provides one set of vital signs from the Nursing 24 hour report sheet, which was identified as not being a part of the clinical record. The vital signs lacked a time taken and indicated only [DATE] evening. The vital signs were as follows: Blood pressure ,[DATE], heart rate 84, respirations 22, temperature 98.4, oxygen saturation ,[DATE]%. This information was not signed. During interview on [DATE] at 11:45 a.m., Unit Manager #2 indicated evening nursing shift was 2:30 p.m. to 11:00 p.m. During interview on [DATE] at 8:10 a.m., The Director of Nursing indicated the facility did not have any additional documentation regarding the monitoring of Resident F's [DATE] condition during the period of time from 12:00 p.m. to 6:25 p.m. She indicated the SBAR-physician notification tool was not a part of the resident's clinical record but could be added if chosen to be. She indicated she believed the resident had been assessed during this period, but had no means to identify if the resident remained the same or his condition deteriorated during the time. The immediate jeopardy that began on [DATE] was removed on [DATE] at 2:30 p.m., when the facility a.) evaluated all residents for the need for services following a significant change of condition. b.) educated all licensed nursing personal regarding the assessment of residents with a significant change of condition, the provision of monitoring of residents with changes in condition and following physician's orders [REDACTED]. and following physician's orders [REDACTED]. This Federal tag related to complaint number IN 116. 3XXX,[DATE](a)

Based on interview and record review, the facility failed to ensure a resident was not involuntarily transferred from the facility without 30 days notice and documentation to support the reason for transfer for 1 of 3 residents reviewed for notice prior to discharge in a sample of 9. (Resident E) This practice resulted in Resident E being discharged from the facility without a place to reside. Findings Include: Resident E's closed record was reviewed on 2/1/12 at 1:30 p.m. Resident E's [DIAGNOSES REDACTED]. Resident E had an 11/30/11, 1:50 p.m., "Resident Progress Note" which indicated "Smoking paraphernalia found on resident's possession in room which was tobacco, cigarette roller which violated agreement (with) facility and has been given ordered immediate discharge from facility (home based hospice name) Hospice notified and resident and wife notified of order also." Resident E had an 11/30/11 Physician's Telephone order for "Discharge from facility." The order contained no discharge location. Resident E had an 11/30/11"Notice Of Transfer Or Discharge" which indicated "Resident is being transferred to: Other (Please specify) Custody of Hospice (hospice name). ...The safety of the individuals in the facility is endangered." Resident E record had a 10/5/11, "Smoking Policy" which indicated "Any resident who violates this policy will be given a discharge notice and be discharged from the facility." Resident E's record lacked: a.) A 30 day discharge notice b.) Documentation of Resident E having any source of fire or flame on his person or on facility grounds. c.) Documentation of Resident E smoking on facility premises anytime after 10/13/11. d.) A discharge location which provided a residence/housing. Review of a 10/13/11, facility "Resident/Family Education Record", which was provided by the Administrator on 2/2/12 at 9:00 a.m., indicated "Resident found smoking in res (resident's) bathroom. Res immed (immediately) put out cig (cigarette)...Res O2 ( oxygen) was not on during discussion." Resident E had an 11/30/11, 3:00 p.m., Resident Progress Note which indicated the resident and his wife left the facility without notifying staff and the home based hospice provider had called to say the resident had arrived. Review of an untitled, 10/13/11, facility document, which was provided by the Administrator on 2/2/12 at 9:00 a.m., indicated "Director informed resident he could leave facility with spouse to smoke, but make sure he signed himself or spouse signed him out." Review of a current, 4/28/10, facility policy title "Transfer & Discharge," which was provided by the Administrator on 2/1/12 at 3:25 p.m., indicated the following: "The resident is transferred or discharged on ly when: ...4. The health of individuals in the center would be endangered; ...The medical record must reflect the process by which the transfer/discharge was determined necessary due to safety reasons. ...The resident and, if known, the family member, surrogate or legal representative, are notified at least 30 days prior to the transfer, unless transfer is effected when: notified at least 30 days prior to the transfer, unless the transfer is effected when: a. The resident's continued stay would be an endangerment to the health or safety of others in the center, ...The written notice of transfer/discharge includes: ...Location to which the resident is transferred/discharged ." During a 2/1/12, 3:15 p.m. interview, the Social Services Director indicated Resident E was not given 30 days notice prior to discharge. Resident E was discharged immediately due to a violation of the smoking policy. She indicated possession of any smoking paraphernalia was a violation of the smoking policy. The resident had tobacco and a cigarette roller, but no flame or source of fire on the day of his 11/30/11 immediate discharge. She indicated the resident was discharged due to danger to self and others. She could not identify how the possession of smoking paraphernalia without a flame was danger. She indicated the resident had no documented episode of smoking or using a source of fire anywhere on the facility property anywhere after 10/13/11. The Social Service Director also indicated Resident E was discharged to a home based hospice service which was not a place of residence. The hospice provider had indicated hospice would work to find the resident a home. Hospice had placed Resident E in a shelter that same day. She indicated the resident's family could not provide a home for the resident because his wife was homeless. She indicated the resident and his wife had walked to the home based hospice office at the time of discharge. Additionally, the resident had walked to the hospice facility on other occasions. During a 2/1/12, 3:30 p.m., interview, the Director of Nursing indicated Resident E had not been given a 30 day notice due to his violation of the facility policy. She indicated the facility policy allowed the facility to discharge a resident immediately if a resident had smoking paraphernalia. She indicated Resident E did not have fire or flame of any kind and had not been smoking on the premises. The Director of Nursing also indicated Resident E was discharged to a home based hospice provider, which did not offer a place for the resident to reside. The hospice provider had found a place for the resident at a shelter. She indicated she had been involved in the decision to immediately discharge Resident E from the facility due to a violation of the facility's smoking policy. She indicated she believed the facility had the right to discharge a resident immediately if they violated smoking policy. She indicated she was aware the resident did not have a place to live at the time of discharge, but knew hospice would work with him to find a place to live. This Federal tag related to complaint number IN 116. 3.1-12(a)(3) 3.1-12(a)(4)(A) 3.1-12(a)(4)(C) 3.1-12(a)(4)(D) 3.1-12(a)(7) 3.1-12(a)(8)(A) 3.1-12(a)(8)(B)