Every finding on record at Life Care Center of Lagrange

Based on observation, interview and record review, the facility failed to ensure staff followed a resident's care plan intervention requiring 2 staff for bed mobility. The resident fell from bed resulting in multiple fractures, severe pain, and hospitalization for 1 of 3 residents reviewed for accidents (Resident B). The deficient practice was corrected on 7/16/26, prior to the start of the survey, and was therefore Past Noncompliance. Findings include:Resident B's record was reviewed on 8/6/26 at 11:43 A.M. Diagnoses included morbid obesity, diabetes, osteopenia of the left foot (but no other bones were documented to have been involved) and obstructive sleep apnea. The diagnoses did not include osteoporosis. An annual Minimum Data Set (MDS) assessment, dated 4/17/26, indicated Resident B had no cognitive impairment. He was dependent on 2 staff for bathing, toileting hygiene, lower body dressing, and bed mobility. The MDS indicated the resident had no falls in the prior 3 months.A care plan, reviewed and updated on 4/30/26, indicated Resident B had a bariatric bed, preferred to stay in bed rather than get up into his chair, required extensive to dependent assistance of 2 staff (initiated 7/7/2022) for turning, repositioning with wedge pillow to his left side, and incontinence care provided while in bed. The resident preferred to have his bed height elevated so he could see out of his window. A CNA task list, dated 7/6/26, indicated Resident B required 2 assist with bed mobility and positioning.A progress note, dated 7/12/26 at 10:00 a.m., indicated Resident B fell out of the right side of his bed and onto the floor of his room. A head-to-toe assessment was completed and neuro checks initiated. The physician was notified and orders given to send to the ER for evaluation and treatment. A hospital note, dated 7/12/26, indicated the resident was seen for injuries due to fall from bed. He had severe pain, a laceration to his right great toe requiring sutures, bruise to the right hand, and laceration to his left lower lip. X-rays were obtained and showed acute comminuted (bone is shattered into more than 3 pieces) to both right and left femurs, and a displaced (the broken ends of the bone are out for the normal straight line) fracture of the right tibial bone (1 of 2 bones in calf). He was unable to have the fractures surgically repaired due to obesity and severe sleep apnea. A statement, provided by the Administrator on 8/6/26 at 11:05 A.M., indicated on 7/12/26, Certified Nurse Aid (CNA) 3 had been providing incontinent care to Resident B. She helped him roll on his side toward the door first, provided incontinent care, and then assisted him to roll over on the other side facing the window, as she pulled the soiled linens out from beneath him. CNA 3 indicated she thought the resident was falling asleep and his legs slipped forward off the bed. She was on the other side of the bed and couldn't keep him from sliding off. He rolled off the bed, landing on his belly. The CNA yelled for help and went to the other side of the bed where the resident lay on his stomach with his neck stretched up and face resting on the drawer of his bedside stand. During an interview with the Administrator, on 8/6/26 at 11:30 A.M., she indicated following a thorough investigation, it was determined CNA 3 had not followed the care plan and provided care by herself, which resulted in the resident rolling off the bed and sustaining injuries. Resident B's care plan, and Kardex (computer and paper forms which tell staff care needs of a resident) communicated to staff, indicated the resident required 2 staff members to safely provide care to the resident while in bed. The Administrator indicated CNA 3 indicated she had known what the care plan and Kardex were and how to access them but hadn't used them. She believed the resident required only 1 staff member for bed mobility and was how staff routinely provided his care. The Administrator indicated Registered Nurse (RN) 7 was the nurse in charge when the incident occurred. She indicated RN 7 thought Resident B required only 1 staff member to assist with bed mobility and incontinence care. RN 7 indicated to the Administrator it was the way staff always provided care to the resident. The Administrator indicated Resident B had been admitted to a different facility (Facility 2) on his release from the hospital. During an observation on 8/6/26 at 4:22PM at Facility 2, Resident B was observed in a bariatric bed with a wedge pillow. He was noted to have bruising on his face and right arm.A fall risk admission assessment, completed by Facility 2 indicated Resident B was a fall risk. Interventions were to include 2 assist with bed mobility and repositioning and a wedge pillow as the resident would allow. In an interview on 8/6/26 at 4:22 PM at Facility 2, Resident B indicated he did not remember the fall. He was very somnolescent and fell asleep frequently during conversation. On 8/6/26 at 3:09 P.M., CNA 3 was interviewed. She indicated Resident B only required 1 person to assist him in rolling in bed. Staff provided only 1 person to assist him with bed mobility. When asked, she couldn't recall if the Kardex had indicated Resident B required 2 assist with bed mobility. She indicated the only time 2 staff members were required was when he was transferred out of bed with the Hoyer lift. RN 7 was no longer employed at the facility and was unavailable for interview.A current facility policy, titled Comprehensive Care Plans, was provided by the Administrator on 8/6/26 at 4:48 P.M. The policy indicated a comprehensive person-centered care plan was to be developed and implemented for each resident, based on resident rights, and comprehensive assessments. The care plan was to be consistently implemented across all shifts. The past noncompliance began on 7/12/26 when staff failed to implement fall interventions for Resident B resulting in fall with injury. The deficit practice was corrected on 7/16/26 when the facility reviewed and updated all resident's bed mobility status, care plans, and Kardex. All staff were re-educated on fall prevention, care plans, Kardex access, and following the resident's proper plan of care. A performance improvement plan was put in place. The plan included monitoring and audits 3x/week for bed mobility/repositioning/incontinent care for 3 months followed by audits 2x/week for 3 months. Audits and findings would be reviewed each month during quality assurance meetings.This Citation relates to Intakes 3091212 and 3120794. 410 IAC (Indiana Administrative Code) 16.2-3.1-45(a)

Based on observation, interview, and record review the facility failed to ensure a resident's body was not exposed and visible to passersby for 2 of 8 residents reviewed (Resident 2, and Resident 8).Findings include:Findings include:1) In an observation, on 4/21/2026 at 8:53 AM, Licensed Practical Nurse (LPN) 2 lifted Resident 2's shirt exposing her abdomen and administered an injectable medication. Resident 2 was seated in a wheelchair in her room in full view from the hallway. The door to Resident 2's room was wide open. 2 unidentified residents were observed passing by the door glancing in the room during the time of preparation and administration. In an interview, on 4/21/2026 8:54 AM, LPN 2 indicated Resident 2's door should have been shut while Resident 2's abdomen was exposed for an injected medication.Resident 2's record was reviewed on 04/21/2026 at 11:35 AM. Diagnoses included Type 2 diabetes mellitus with diabetic neuropathy, major depressive disorder and social phobia.A current significant change Minimum Data Set (MDS) assessment, dated 3/17/2026, indicated Resident 2 had a Brief Interview for Mental Status (BIMS) score of 12 (mild cognitive impairment).Physician orders, dated 1/30/2026, indicated Resident 2 should have Mounjaro 7.5 mg/0.5 ml injected weekly for type 2 diabetes mellitus with diabetic neuropathy.In an interview, on 04/21/2026 2:06 PM, The Assistant Director of Nursing (ADON) indicated a privacy curtain should be pulled or a door should be closed when an injectable medication was administered abdominally to provide privacy.A current policy, titled General Dose Preparation and Administration, dated 11/15/2024, provided by the Administrator on 4/21/2026 at 1:20 PM, indicated privacy rights should be observed during medication administration including using privacy curtains to avoid exposure.2) In an observation, on 4/20/2026 at 9:57 AM, Resident 8 was observed from the hallway, lying in bed. Resident 8 had no clothing on, with his upper body naked and exposed. Resident 8's room door was open, and the privacy curtain was not pulled to block the view from the hallway.In an observation, on 04/20/2026 at 1:43 PM, Resident 8 was observed from the hallway, lying in bed wearing a blue tee shirt and no pants with his lower body loosely covered with a sheet.In an observation, on 04/21/2026 at 9:01 AM, Resident 8 was observed from the hallway, unclothed, with a sheet covering from the waist down.Resident 8's record was reviewed on 4/20/26 at 11:03 PM. Diagnoses included athetoid cerebral palsy, torticollis, spastic quadriplegic cerebral palsy, unidentified intellectual abilities and aphasia.A current quarterly Minimum Data Set (MDS) assessment, dated 2/24/2026, indicated Resident 8 was rarely or never understood with severely impaired decision-making skills. A current care plan, titled ADL (Activity of Daily Living) self-care performance deficit, indicated Resident 8 had a problem of dependance on staff for ADL performance with a goal date of 6/10/2026. The care plan indicated Resident 8 was totally dependent for dressing tasks.In an interview, on 4/21/2026 2:03 PM, the Assistant Director of Nursing (ADON) indicated she did not know why Resident 8 was not wearing any clothing in bed.In an interview, on 4/22/2026 11:51 AM, the ADON indicated staff told her Resident 8 never wore clothing because family had not provided any.In an interview, on 4/22/2026 12:26 PM, the Administrator indicated Resident 8 had not worn a gown since admission, but she could not locate any notes indicating why. She indicated her staff could not recall any specific instructions on what Resident 8 should wear. A current policy, titled Resident Rights, dated 9/26/2025, provided by the Administrator, on 4/22/2026 at 2:51 PM, indicated care should be provided in a manner to promote resident dignity.410 IAC (Indiana Administrative Code) 16.2-3.1-3(a)

Based on observation, interview, and record review the facility failed to ensure a Self-Administration of Medication assessment was completed for medication left at the bedside for 1 of 7 residents reviewed. (Resident 5) Findings include: During an observation, on 4/22/2026 at 11:04, LPN 2 placed a cup with one 500 mg acetaminophen tablet and a cup of water in front of Resident 5. LPN 2 left the room and did not maintain visual observation when Resident 5 consumed the acetaminophen tablet.A record review for Resident 5 began on 4/23/2026 at 1:19 PM. Diagnoses included gout, pain in both legs, depression, post-traumatic stress disorder, and dysphagia (difficulty swallowing).A review of Resident 5's current quarterly MDS, dated [DATE], indicated their BIMS (Basic Interview for Mental Status) score was 15 (cognitively intact).A review of physician orders, dated 2/1/26 at 11:13 PM, indicated one 500 mg acetaminophen tablet was scheduled to be administered three times a day for pain. The order did not indicate Resident 5 was able to self-administer the medication.A review of clinical assessments, dated 1/1/25-4/24/26, indicated a Resident Medication Self-Administration Assessment had not been completed for Resident 5.In an interview, on 4/22/2026 at 11:40 AM, the Director of Nursing indicated staff were to watch the administration of medication for each resident. Residents may administer their own medication when a Self-Administration Assessment had been completed and was determined to be appropriate for an individual resident, or when an order was in place for a resident to self-administer a specific medication.A current policy, dated 12/1/07, provided by the Director of Nursing, indicated staff administering medication were to observe the resident's consumption of the medication.410 IAC (Indiana Administrative Code 3.1-11(a)

Based on interview and record review, the facility failed to ensure bed hold policy notification was provided to resident emergency contacts for 2 of 3 residents reviewed (Resident 5 and Resident 57).Findings include: Resident 5's record was reviewed on 4/23/26 at 9:45 AM. Diagnoses included chronic kidney disease, diabetes and seizure disorder.Resident 5's quarterly Minimum Data Set, (MDS) dated [DATE], indicated their Brief Interview for Mental Status (BIMS) score was 15 (no cognitive deficit).A progress note, dated 1/23/26 at 6:30 PM, indicated a physician had ordered Resident 5 to be transferred to the hospital for evaluation. The progress note indicated Resident 5 was not responding.An Indiana Bed Hold Notification, signed and dated by Resident 5 on 1/23/26, indicated the resident did not request their bed to be held during their absence.In an interview, on 4/23/26 at 10:11 AM, the Administrator indicated Resident 5 was the responsible party for themselves. The Administrator indicated Resident 5's sister was their durable power of attorney. The Administrator indicated Resident 5's sister was their emergency contact.In an interview, on 4/23/26 at 11:30 AM, the Administrator indicated Resident 5's sister should have been contacted if the resident was not responding.2. Resident 57's record was reviewed on 4/23/26 at 10:10 AM. Diagnoses included atrial fibrillation, (irregular heartbeat) lumbar fracture, lumbar spine wound dehiscence, (split open) and malnutrition.Resident 57's discharge Minimum Data Set (MDS), dated [DATE], indicated their Brief Interview for Mental Status (BIMS) score was 5 (severe cognitive impairment).Resident 57's care plan, dated 3/2/26, indicated the resident had severe cognitive impairment.A progress note, dated 3/3/26 at 1:52 PM, indicated Resident 57 had been transferred to the hospital. The progress note indicated the bed hold policy was sent with the Emergency Medical Technician. The progress note indicated Resident 57's emergency contact had been made aware of the hospital transfer. The progress note did not indicate Resident 57's emergency contact had been made aware of the facility's bed hold policy.A Transfer Form, dated 3/3/26, indicated Resident 57's emergency contact had been made aware of the resident's transfer to the hospital. The transfer form did not indicate the emergency contact had been made aware of the bed hold policy.An Indiana Bed Hold Notification, signed and dated by Resident 57 on 3/33/26, indicated the resident did not request their bed to be held during their absence.In an interview, on 4/23/26 at 11:30 AM, the Administrator indicated Resident 57 was cognitively impaired. The Administrator indicated Resident 57's emergency contact should have been notified of the bed hold policy.No facility policy was available for review at the time of exit from the facility.

Based on observation, interview and record review, the facility failed to ensure a resident received oral hygiene for 1 of 5 residents reviewed (Resident 10). Findings include: On 3/5/25 at 10:30 AM, Resident 10 was observed from the hallway lying in bed. Resident 10 was lying on their right side facing the open door. Resident 10's mouth was open with their tongue protruding. Resident 10's record was reviewed on 3/7/25 at 9:08 AM. Diagnoses included cerebral palsy, curvature of the spine and curvature of the neck. Resident 10's Quarterly Minimum Data Set (MDS) dated [DATE],Brief Interview for Mental Status (BIMS) assessment indicated Resident 10's cognition was severely impaired. The MDS indicated Resident 10 was entirely dependent on the staff for all aspects of care. Resident 10's Care Plan, dated 12/14/23, indicated the resident was totally dependent on staff for oral care. On 3/6/25 at 10:04 AM, Resident 10 was observed lying in bed. The resident's mouth was open, their tongue was protruded. On 3/7/25 at 1:33 PM. Resident 10 was observed lying in bed. The resident's mouth was open, their tongue was protruded. The resident's lips were dry with white caking. Resident 10's tongue was protruding and covered with a dry, white colored coating. In an interview, on 3/7/25 at 1:51 PM, Registered Nurse (RN) 25 indicated Resident 10's lips and tongue were extremely dry. RN 25 indicated Resident 10 should receive oral care every 2 hours. A current facility policy, titled Oral Care provided by the Administrator on 3/11/25 at 9:30 AM, indicated dependent residents should be provided with oral care every 2 to 4 hours. 3.1-38(a)(3)

Based on observation, interview and record review, the facility failed to ensure maintenance of a tube feeding for 1 of 1 resident reviewed (Resident 10). Findings include: On 3/5/25 at 10:30 AM, Resident 10 was observed lying in bed. A tube feeding pump was observed in Resident 10's room. Resident 10's record was reviewed on 3/7/25 at 9:08 AM. Diagnoses included cerebral palsy, curvature of the spine and curvature of the neck. Resident 10's Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident 10's Brief Interview for Mental Status (BIMS) assessment indicated the resident was severely impaired. The MDS indicated Resident 10 was entirely dependent on the staff for all aspects of care. Resident 10's Care Plan, dated 1/3/24, indicated the resident required tube feeding and was to have nothing by mouth. On 3/7/25 at 1:33 PM, Resident 10 was observed lying in bed. Resident 10's tube feeding pump was running. The tube feeding formula container was dated 3/5/25 at 9:00 PM. The tube feeding water container was dated 3/5/25 at 9:00 PM. In an interview, on 3/7/25 at 1:51 PM, Registered Nurse (RN) 25 indicated Resident 10's tube feeding bags were dated 3/5/25 at 9:00 PM. RN 25 indicated tube feeding supplies were supposed to be changed daily and labeled with the date and time. A current facility policy, titled Enteral Nutrition Therapy, dated 9/20/24, provided by the Administrator on 3/10/25 at 9:00 AM, indicated the tube feeding sets should be replaced every 24 hours. 3.1-44(a)(1) 3.1-44(a)(2)

Based on interview and record review, the facility failed to ensure freedom from unnecessary medications for 1 of 3 residents reviewed (Resident 17). Findings include: Resident 17's record was reviewed on 3/7/25 at 10:16 AM. Diagnoses included diabetes, chronic kidney disease, Parkinson's and coronary artery disease. Resident 17's Quarterly Minimum Data Set, (MDS) dated [DATE], indicated the resident's Brief Interview for Mental Status (BIMS) was 14 (no cognitive loss). The MDS indicated Resident 17 required an indwelling urinary drainage catheter. A physician order, dated 6/12/24, indicated resident 17 was to be administered an antibiotic injection every day for 3 days for a UTI. A progress note, dated 6/20/24 at 11:36, indicated Resident 17 had completed antibiotics for an unknown infection. The note indicated a medication error had been made by the prescriber. The note indicated the resident did not have a urinalysis to support the diagnosis of a urinary tract infection (UTI). Resident 17's Medication Administration Record, (MAR) dated June 2024, indicated the resident had been administered an antibiotic injection for UTI on 6/11/24, 6/12/24 and 6/13/24. In an interview, on 3/11/25 at 9:20 AM, the Administrator indicated they had not been aware of Resident 17 receiving an antibiotic without infection. A current facility policy, titled Medication Related Errors, dated 5/1/10, provided by the Administrator on 3/11/25 at 9:45 AM, indicated in the event of a medication prescribing error, the facility staff should follow incident policy, associated forms and performance improvement processes. 3.1-48(a)(1)-(6)

Based on observation, interview, and record review the facility failed to ensure a sanitary environment free of hazards on 4 of 4 halls where residents resided or received services. Findings include: During an observation on 3/24/24 at 10:15 AM. handrails on the 200, 300, 400, and 500 halls were observed to have bare portions missing finish. Baseboards were missing throughout the 100, 200, 300, 400, and 500 halls. Drywall on portions of the walls on each hall below the handrails had grey linear marks scattered throughout in too many locations to count. The bottom of the drywall had chipped, jagged edges observed on all halls. In an observation and interview on 3/27/24 at 9:45 AM the Maintenance Director indicated repairs had been delayed due to problems with the company contracted to install flooring throughout the building. A raised buckle in the vinyl plank flooring was observed on the 100 hall near the door to the maintenance office. The Maintenance Director indicated the flooring installers did not install the flooring correctly resulting in the raised area in the floor. He indicated he had contacted the flooring company requesting repair of this area and others throughout the building. He indicated he was not aware of any current plans for contractors to fix the flooring problems. He indicated the lower portions of the walls were to be painted, then baseboards applied, and handrails refinished after the flooring was laid. He indicated the flooring was completed about three months ago. During an observation and interview on 3/27/24 at 10:35 AM, a buckle in the flooring was observed in front of the door to room [ROOM NUMBER]. Buckled areas were also identified outside rooms 210, 308, 310, 311, 312, 314, 401, and 410. Qualified Medicine Aide (QMA) 2 indicated he noticed raised areas in the flooring throughout the halls and the flooring had not been installed properly. During an interview on 3/27/24 at 10:58 AM, the Executive Director (ED) indicated he began work for the facility in December 2023 and the flooring was complete at that time. He indicated he was not aware of any plans for repairs of the floor. He indicated the painting was in progress and he had not been aware of handrail concerns. A current policy titled Plant Operations last reviewed 7/12/23 provided by the ED on 3/27/24 at 11:12 AM indicated the facility should maintain a safe, clean, and structurally sound environment. 3.1-19(4)(f)

Based on interview and record review the facility failed to ensure quality improvement plans were developed for identified recurrent environmental concerns. 41 residents resided in the facility. Findings include: The facility annual survey completed on 6/7/23 identified concern regarding repair and maintenance of facility floors, walls, and handrails. The facility indicated the noncompliance would be corrected by 6/30/23. The repair and maintenance of facility floors, walls, and handrails was also found to be a concern on the annual survey completed 3/28/24. See F921 for additional information about current environmental findings. A QAPI (Quality Assurance Performance Improvement) committee list was provided by the ED on 3/25/24 at 12:39 PM. The member list included the Executive Director, Director of Nursing Services, Assistant Director of Nursing/Infection Preventionist, Rehab Director, Social Services, Business Office Manager, Admissions/Marketing, Dietary Manager, Activity Director, Medical Records, Maintenance Director, and Compliance Coordinator. In an interview on 3/28/24 at 10:25 AM, the Executive Director (ED) indicated segments of care including clinical services, dietary, maintenance, housekeeping and administration were reviewed in each monthly QAPI meeting. He indicated the meeting reviewed topics identified by staff observations discussed in daily morning meetings, resident and family reports of concerns, survey results, electronic medical record software generated reports and corporate quality measure reports. The environment was an ongoing topic in QAPI meetings. He indicated there was not a current performance improvement plan pertaining to the environment in place. A current policy dated 2024 provided by the ED on 3/25/24 at 12:39 PM indicated Maintenance should provide comprehensive building safety and repairs to ensure all aspects of safety and well-being for each resident, visitor, and associates. The policy indicated the QAPI committee was ultimately responsible for assuring compliance with federal and state regulations. 3.1-52

Based on observation, interview and record review the facility failed to ensure nurse staffing hours were posted for 3 of 4 days reviewed. Findings include: On 3/24/24 at 9:35 AM the facility nurse staffing hours were observed posted near the facility entrance. The nurse staffing hours form was a single sheet of paper dated 3/21/24. On 3/24/24 at 11:45 AM the posted facility nurse staffing hours were observed to be dated 3/21/24. On 3/24/24 at 1:10 PM the posted facility nurse staffing hours were observed to be dated 3/21/24. In an interview on 3/26/24 at 2:20 PM the Director of Nursing (DON) indicated they had been unaware of the nurse staffing hours posted on 3/24/24 was dated 3/21/24. The DON indicated nurse staffing hours should be posted daily. In an interview on 3/28/24 at 10:14 AM the Administrator indicated they were unaware nurse staffing hours had not been posted for 3 days on 3/24/24. The Administrator indicated nurse staffing hours should be posted daily. A current facility policy dated 4/24/19 provided by the Administrator on 3/27/24 at 9:15 AM indicated the facility must post the nurse staffing data every day at the beginning of each shift. No State Rule.

Based on observation, interview and record review, the facility failed to ensure the environment was maintined in 5 of 5 rooms reviewed. 5 residents resided in the 5 rooms affected (Resident 9, Resident 10, Resident 12, Resident 26 and Resident 38). Findings include: During an observation on 6/1/23 at 9:23 AM all handrails on the 300, 400, and 500 halls were observed to have bare portions missing finish. Carpeted walls on each of these halls had stains in one-to-six-inch strips. Floor carpeting was observed to have round brown, red and yellowish stains form quarter to dinner plate sized throughout all halls too many to count. A document titled Resident Room Check dated 5/31/23 received from the Administrator on 6/1/23 at 2:10 PM was reviewed. The document indicated rooms should be checked for wall and trim paint damage and floor tile damage. The document indicated rooms 305, 306, 308, 309 and 310 were checked and marked completed on time by the Maintenance Man on 5/31/23. room [ROOM NUMBER] was observed on 6/5/23 at 9:38 AM. A 2-inch section and a 3.5-inch section of chipped paint was observed on the corner of the wall adjacent to the bathroom. Floor tiles in the main walkway of the room contained a large crack across 3.5 tiles. Two residents reside in room [ROOM NUMBER]. In room [ROOM NUMBER], a 12-inch scratch was observed on the back side of the door. 6 floor tiles had large cracks across the entire length of each tile. No residents resided in room [ROOM NUMBER]. In room [ROOM NUMBER], 6-inch by 1-inch black [NAME] were observed near the bottom of the inside of the bathroom door. 6-inch by 2-inch black [NAME] were observed near the bottom of the closet door. No residents resided in room [ROOM NUMBER]. In room [ROOM NUMBER], a 6-foot section of the wall had grey markings, linear in all directions, too many to count. 6 inch by 0.25-inch black [NAME] were present on the bottom door panels. Rust colored discolorations the size of a pencil lead were present, too many to count throughout the molding on the closet doors. A 12-inch by 1-inch area of chipped paint was observed on the back of the entry door. 1 to 2-inch segments of chipped paint, too numerous to count, were observed on the lower third of the inside of the bathroom door. One resident resided in room [ROOM NUMBER]. In room [ROOM NUMBER], 6-inch linear markings were observed on the bottom of the closet door. Rust colored spots the size of a pencil lead were observed on the closet doors, too numerous to count. In an interview and observation conducted on 6/5/23 at 10:09 AM, the Administrator indicated the observations in rooms 305, 306, 308, 309, and 310 did not meet the facility's environmental standards. In an interview on 6/5/23 at 11:09 AM, the Maintenance Man indicated he was unable to get to everything on the room check list and prioritized the greatest needs. An invoice dated 11/9/22 from [NAME] Steemer for carpet cleaning services was received on 6/1/23 at 2:10 PM from the Administrator. No other invoices or carpet cleaning records were available for review at the time of exit. A current policy titled Plant Operations last reviewed 7/28/22 provided by the Administrator on 6/7/23 at 11:30 AM indicated the facility should maintain a safe, clean, and structurally sound environment. A current policy titled Carpet Shampooing last reviewed 7/28/22 provided by Administrator on 6/7/23 at 11:27 indicated all carpeted floors should be cleaned in a manner to ensure that carpets were free of obvious carpet spots and stains. 3.1-19(4)(f)

Based on interview and record review the facility failed to ensure a personalized plan of care was initiated related to post-traumatic stress disorder for 1 of 1 resident reviewed. (Resident 24) Findings include: In an interview on 6/2/23 at 11:42 AM, Resident 24 indicated she suffered from anxiety, panic attacks, and post-traumatic stress disorder. The resident indicated she had problems sleeping and at times was reluctant to voice her needs to the staff due to the fear of being a bother. Resident 24's record was reviewed on 6/5/23 at 9:45 AM. Diagnoses included major depressive disorder, post-traumatic stress disorder (PTSD) and night terrors. A review of Resident 24's current quarterly Minimum Data Set (MDS) assessment indicated their Basic Interview for Mental Status (BIMS) score was 14 (cognitively intact). The MDS indicated the resident had sleeping difficulties. A review of Resident 24's current Care Plan titled Behavior indicated the resident had a problem of feeling burdensome to the facility staff with a goal date of 7/7/23. Interventions included administer medications as ordered, verbal assurance, distraction, attempt to determine underlying cause, and positive praise. A review of Resident 24's current Care Plan titled Mood indicated the resident had a problem with depression and night terrors with a goal date of 7/7/23. Interventions included a psychiatric consult, gradual reduction of medications, verbal assurance, positive redirection, and encouragement of expression. A review of Resident 24's Trauma Informed Care (TIC) assessment dated [DATE] indicated the resident had personally experienced and witnessed multiple traumatic events. The TIC assessment indicated the resident had frequent, strong physical reactions to unwanted memories of the events. The TIC assessment indicated the resident had strong negative feelings of guilt and self-blame, and frequently had problems falling asleep or staying asleep. In an interview on 6/6/23 at 11:50 AM, the Administrator indicated Resident 24 had been speaking with a counselor related to PTSD. The Administrator indicated the Social Service Director (SSD) was responsible for mental health condition care, but there was currently no SSD for the facility. The Administrator indicated the facility was responsible to identify stressors related to the resident's night terrors and negative self-viewas well as symptoms of PTSD. The Administrator indicated the facility did not have a policy related to TIC or PTSD care. The American Psychiatric Association (APA, 2022) indicated patients diagnosed with PTSD may experience frequent intrusive thoughts, nightmares, sleep disturbances, and strong feelings of guilt, shame and unworthiness. Reference American Psychiatric Association. (2022). Trauma and Stressor Related disorders. In Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). https://www.psychiatry.org/patients-families/ptsd/what-is-ptsd

Based on observation, interview and record review, the facility failed to ensure wheelchair mobility was provided for 1 of 4 residents reviewed (Resident 3). Findings include: During an interview on 6/1/23 at 10:16 AM, Resident 3 indicated she stays in her bed most times because she has difficulty mobilizing her wheelchair. She indicated staff had not assisted her with her wheelchair concerns. During an observation on 6/2/23 at 11:43 AM Resident 3 was lying in bed. During an observation on 6/2/23 at 2:40 PM Resident 3 was lying in bed. During an observation and interview on 6/6/23 11:47 AM Resident 3 was lying in bed. Licensed Practical Nurse (LPN) 6 indicated Resident 3 was almost always in bed, and she did not know why. Certified Nurse Aide (CNA) 7 indicated Resident 3 only got up for showers and returned to bed. She did not know why Resident 3 did not get up in her wheelchair and move about the facility. LPN 6 and CNA 7 indicated they were assigned to care for Resident 3 on a frequent basis. During an interview on 6/6/23 at 11:53 AM the Minimum Data Set (MDS) Coordinator indicated any care refusals should be documented in the medical record. She also indicated frequent refusal of any specific area of care should be addressed in the care plan. Resident 3's record was reviewed on 6/5/23 at 2:56 PM. Diagnoses included diabetes mellitus without complications, essential hypertension, and polyneuropathy. A review of Resident 3's current MDS dated [DATE] included a Basic Interview for Mental Status (BIMS) score of 15 (cognitively intact). There was no indication of refusal behavior noted on the MDS. A review of Resident 3's current Care plan titled ADL (activities of daily living) indicated the resident had a problem with self-care deficit, with a goal date of 7/23/23. Interventions included using a high-back wheelchair for mobility and a hoyer lift for transfers. Refusal of care or preference to remain in bed was not addressed on the care plan. A review of progress notes between January 2023 and May 2023 did not indicate the staff had offered to get the resident up nor the resident refused to get up. A current policy titled Activities of Daily Living last reviewed 8/22/22 provided by the Administrator did not address assistance with wheelchair mobility. She indicated there were no other policies pertaining to wheelchair mobility. 3.1-3(v)(1)

Based on interview and record review the facility failed to ensure resident request for a shower schedule was honored for 1 of 4 residents reviewed. (Resident 24) Findings include: In an interview on 6/1/23 at 10:09 AM, Resident 24 indicated she was waiting to receive a shower. The resident indicated she had to miss an activity at 10:00 AM due to waiting on a shower. The resident indicated numerous requests had been made to receive showers early in the morning prior to activities being scheduled. The resident indicated the staff had promised to accommodate the request of 5:00 AM showers but showers continued to be offered during activities. Resident 24's record was reviewed on 6/5/23 at 9:45 AM. Diagnoses included seizure disorder, history of falling, lack of coordination, and muscle weakness. A review of Resident 24's current quarterly Minimum Data Set (MDS) assessment indicated their Basic Interview for Mental Status (BIMS) score was 14 (cognitively intact). The MDS indicated the resident required moderate staff assistance for bathing. A review of Resident 24's current Care Plan titled Activities of Daily Living (ADLs) indicated the resident was an early riser and preferred early morning showers. A review of Resident 24's quarterly preference questionnaire dated 5/18/23 indicated the resident preferred to wake at 5:00 AM and to receive early morning showers. The resident's shower documentation indicated the resident had received a shower on 5/15/23 at 1:59 PM, on 5/18/23 at 1:59 PM, on 5/22/23 at 11:25 AM A review of Resident 24's Activity Log dated May 2023 indicated the resident had declined an activity scheduled for 5/15/23 at 2:00 PM, on 5/18/23 at 2:00 PM, on 5/22/23 at 11:00 AM. A review of Resident 24's Activity Log dated June 2023 indicated the resident declined an activity scheduled for 6/1/23 at 10:00 AM. In an interview on 6/1/23 at 10:09 AM the resident indicated they were upset due having to miss an activity while waiting to have a shower. In an interview on 6/6/23 at 11:55 AM the Administrator indicated they were not aware of Resident 24 missing activities on scheduled shower days. The Administrator voiced understanding Resident 24's Activity Log contradicted the resident's interview and shower documentation. A current policy dated 10/2/22 provided by the Administrator on 6/7/23 at 11:28 AM indicated planned programming of activities would be coordinated with and communicated to all departments. The policy indicated the facility would support residents in their choice of activities. 3.1-3(u) (u)(1) (u)(2)

Based on record review and interview the facility failed to ensure code status was clearly indicated for 1 of 16 residents reviewed. (Resident 149). Findings include: Resident 149's record was reviewed on 6/1/23 at 3:49 PM. Diagnoses included lumbar vertebra osteomyelitis, infection of lumbar intervertebral disc (pyogenic), repeated falls, metabolic encephalopathy, altered mental status, unspecified severe protein-calorie malnutrition, and alcohol abuse. A review of Resident 149's current baseline care plan titled Advanced Directives indicated the resident was a Full Code (all resuscitation procedures including chest compressions, intubation, and defibrillation). A review of a physician order dated 5/22/23 indicated Resident 149 was a Full Code. A review of the Resident 149's current medical record indicated the resident was a Full Code. A form regarding code status was reviewed on 6/1/23 at 4:02 PM. the form included code status had been discussed with facility representative, family and the resident. Everyone was in agreement on the wishes indicated on the form. The form indicated Resident 149 was a Full Code with no intubation. The form was dated 5/22/23 by Resident 149's wife on his behalf. A current Indiana Default Surrogates hierarchy, undated, provided by the Regional Director of Clinical Operation, indicated who can make decisions for incapacitated individuals if there is no legally appointed representative. The hierarchy indicated the resident's spouse was able to sign the form. In an interview on 6/06/23 at 9:47 AM, the Assistant Director of Nursing indicated the code status discussed, signed by Resident 149's wife, the physician orders should be the same and they are not. In an interview on 6/07/23 at 9:48 AM, the Administrator indicated the code status discussed, signed by Resident 149's wife, the physician orders should be the same and they are not. A current policy titled Advance Directives and Advance Care Planning, dated 9/30/22, provided by the Administrator, indicated a health care surrogate is any competent adult who carries out the resident's medical decisions if he/she is not able to give informed consent .if not named .order of consideration .a) resident's spouse. The policy indicated documentation in the MDS should reflect the correct advance directives. No additional policies regarding advance directives were provided by time of the survey exit. 3.1-4(l)(5)

Based on interview and record review the facility failed to ensure a comprehensive assessment was completed upon a significant change in condition for 1 of 4 residents reviewed (Resident 28). Findings include: Resident 28's record was reviewed on 6/6/23 at 10:28 AM. Diagnoses included hemiplegia and hemiparesis following cerebral infarction right dominant side, unspecified dementia, and muscle weakness. A review of Resident 28's current quarterly Minimum Data Set (MDS) indicated her BIMS (Basic Interview for Mental Status) score was not obtained due to inability to complete the interview. An MDS dated [DATE] indicated Resident 28 required supervision and set-up help only for transfers, toileting, and personal hygiene. The MDS indicated Resident 28 needed supervision and one-person physical assistance with bed mobility. An MDS dated [DATE] indicated Resident 28 required extensive assistance and two-person physical assistance with bed mobility, transfers, toileting, and personal hygiene. A document titled Rehabilitation Services Multidisciplinary Screening Tool dated 1/2/23 received from the Administrator on 6/6/23 at 3:34 PM indicated Resident 28 declined in activities of daily living, transfers, and mobility. In an interview on 6/6/23 at 11:57 AM the MDS Coordinator indicated a significant change assessment should be completed when a resident has a decline in two or more areas. The MDS Coordinator indicated she was not sure why a significant change assessment was not completed. During an interview on 6/6/23 at 4:15 PM, the Regional Director of Clinical Services indicated there was no specific facility policy for completing a comprehensive assessment upon a significant change in condition. She indicated the facility should follow the RAI guidelines. The Resident Assessment Instrument (RAI) Manual dated 10/1/19 indicated a significant change MDS should be completed when a resident has a major decline in more than one care area. RAI guidelines indicate if a significant change is determined during the process of completing a quarterly assessment, a significant change comprehensive assessment should be performed instead. 3.1-31(d)(1)

Based on observation, interview and record review, the facility failed to ensure culturally appropriate communication interventions were attempted in a non-English speaking resident in 1 of 2 residents reviewed (Resident 28). FIndings include: During an observation on 6/5/23 at 9:32 AM Resident 28 was observed receiving medication from Registered Nurse (RN) 4. During the interaction, Resident 28's daughter indicated to RN 4, Resident 28 spoke Polish and was unable to speak or understand English. During an interview on 6/6/23 at 2:12 PM, Certified Nurse Aide (CNA) 5 indicated Resident 28 only spoke Polish and was not able to understand English. CNA 5 indicated new, or agency staff would normally look at the Kardex to learn the care needs of the residents. CNA 5 reviewed the Kardex screen for Resident 28 and indicated it did not contain any information about Resident 28 speaking Polish. Resident 28's record was reviewed on 6/6/23 at 11:21 AM. Diagnoses included hemiplegia and hemiparesis following cerebral infarction following right dominant side, unspecified dementia, and muscle weakness. A review of Resident 28's current quarterly Minimum Data Set (MDS) indicated her BIMS (Basic Interview for Mental Status) score was not available due to the interview not being completed. The MDS indicated Resident 28 was sometimes able to make herself understood and usually understands others. A review of progress notes dated 12/16/22 at 12:13 AM indicated Resident 28 had fallen and was not able to communicate with the staff due to only speaking Polish. A review of Resident 28's current Care plan titled Communication indicated the resident had a problem communicating, with a goal date of 8/7/23. Interventions included anticipating and meeting needs, observe for effectiveness of communication, and refer to speech therapy for evaluation and treatment as ordered. There were no interventions regarding communication helps addressed in the care plan. No care plan pertaining to the use of the Polish language was available for review at the time of exit. No speech therapy notes pertaining to communication in the last 12 months were available for review at the time of exit. No progress notes pertaining to offering an interpreter were available for review at the time of exit. A current policy titled Meaningful Communication with Persons with Limited English Proficiency last reviewed 10/7/22 provided by the Administrator on 6/7/23 at 11:27 AM indicated interpreter services should be offered to the resident or representative. 3.1-38(a)(2)(E)

Based on observation, record review and interview, the facility failed to ensure oxygen tubing was properly stored and labeled when not in use for 1 of 3 resident reviewed for respiratory care. (Resident 8). Findings include: During an observation on 6/1/23 at 10:17 AM, Resident 8 was in her chair sleeping wearing her nasal cannula (NC) oxygen tubing (a lightweight tube split into two prongs on one end and placed in the nostrils used to deliver supplemental oxygen) attached to her oxygen condenser (a medical device that gives you extra oxygen). Her portable oxygen condenser (a lightweight transportable oxygen condenser), not in use at that time, was attached to the back of her wheelchair with NC oxygen tubing attached. The NC oxygen tubing extended from the portable oxygen unit and laid on the floor. The NC oxygen tubing was not in a bag labeled with the resident's name. During an observation on 6/1/23 at 11:40 AM, Resident 8 portable oxygen condenser was attached to the back of her wheelchair with NC oxygen tubing attached. The NC oxygen tubing was not being used and wound around the oxygen tank handle. The NC oxygen tubing was not in a bag labeled with the resident's name. During an observation on 6/2/23 at 1:02 PM, Resident 8's portable oxygen condenser (a lightweight transportable oxygen condenser) was attached to the back of her wheelchair with NC oxygen tubing attached. The NC oxygen tubing was not being used and wound around the oxygen tank handle. The NC oxygen tubing was not in a bag labeled with the resident's name. Resident 8's record was reviewed on 06/02/23 at 1:28 PM. Diagnoses included heart failure, and dyspnea. A review of Resident 8's current quarterly Minimum Data Set (MDS) assessment, dated 4/24/23, indicated her Basic Interview of Mental Status (BIMS) score was 15 (cognitively intact). The MDS indicated she wore oxygen after arriving at the facility. A review of Resident 8's current care plan titled Cardiac indicated the resident was at risk for altered cardiovascular status related to hypertension and a history of heart failure with a goal to be free from cardiac complications. Interventions included the staff may titrate oxygen from 1-5 liters up or down for comfort or complaints of shortness. A review of physician orders dated 1/12/21 at 9:00 AM indicated Resident 8's oxygen could be titrated between 1-5 liters up or down for comfort or complaints of shortness of breath. In an interview on 6/06/23 at 02:15 PM, the Assistant Director of Nursing (ADON) indicated, per facility policy, the NC oxygen tubing should have been in a bag and labeled with Resident 8's name when not in use. A current policy titled Oxygen Administration/Safety/Storage/Maintenance, reviewed 10/7/22, provided by the Administrator indicated respiratory supplies should be stored in a bag labeled with the resident's name when not in use. 3.1-47(a)(4)(5)(6)

Based on interview and record review the facility failed to ensure interventions were implemented to correct significant weight loss for 2 of 8 residents reviewed. (Resident 41 and Resident 23) Findings include: 1. Resident 23's record was reviewed on 6/1/23 at 2:47 PM. Diagnoses included Alzheimer's disease, dementia without behavior, psychotic, and mood disturbance, psychosis not due to a substance or known physiological condition, generalized anxiety disorder, major depressive disorder, cognitive impairment, lymphedema, diaphragmatic hernia without obstruction or gangrene, chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM) type 2, heart failure, stage 4 chronic kidney disease (severe) and adult body mass index [BMI] 36.0-36.9. Resident 23's current comprehensive Minimum Data Set (MDS) assessment, dated 2/22/23, indicated her Basic Interview for Mental Status (BIMS) score was 99 (unable to complete the interview). The MDS indicated the resident was sometimes understood and she usually understood others. The MDS indicated she received diuretics 7 days a week. The MDS did not indicate the resident was at risk for losing weight. Resident 23's current care plan titled Nutrition indicated the resident had a problem of weight fluctuation related to severe cognitive impairment, heart disease, pain, COPD, DM type 2, and use of high-risk medications with a goal to maintain current weight. Interventions included a mechanically altered diet with no salt packets and thin liquid, to obtain and observe weight as scheduled, and refer to the Registered Dietitian for screen as needed. Physician orders dated 3/5/21 at 6:00 AM indicated Resident 23 received 20 mg of Furosemide (a medication to treat fluid retention and swelling) by mouth once a day related to heart failure. Resident 23's weights indicated a 5.70% (severe) weight loss in 1 month and 10.66% (severe) weight loss in 6 months as follows: Date Weight Calculation* Percentage Loss 5/31/2023 183.5 lbs. 4/10/2023 194.6 lbs. 194.6-183.5/194.6 x100 5.70% 11/7/2022 205.4 lbs. 205.4-183.5/205.4x100 10.66% *(Starting weight minus current weight) / (starting weight) x 100 = % of body weight loss In an interview on 6/7/23 at 10:06 AM, the Administrator indicated Resident 23's nurse should have identified the weight loss, had the resident's weight rechecked, and if the weight loss exceeded 5% in 1 month or 10% in 6 months notified the physician of Resident 23's weight loss. The Administrator indicated the resident's nurse did not recheck the resident's May weight. The Administrator indicated Resident 23's record had shown a greater than 5% weight loss in 1 month and 10% weight loss in 6 months. The Administrator indicated the resident's physician should have been notified of Resident 23's weight loss. 46156 2) In an interview on 6/1/23 at 10:15 AM, Resident 41 indicated she had not unintentionally lost weight. Resident 41's record was reviewed on 6/5/23 at 10:41 AM. Diagnoses included high blood pressure, heart disease and a pressure wound. Resident 41's current quarterly Minimum Data Set assessment (MDS) indicated the residenet's Basic Interview for Mental Status (BIMS) score was 13 (cognitively intact). The MDS indicated the resident had a 5 % weight loss in the last month. Resident 41' s current Care plan titled Alteration in Nutrition indicated the resident had a problem of weight loss with a goal date of 8/23/23. Interventions included assistance with meals as needed, diet supplement as ordered for increased protein to promote wound healing, offer substitutes as needed, and obtain weights as ordered and observe for changes. Resident 41's weight summary indicated the resident weighed 106.4 pounds on 4/19/23. The resident weighed 103.6 pounds on 5/5/23. The resident weighed 97.5 pounds on 5/15/23. There were no reweights available for review. Weekly weights were not documented as completed as recommended by the Registered Dietician on 5/5/23. Resident 41's weight on 6/6/23 was 103.1. Current physician orders dated 4/21/23 indicated Resident 41 was to have Prosource Plus 30 milliliters by mouth once daily for wound healing. Progress notes dated 5/3/23 indicated the Registered Dietician (RD) recommended an increase of protein supplements from once to twice daily and weekly weights until the wound healed. An MAR dated May, 2023 indicated Resident 41's Prosource plus was not increased to twice daily. Progress notes dated 5/17/23 the RD indicated the resident had an 8.7% weight loss in 30 days. The RD recommended an increase of protein supplements from twice to three times daily, fortified pudding twice daily and to continue weekly weights until the wound heals. An MAR dated May, 2023 indicated Resident 41's Prosource plus was not increased to three times daily. Resident 41's current tray card did not include fortified pudding. In an interview on 6/5/23 at 3:28 PM Registered Nurse 3 indicated the nursing staff should have notified the physician of RD recommendations A current policy dated 4/25/23 provided by the Administrator on 6/5/23 at 3:05 PM indicated a nursing staff designee was to ensure the physician, resident and family representative were to be notified of a significant change in weight. 3.1-46

Based on interview and record review, the facility failed to maintain adequate staffing levels to implement fall prevention interventions and meet personal needs for 2 of 6 residents reviewed (Resident R and Resident V ). Findings include: An anonymous complaint to the Indiana Department of Health, indicated there was a concern regarding not enough staff available to care for residents, especially on weekends. 1. On 3/30/23 at 10:17 A.M., Resident R was observed lying in a low bed, snoring loudly. A family member, who was sitting in the room, indicated the resident had just returned from the hospital the day before following a fall and fractured hip. The resident had several falls recently with the last one occurring on 3/26/23 which resulted in the fracture and need for surgery. The family member indicated they believed the resident wouldn't have fallen so often had there been adequate staffing to monitor her. On 3/30/23 at 3:10 P.M., Staff 3 was interviewed. They indicated on Sunday, 3/26/23, Resident R had been restless all day long. She wandered up and down the hallways in her wheelchair and when she stopped, would get up from the chair and attempt to walk. Staff tried to keep her at the nurses station for closer monitoring but were unable to provide 1:1 supervision. On 3/26/23 at 3:00 p.m., A visitor reported they heard a fall. Resident R was found on the floor in the hallway by the nurses station. 2. On 3/30/23 at 11:00 A.M., Resident V, identified as interviewable by the facility, indicated they were not assisted to bed at their preferred time late in the evening after their last medication was given. The resident indicated they hadn't known why the staff couldn't do it consistently and believed staffing was the reason. On 3/30/23 at 10:14 A.M. and 4:04 P.M., the Director of Nursing was interviewed. She indicated she tried to schedule 2 nurses for the 6 a.m. to 6 p.m. shift and 2 nurses from 6 p.m. to 6 a.m. but wasn't able to always have a nurse. She indicated at times, there would be only 1 nurse scheduled with a QMA (Qualified Medication Aide) to cover a 12 hour shift. There were to be 4 CNA's (Certified Nurse Aide) scheduled for the day shift (6 a.m. to 2 p.m.); 4 CNA's for evening shift (2 p.m. to 10 p.m.); and 2 CNA's for night shift (10 p.m. to 6 a.m.). She indicated weekends were very difficult to staff, especially since the facility no longer used agency staff. She indicated currently, of the 44 residents in the facility, 17 residents required assistance of 2 staff members for completing activities of daily living. On 3/30/23 at 12:30 P.M., the Interim Administrator provided a copy of the Facility Assessment (used to determine what resources, including nursing staff, are necessary to care for residents), dated 10/21/22. The facility's calculated per patient day (PPD-hours worked by nursing staff in a 24 hour day divided by number of residents) staffing for nurses was to be 1.08. For CNA's the PPD was to be 2.25 based on care needs of residents who were independent, needed assistance from 1 or 2, or were totally dependent on staff. Residents requiring assistance from 2 staff members were assessed at 7. However, the CNA's were currently providing care for 17 residents who required assistance of 2 staff for ADL's. Review of average daily census, licensed nurse, and CNA time cards, in March 2023, indicated the following days PPD's were not met according to the facility assessment: -3/4/23: CNA PPD = 1.77 -3/5/23: CNA PPD = 1.95 -3/11/23: Nurse PPD = .56 and CNA PPD = 2.19 -3/12/23: Nurse PPD = .56 and CNA PPD = 1.63 -3/18/23: Nurse PPD = .84 and CNA PPD = 1.63 -3/19/23: CNA PPD = 1.5 -3/25/23: Nurse PPD = .53 and CNA PPD = 2.25 -3/26/23: Nurse PPD = .55 and CNA PPD = 2.0 This Federal tag relates to Complaint IN00404252. 3.1-17(b)

Based on interview and record review the facility failed to ensure 1 of 3 residents reviewed were free from a significant medication error that resulted in monitoring in emergency room . (Resident B). Findings include: The clinical record for Resident B was reviewed on 8/5/20 at 10:30 A.M. [DIAGNOSES REDACTED]. A medication error report sheet dated 7/13/20, indicated Resident B received Resident D's medication during the morning medication pass. Licensed Practical Nurse (LPN) 4 asked Resident B if she was Resident D. Resident B responded that she was Resident D and LPN 4 gave her Resident D's medications. Resident B experienced lethargy, diaphoresis, vomiting, [MEDICAL CONDITION], pale lips, and tremors to the hands after the medication error occurred. An active order summary report dated 7/13/20, indicated Resident B was to receive 10-12.5 milligrams of [MEDICATION NAME]-[MEDICATION NAME] (blood pressure medication) during morning medication pass. An active order summary report dated 7/13/20, indicated Resident D was to receive 20 milligrams of atorvastatin (for high cholesterol; Side effects includedlow blood sugar and nausea), 125 micrograms of [MEDICATION NAME] (to prevent Vitamin D deficiency side effects include vomiting), 120 milligrams of [MEDICATION NAME] (for high blood pressure, side effects include low blood pressure and slow heart rate), 2.5 milligrams of Eliquis (to prevent blood clots and stroke, side eefects includedizziness), 25 milligrams of [MEDICATION NAME] (for high blood pressure, side effects include slow heart rate and low blood pressure), 2 milligrams of [MEDICATION NAME] (for [MEDICAL CONDITION], side effects include weakness and confusion), 1 multi-vitamin, and 100 milligrams of [MEDICATION NAME] during morning medication pass. A progress note dated 7/13/20 at 9:10 A.M., indicated Resident B was sitting at the dining room table with her hand hanging forward. Tremoring was in her hands, her lips were pale, and she was diaphoretic. Resident B's temperature was 96.6, blood pressure was 88/49, pulse was 48 and her O2 saturation was 90% on room air. Resident B was taken to her room and was assisted to lie down. Resident B indicated she was nauseated, she was assisted to the side of the bed, and then vomited a large amount of yellow fluid. A progress note dated 7/13/20 at 9:27 A.M., indicated the Director of Nursing Services (DNS) and physician were notified. A new order was received to send Resident B to the emergency room for an evaluation and treatment. A progress note dated 7/13/20 at 9:43 A.M., indicated Emergency Medical Services had arrived. Resident B was resting quietly in bed, her color was pink, but she was still diaphoretic. Resident B's temperature was 96.6, blood pressure was 150/65, pulse was 73, and her O2 saturation was 94% on room air. Resident B was nauseated and vomited a small amount during the Emergency Medical Technician assessment. A progress note dated 7/13/20 at 9:52 A.M., indicated Emergency Medical Services transported Resident B by stretcher to the emergency room at a local hospital. The DNS was interviewed on 8/5/20 at 12:49 P.M. During the interview the DNS indicated the resident was at the hospital several hours so they could monitor her blood pressure and heart rate. She indicated would expect staff to know the residents in the facility and if they were not sure who someone was they should find out. She would also expect staff to use the 5 rights of medication administration to make sure the right residents are receiving the right medications. A policy, dated 5/6/2020, was provided by the Administrator on 8/5/20 at 1:47 P.M., titled Administration of Medications. The policy indicated .Significant medication error means one which causes the resident discomfort or jeopardizes his or her health and safety. This Federal tag relates to Complaint IN 632. 3.1-48(c)(2)

Based on interview and record review the facility failed to ensure dietary recommendations were implemented for 1 of 3 residents reviewed. This resulted in severe weight loss (Resident 28). Findings include: The clinical record for Resident 28 was reviewed on 5/29/19 at 10:45 A.M. [DIAGNOSES REDACTED]. During an observation in the hallway on 5/29/19 at 9:53 A.M., Resident 28 appeared thin and unsteady on his feet. During an observation on 5/31/19 at 11:46 A.M., Resident 28 was in the assist dining room. Most of his meal appeared to have been eaten. In a weight summary report dated 3/15/19 to 5/30/19, the following weights were recorded for Resident 28: 3/15/19-151.4 pounds (lbs) 3/19/19- 152.2 lbs 3/20/19- 152.2 lbs 3/27/19- 152.2 lbs 3/28/19- 152.2 lbs 4/3/19- 153.4 lbs 4/10/19- 141.6 lbs 4/17/18- 153.4 lbs 4/24/19- 145.8 lbs 5/8/29- 145.8 lbs 5/15/19- 124.2 lbs (severe weight loss of 14.8% from previous week) 5/16/19- 125.8 lbs 5/22/19- 124.4 lbs 5/30/19- 129.4 lbs. The Director of Nursing Services was interviewed on 5/30/19 at 10:27 A.M. During the interview the DNS indicated when a resident has a significant weight loss the Physician and Dietitian are notified, recommendations from the Registered Dietitian are followed and the resident is followed in weekly Resident at Risk (RAR) meetings. A Registered Dietician note dated 4/17/19, indicated Resident 28 had a significant weight loss of 8.9 pounds from his admission weight (3/15/19- 151.4 lbs) to his current weight (4/10/19- 141.8 lbs). The weight loss was most likely related to a new pneumonia [DIAGNOSES REDACTED]. Resident 25 had poor intakes and usually consumed about 25% of his meals. Recommendations were to give chocolate milk and juice three times a day with meals and to give ice cream three times a day with meals. Also, medpass (a supplement) 90 milliliters was to be given three times a day for additional nutritional support until meal takes improved. Resident 28 was to be monitored in RAR meetings and weekly weights were to be taken until they were stable. There was no documentation indicating the Dietitian Recommendations from 4/17/19 were implemented for Resident 28. There was no documentation indicating the Physician was notified of Resident 28's weight loss on or after 5/15/19. There was no documentation indicating Resident 28 had been monitored in weekly RAR meetings on 4/24/19, 5/1/19 or 5/8/19. The Director of Nursing Services (DNS) was interviewed on 5/30/19 at 1:18 P.M. During the interview the DNS indicated the Registered Dietitian recommendations from 4/17/19 had not been followed and there was no documentation indicating the Physician had been notified of Resident 28's weight loss on or after 5/15/9. She also indicated the Registered Dietitians recommendations should have been followed and the Physician should have been notified of the weight loss. Resident as Risk notes from a 5/15/19 meeting that the Registered Dietitian attended, indicated Resident 28 was unlikely to have a 21.6 pound weight loss in one week and a re-weight was requested. A re-weight was taken on 5/16/19. There was no documentation indicating the Registered Dietitian was notified of the re-weight taken on 5/16/19. A progress note dated 5/22/19, indicated a re-weight was being obtained on Resident 28 and it would be followed up on, but there was no documentation indicating a re-weight was taken until 5/30/19. The DNS was interviewed on 5/31/19 at 12:11 P.M. During the interview the DNS indicated the Registered Dietitian was not notified of the re-weight on 5/16/19. She also indicated Resident 28 was not discussed in the 4/24/19, 5/1/19 or 5/8/19 RAR meetings. She did indicate Resident 28 was discussed during the 5/15/19 and 5/22/19 RAR meetings. The DNS indicated the progress note from 5/22/19 was placed after Resident 28 had been discussed in a RAR meeting on that date and the Dietitian was in attendance. A policy, dated 3/1/13, was provided by the DNS on 5/30/19 at 2:44 P.M., titled Weight Monitoring and she indicated it was the policy currently used by the facility. The policy indicated .The criteria for reweighs are as follows. A reweigh is obtained when a resident's weight varies by 5 lbs in a month or 3 lbs in a weekly or bimonthly weigh. Reweighs should occur in the same shift but no more than 24 hours after the first weighing .For evaluating weight changes: Weight variances are reviewed for residents with a 5% weight change in 30 days, 7.5% weight change in 90 days, and a 10% weight change in 180 days. This includes gain or loss .Any resident who experiences an unplanned weight loss, significant weight change, or undesirable weight change. Notification will be made to the physician and responsible party .Each identified resident with a weight change has a current nutrition assessment/progress note. The Interdisciplinary Care Plan team addresses the issue of the weight loss/poor intake or weight gain, assesses dining needs if indicated, provides realistic and measurable goals, indicated specific and individualized interventions, and more as needed. The resident's interdisciplinary care plan reflects the current interventions, evaluations, and revisions. The nutrition progress notes describe the changes, plan of action, and progress or lack of progress. 3.1-46

Based on interview and record review, the facility failed to obtain a PT ([MEDICATION NAME] time) and INR (international normalized ratio) (a laboratory blood clotting test) for residents who were receiving [MEDICATION NAME] (a medication that thins blood) as ordered by the physician for 2 of 9 residents reviewed for unnecessary medications (Resident K and Resident S). The deficient practice resulted in hospitalization for spontaneous bruising, bleeding from multiple wounds and skin tears, and a critically elevated PT/INR level for Resident K. The Immediate Jeopardy began on 7/13/17 when the facility failed to obtain laboratory tests as ordered and was identified on 7/15/17. Resident K was transferred to the emergency roiagnom on [DATE] and required hospitalization and stabilization and treatment of [REDACTED]. The Administrator was notified of the Immediate Jeopardy at 1:00 P.M. on 7/21/17. The Immediate Jeopardy was removed and the deficient practice corrected on 7/19/17, prior to the state of the survey and was, therefore, past noncompliance. Findings include: 1. On 7/21/17 at 9:57 A.M., Resident K's record was reviewed. [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 6/13/17, indicated Resident K had a BIMS (Brief Interview Mental Status) score of 7 which signified severe impaired cognition. A Nurse Note, dated 6/26/17 at 3:30 P.M., Resident K was noted to have increased [MEDICAL CONDITION] (swelling) to the right leg. A physician's orders [REDACTED]. A Nurse Note, dated 6/27/17 at 9:40 A.M., indicated the ultrasound doppler study showed a [MEDICAL CONDITION] in the resident's right groin. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A SBAR Communication form, dated 7/11/17 at 4:00 P.M., indicated the physician was notified of Resident K's increased confusion. A physician's orders [REDACTED]. A physician's orders [REDACTED]. According to WebMD.com,[MEDICATION NAME] cause an interaction with [MEDICATION NAME] to increase the anticoagulant effects. A MAR (Medication Administration Record) indicated Resident K received 7 doses [MEDICATION NAME] 7/12/17-7/15/17 as follows:[MEDICATION NAME] administered on 7/12, 13, and 14, 2017 at 8:00 A.M and 8 P.M. and at 8 A.M.on 7/15/17 as ordered. A physician's orders [REDACTED]. A Nurse Note, dated 7/15/17 at 10:56 A.M., indicated Resident K was alert and lethargic and continued with multiple areas of bruising to upper arms and chest with multiple open areas. A Nurse Note, dated 7/15/17 at 2:45 P.M. indicated Resident K had bloody lips and bleeding from multiple scabs on bilateral upper arms. Resident has been oozing blood at times. The nurse indicated a concern for increased bleeding due to the resident being on [MEDICATION NAME] and Cipro. Review of PT/INR labs indicated the last PT/INR completed was on 7/6/17 and had been ordered to be done on 7/13/17. The physician was notified of the missed lab and the resident was sent to the emergency room for evaluation and treatment. The emergency room provider notes, dated 7/15/17, indicated the resident had been brought to the emergency room due to spontaneous oozing from skin tear sites. Patient without any signs of major bleeding .Per (hospital) protocol the patient was given 5mg of IV vitamin K .Patient likely supratherapeutic from being placed [MEDICATION NAME] a urinary tract infection. The resident's lab results at the hospital on [DATE] were as follows: PT ([MEDICATION NAME] time) >100.0 Normal range 9.2-11.1 INR >9.7 PANIC RESULT Normal range .9-1.1 On 7/21/17 at 11:14 A.M., the Administrator and DON (Director of Nursing) were interviewed. The DON indicated the facility, immediately, took steps to address the missed PT/INR lab test which included review of all resident's PT/INR's that were currently on [MEDICATION NAME] and none were found to have been missed. She indicated labs are drawn in the mroning and the physician usually visits later in the day to get the lab results. 2. On 7/23/17 at 1:35 P.M., Resident S's record was reviewed. [DIAGNOSES REDACTED]. Physician admission orders [REDACTED]. A lab result form, dated 7/3/17, indicated Resident S's PT was 44.7 Normal range 9.2-11.1 and INR was 4.4 Normal range .9-1.1. The physician was not notified of the elevated PT/INR result of 7/3/17 and Resident S was continued on [MEDICATION NAME] 7.5mg every day. A Nurse Note, dated 7/17/17 at 3:00 P.M., indicated a physician's orders [REDACTED]. A lab result form, dated 7/17/17, indicated Resident S's PT was 82.7 and her INR was 8.0 which was a Panic Result and was reported to the facility by the laboratory via phone call. A Nurse Note, dated 7/17/17 at 5:45, indicated Resident S's [MEDICATION NAME] was to be held and a PT/INR lab to be drawn on 7/18/17. A lab result form, dated 7/18/17, indicated the resident's PT was 74.5 and INR 7.2. Lab results remained at Panic Result and were reported to the facility by the laboratory via phone call. On 7/23/17 at 1:48 P.M., the DON was interviewed. During the interview, she indicated Resident S's missed physician notification of elevated PT/INR on 7/3/17 was noted on 7/17/17. The DON indicated it was the facility policy to fax the lab results, including PT/INR results to the physician's offices. She indicated there had been no response from the physician following fax notification of Resident S's PT/INR results on 7/3/17 and the nursing staff failed to contact the physician. 7/24/17 at 10:59 A.M., the DON provided a undated copy of the facilities policy titled [MEDICATION NAME]. The DON was interviewed and indicated the copy of the facility policy titled [MEDICATION NAME] was current and had been obtained from the facilities company network website. The policy indicated the following: An INR above 4 has been associated with a higher risk of bleeding without an increase in therapeutic benefit. For INR results 4 or greater, hold medication and notify physician for further orders. Policy: Residents receiving [MEDICATION NAME] are monitored for side effects and receive [MEDICATION NAME] time studies and the International Normalization Ratio (INR) regularly to determine therapeutic dosing .Procedure .8. When a PT and INR test is done, the physician is notified of the results. 9. The Facility ensures follow-up by the physician regarding [MEDICATION NAME] dose changes and the next PT and INR test The Immediate Jeopardy that began on 7/13/17 was removed on 7/19/17 when the facility completed audits on all residents receiving [MEDICATION NAME], reviewed PT/INR labs, inserviced nurses on the facility [MEDICATION NAME] protocol, and implemented a new system for tracking and monitoring of PT /INR lab results. The Immediate Jeopardy was removed and the deficient practice corrected on 7/19/17, prior to the state of the survey and was, therefore, past noncompliance. This Federal tag relates to Complaint IN 439. 3.1-47(a)(3)

Based on interview and record review, the facility failed to ensure end of life care needs were provided to 1 of 2 residents receiving end of life care (Resident L). This resulted in increased, persistent severe anxiety regarding death. Findings include: On 6/15/17 at 3:30 P.M., Resident L's record was reviewed. [DIAGNOSES REDACTED]. A Significant Change MDS (Minimum Data Set) assessment, dated 4/6/17, indicated a BIMS (Brief Interview Mental Status) score of 15 which indicated Resident L had no cognitive impairment. The MDS indicated the resident had no mood issues identified nor behaviors such as rejecting care or yelling out identified during the assessment period. A physician progress notes [REDACTED]. The plan was for palliative care (care focused on providing relief from symptoms of a serious illness) to be provided for the resident. A Nurse Note, dated 5/28/17 at 10:25 A.M., indicated the (physician) had been in to visit with Resident L and discussed with her that she is passed the point of [MEDICAL TREATMENT] now and will be made as comfortable as possible. A Social Service Note, dated 5/30/17 at 12:50 P.M., indicated that the SSD (Social Service Director) and the MDS nurse had spoken with Resident L about hospice services. The note further indicated Resident L's family members had been contacted and they wished to speak with the resident about hospice before making a decision. A Nurse Note, dated 5/30/17 at 5:23 P.M., indicated the MDS nurse and SSD had spoken with Resident L about Hospice services, resident's current condition with build up of fluid and kidney's no longer functioning, resident did agree to meet and speak to a hospice representative regarding additional services offered. Resident reassured that it is with the intention to keep her as comfortable as possible. A psychological evaluation, dated 6/2/17, indicated Resident L feared death and avoids thoughts (of dying) I don't want hospice. I don't want to die. Resident L was diagnosed with [REDACTED]. Review of Nurse Notes indicated the following: On 5/31/17 at 1:20 P.M., the resident is [MEDICAL CONDITION] and fluid filled in bilateral hands, abdomen is very large and rounded with [MEDICAL CONDITION] in the lower abdomen. Resident has increased difficulty when laying down with congestion and coughing, oxygen on, head of bed elevated most of time but resident continues to complain. On 5/31/17 at 10:40 P.M., Resident L has shown no increase of discomfort this shift. The resident had several family members into visit. A few family members wanted to stay the night with the resident. Resident L indicated she was told if she wanted anyone to stay with her, they could. The nurse contacted the SSD and Administrator to see if this was allowed and if arrangements had been made with administration. The nurse documented no prior arrangements made per Administrator. The nurse documented Resident has had no signs of increase of distress or signs of eminent passing in near future. Resident (brother) educated that visitation was permitted 24 hours but not to stay sleeping at the bedside at this time as resident being stable and no signs of condition change was noted. Family left the building and stated they would speak to the SSD about this. On 6/6/17 at 10:00 P.M., Resident L constantly yelled out for help unnecessary without using call light and has no signs of need or acute distress. Yells for staff to pull her up in bed and uses control to bed constantly. 6/6/17 at 1:00 A.M., Resident had call light on and yelling out for help again. Resident is disturbing other residents during sleeping hour. There was no documentation to indicate the physician had been notified of Resident L's new behavior of yelling out. 6/7/17 at 6:30 P.M., Resident is yelling help. Reminders to not yell out, use call light and give staff time to arrive to her room. 6/7/17 at 7:30 P.M., Resident yelling help and was assisted to reposition in bed. 6/7/17 at 8:30 P.M., Resident yelling help over and over. Writer informed her and educated her on not appropriate to do, others are alarmed, visitors are concerned, she is too loud, call light is at side to be used, her visitors do not like her yelling out. 6/7/17 at 9:30 P.M., Resident is yelling help. Writer and staff addressed with resident, resident is making excuses for her yelling out help this shift, writer informed her again, not appropriate. DON (Director of Nursing) aware of behavior from resident, aware of writer's teaching and educating on call light and inappropriate behavior. There was no documentation to indicate the physician had been notified of Resident L's new behavior of yelling out and increased anxiety. 6/8/17 at 9:15 P.M., Resident L complained of abdominal pain. 6/8/17 at 9:30 P.M., Resident L continuing to complain of discomfort and is wanting to go to the hospital. writer left a message for (physician) and informed the family that we felt there was no more to do at the hospital for her than we can do here. New order received for anti-anxiety medication. The anti-anxiety medication was not administered until 6/9/17 at 12:40 P.M. 6/10/17 at 8:00 P.M., Resident L when awake asking or yelling out for 'help'. Resident with increased shortness of breath, wet cough, congestion, and complaint of feeling 'tight in chest'. 6/11/17 at 3:31 P.M., Resident complaining of pain/tightness with respirations, moaning and yelling out help frequently. A Plan of Care with a problem of anxiety with onset date of 6/9/17, indicated Resident L has a [DIAGNOSES REDACTED]. The goal was that Resident L would have a decrease in signs and symptoms of anxiety. Approaches were to encourage resident to take medication per physician orders, refer for psych services as needed, and encourage to ask for reassurance and support. On 6/16/17 at 10:52 A.M., the DON (Director of Nursing) was interviewed. During the interview, the DON indicated she did not know why the anti-anxiety medication had not been administered immediately to Resident L on 6/8/17 at 9:30 p.m. when an order had been obtained for [MEDICATION NAME]. The DON indicated she was not sure if this medication was kept in the EDK (Emergency Drug Kit). The DON provided a copy of the list of medications kept in the EDK and [MEDICATION NAME] .5 mg was found to be in the EDK and had been available for administration on 6/8/17 when the the order was obtained. On 6/16/17 at 10:57 A.M., the SSD was interviewed. During the interview, the SSD indicated the following: 1. There was no further follow up for hospice services for Resident L. 2. The SSD was notified by phone on 5/31/17, that Resident L's family wanted to stay the night with her. The SSD indicated she told the nurse it was okay but discouraged if the resident was not actively dying. SSD indicated she spoke with Resident L's family the next day and reiterated that family could stay overnight if the resident was actively dying. The SSD had no documentation of this conversation with family or that staff had been notified that this was allowed. 3. The resident had been seen by the psychologist on 6/2/17 because the resident was dying. SSD indicated that she received the psychologist report on 6/5/17 and placed it into Resident L's physician folder to review at his next visit. Resident L was not seen for follow up psychotherapy as recommended and passed away on 6/12/17. There was no plan of care to address Resident L's end of life needs. There was no documentation to indicate hospice services had been contacted or had been in to speak with Resident L or her family. This Federal tag relates to Complaint IN 973. 3.1-37(a)