Every finding on record at Majestic Care of Jefferson Pointe

Based on interview and record review, the facility failed to document, monitor and report changes in a skin condition for 1 of 3 residents reviewed (Resident B). Findings include: Resident B's record was reviewed on 7/20/26 at 9:51 AM. Diagnoses included end stage renal disease, dependance on renal dialysis, diabetes type 2, and chronic peripheral renal insufficiency and arterial stenosis.A current significant change Minimum Data Set assessment (MDS), dated [DATE], indicated Resident B had a Basic Interview for Mental Status (BIMS) score of 15 (cognitively intact).A progress note, dated 7/1/26 8:59 PM, indicated Resident B was seen by Nurse Practitioner (NP) 3 for a follow up visit related to bilateral lower leg cellulitis. NP 3 indicated the cellulitis was improving and no seeping or drainage was noted. No additional progress notes describing the condition of Resident B's lower legs were available for review.A skin assessment dated [DATE] indicated there were no new skin areas.A transfer form, dated 7/15/26 at 11:21 AM, indicated Resident B was sent to the hospital for shortness of breath, decline in blood pressure and elevated temperature. The transfer form indicated Resident B had skin areas on her hips and edema of the lower extremities that could seep.A skin condition evaluation form, dated 7/14/26, indicated Resident B had wounds on her left thigh, left trochanter (hip), left lateral thigh, right thigh (rear), and no other wounds.A resident care team review, dated 7/14/26, indicated Resident B received education to lie down in bed to promote wound healing and indicated Resident B refused to sleep in the bed, sleeping in a wheelchair instead. The note did not mention any open areas, weeping edema of the lower legs, or elevation of legs while in the wheelchair.A current care plan, titled smoking, indicated Resident B had a problem of smoking cigarettes, with a goal date of 9/3/26. Interventions included using designated areas to smoke.A current policy, titled Smoking, provided by the Regional Nurse Consultant (RNC) on 7/202/26 at 2:51 PM indicated smoking was only permitted in a designated outdoor area.A current care plan indicated Resident B had a problem of risk of skin breakdown related to weeping edema with a goal date of 9/3/26. Interventions included weekly skin assessments with documentation and physician notification of changes.A current physician order, dated 6/17/26, indicated Resident B's bilateral lower extremities should be washed, patted dry and then short-stretch compression wraps should be applied.A treatment administration record, dated July 2026, did not contain documentation of application of short stretch compression wraps on 7/1/26, 7/2/26, 7/3/26, 7/7/26, and 7/12/26.A wound care document, dated 7/16/26 11:00 AM, provided by the hospital medical records department on 7/20/26 at 2:05 PM, indicated Resident B had a closed, non-pressure venous ulcer under a dressing on Resident B's lower right leg. A photograph dated 7/15/26 7:08 PM contained dark pink skin with yellowish slough and a melon-colored sponge dressing rolled partially open beside the area.In an interview, on 7/20/26 at 3:18 PM, Licensed Practical Nurse (LPN) 2 indicated Resident B had a large amount of bilateral lower extremity edema. LPN 2 indicated Resident B prioritized smoking and often went to the smoking area before staff could apply ordered dressings to her legs. LPN 2 indicated Resident B had taken her dressings off at times because they were wet or tight and did not notify staff. LPN 2 indicated staff sometimes had a hard time finding Resident B after she left the unit to smoke. LPN 2 indicated she did not know why sign off boxes for Resident B's leg treatments were not signed on 7/1/26, 7/2/26, 7/3/26, 7/7/26, 7/12/26. LPN 2 indicated staff should note any refusals of care or any occurrence of Resident B's removal of dressings in the progress notes. LPN 2 indicated the care plan should address Resident B's removal of dressings.In an interview, on 7/21/26 at 9:19 AM, LPN 2 indicated on the morning of 7/15/26, Resident B was outside smoking when LPN 2 arrived for work at 6:00 AM. LPN 2 indicated Resident B normally started dialysis around 6:30 AM, so dressing changes were typically done after dialysis LPN 2 indicated Resident B frequently removed her leg dressings or asked other residents to remove them for her when the dressings became uncomfortable and did not tell staff when the dressings were removed. LPN 2 indicated Resident B approached her before dialysis, complaining of seeping on her right lower leg, asking for some padding to be placed in the area before she started dialysis. LPN 2 indicated she rinsed the area with wound wash quickly, applied a small gauze pad and Mepilex (a melon-colored absorbent, sponge wound dressing) to contain the seeping. LPN 2 indicated she was unable to see an open skin area of the right lower leg prior to applying the pad. LPN 2 indicated she did not provide education to Resident B about the risk of flies or other insects when spending time outdoors with uncovered open skin areas. LPN 2 indicated she was not aware of any education about the risk of flies by any other staff member.A current policy, titled Wound Care Policy, dated 3/17/26, provided by the RNC on 7/20/26 at 4:23 PM, indicated Residents with skin integrity problems were recognized by the care team, and healing interventions were exhausted until the skin was healed. The policy indicated staff should act to prevent infection of impaired skin areas.A current policy, titled Change in Condition/Physician Notification, dated 3/19/25, provided by the Administrator on 7/21/26 at 10:38 AM, indicated when a change in condition is discovered, the nurse should evaluate the resident and report pertinent findings to the physician.410 IAC 16.2-3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure a resident was adequately assessed and provider orders were followed after a change in condition for 1 of 3 residents reviewed. The facility failed to ensure bowel assessments were performed and an abdominal X-ray was completed as ordered. This resulted in the facility sending the resident to the hospital with a perforated bowel (Resident C).The Immediate Jeopardy began on 5/15/26 when the facility failed to assess Resident C's change of condition and complete an order for a follow-up x-ray. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on May 19, 2026, at 4:12 P.M. The immediate jeopardy was removed on 5/20/26 but noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy.Findings include: On 5/18/26 at 9:50 A.M., Resident C was observed seated in a recliner chair with his feet elevated, in the lounge area of the secured memory care unit (MCU). His eyes were closed and breathing was easy and non-labored.On 5/18/26 at 12:38 P.M., Resident C was observed seated in the recliner chair with his feet down, in the lounge area of the secured MCU. His eyes were closed and he was wearing oxygen per nasal cannula. His skin color was ashen, and his respirations were labored and irregular. The Nurse Practitioner (NP) was present. Both she and Licensed Practical Nurse (LPN) 2 were on the phone trying to contact the resident's family. The NP indicated the resident had a change in condition and was declining rapidly. She was trying to contact the resident's family to see what their wishes were for hospitalization but could not contact them. The NP indicated the resident was a full code so was ordering the facility to send him to the hospital for evaluation and treatment.Resident C's record was reviewed on 5/18/26 at 12:01 P.M. Diagnoses included dementia and obstructive hydrocephalus (blockage preventing fluid from flowing normally through the brain).A nurse note, dated 5/13/26 at 12:50 p.m., indicated Resident C vomited a very dark colored substance. The Assistant Director of Nursing (ADON) was notified, she assessed the resident and substance vomited. She advised LPN 2 to give milk of magnesia, as ordered, for no bowel movement. The ADON indicated she would contact the Nurse Practitioner (NP) for an order for abdominal x-ray.There was no assessment of the resident or substance he had vomited, documented in the record. There was no documentation indicating the NP had been notified of Resident C vomiting and the dark colored substance observed.A nurse note, dated 5/13/26 at 7:54 p.m., indicated Resident C had been up for supper but had decreased intake. The abdominal x-ray had been completed, as ordered. He had no further vomiting of BM (bowel movement/stool).A Critical abdominal x-ray result, reported on 5/13/26 at 6:29 p.m., indicated there was considerable distention of the colon which appeared to be due to a non-specific ileus (slowed bowel function).There was no documentation in the clinical record indicating the NP had been notified of the critical abdominal x-ray results at the time they were received. An NP progress note, dated 5/19/26 for a visit which occurred 5/14/26, indicated Resident C was seen for abnormal abdominal x-rays. An abdominal x-ray had been obtained due to an episode of dark in color vomiting. Resident C was visited while seated in the common area (lounge). He hadn't appeared in any distress and denied abdominal pain. His abdomen was soft, non-distended and non-tender, with normal bowel sounds. Treatment for ileus was to give Lactulose by mouth 2 times/day X 5 days for constipation and Reglan 3 times per day x 5 days (increases intestinal movement). Resident C was to have clear liquids for 24 hours, extra fluids, and a repeat abdominal x-ray. Labs had been drawn and the NP was waiting on results of complete blood count (CBC) and comprehensive metabolic panel (CMP). Labs were to be repeated on 5/18/26. Staff were to call the NP with any further vomiting or abnormal vital signs.There was no order in Resident C's physician orders, on the Treatment Administration Record (TAR), or referenced in nurse notes to indicate a new order to repeat the resident's labs on 5/18/26 had been received. A physician order, dated 5/14/26, was for an abdominal x-ray to be done the morning of 5/15/26 for diagnosis of Ileus.There was no documentation in Resident C's record (Medication Record, Treatment Record, Progress Notes, or event documentation) indicating an abdominal x-ray had been completed on 5/15/26. There were no assessments of bowel sounds, abdominal distention, abdominal pain, or increased fluid intakes documented in the record (Medication Record, Treatment Record, Progress Notes, or event documentation) between 5/14/26 and 5/18/26.A nurse note, dated 5/18/26 at 1:18 p.m., indicated Resident C was observed with shortness of breath and was difficult to arouse from sleep. His oxygen saturation was 65% (normal >90%) and his pulse was irregular at 101 beats per minute (bpm) (normal 60-80 bpm). Oxygen at 2 liters per nasal cannula was administered and the NP was notified. Attempts were made to contact family but were unable to be reached. The resident was sent to the hospital due to rapid decline in condition.The Director of Nursing (DON) was interviewed on 5/18/26 at 1:18 P.M. She indicated the follow-up abdominal x-ray, to have been completed on 5/15/26, had not been done as ordered.LPN 2 was interviewed on 5/19/26 at 10:06 A.M. She had just spoken with the hospital nurse and was told Resident C was in the ICU with a diagnosis of bowel perforation (a tear in the wall of the colon). LPN 2 indicated an abdominal x-ray was ordered to be done on 5/15/26 but hadn't been completed due to an error with scheduling. LPN 2 indicated she had not been aware of the 2-step process required when scheduling x-rays and had only completed step 1 therefore, the x-ray was not done.The Regional Nurse Consultant (RNC) was interviewed on 5/19/26 at 12:30 P.M. She indicated nurses should have assessed and documented Resident C's condition as it related to the ileus including assessment of further vomiting, abdominal pain, distention, bowel sounds, and food and fluid intakes.Hospital ER records, dated 5/18/26 at 12:58 p.m., indicated Resident C arrived at the emergency room, unresponsive, profoundly hypotensive (low blood pressure) at 55/24 (normal 120/80), with poor blood flow and dusky feet. His abdomen was distended and he had brown stool in his brief. A chest x-ray showed a large amount of free fluid in his abdomen. He was diagnosed with Pneumoperitoneum (abnormal fluid or gas in the abdominal cavity), respiratory failure, and septic shock. He was sent emergently to the operating room where he was observed with a sigmoid colon (lower left side of abdomen/bowel) perforation. After surgery he was admitted to the intensive care unit where he later died on 5/19/26 at unknown time.Standards of Nursing Care for diagnosed ileus was retrieved from nursetogether.com on 5/20/26 at 9:15 A.M. which indicated nurses should assess and monitor the abdomen for abdominal discomfort due to bloating and distension; palpate the abdomen for tenderness; check bowel sounds with stethoscope for decreased sounds; monitor bowel movements and passing of gas; measure the abdominal girth for increasing size indicating worsening distention; and monitor and record vital signs such as low blood pressure or elevated heart rate which could indicate shock requiring immediate emergency care.Current facility policies, titled Change in Condition/Physician Notification and Physician Orders were provided on 5/20/26 at 12:38 P.M. by the DON. Change in Condition/Physician Notification policy indicated significant changes in a resident's condition should be reported to the physician/NP within 24 hours and the Charge Nurse was to document the change, interventions, and notifications timely. Physician Orders policy indicated the purpose was to provide a reliable process for proper and consistent provision of physician ordered services according to professional standards of quality. The facility was to maintain a schedule of diagnostic tests in accordance with the physician's orders. Nursing personnel were to submit timely requests for physician ordered services (labs, x-rays) to the appropriate entity. Upon receipt of critical lab or x-ray result reports, nurses were to communicate the results to the ordering provider for immediate attention. Nursing personnel were to document diagnostic test results and date/time of physician notification in the resident's record.A request for a policy indicating how the facility monitored and assessed acute significant changes was not provided. No policy was available at exit regarding assessments and monitoring after change of condition. The Immediate Jeopardy that began on 5/15/26 was removed on 5/20/26 when the facility re-educated floor nurses on facility policies for change in condition, physical assessments for GI (gastrointestinal) complaints and process for entering labs/x-rays in the facility designated system but will remain at the lower scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy.This Citation relates to Intake 3014046.410 IAC (Indiana Administrative Code) 16.2-3.1-37

Based on interview and record review, the facility failed to ensure appropriate weight management interventions were implemented, including follow-up for identified weight loss and notification of the physician regarding significant weight changes for 2 of 3 residents reviewed (Resident 11 and Resident 50). This resulted in severe unintended resident weight loss for Resident 11 and Resident 50. Findings include:1. Resident 11's record was reviewed on 3/17/2026 at 11:55 AM. Diagnoses included dehydration, urinary tract infection (UTI), acute kidney failure and severe sepsis without septic shock.A review of Resident 11's weights indicated on 2/10/26, Resident 11 weighed 110 pounds. On 2/16/2026, Resident 11 weighed 110.0 pounds. On 2/17/2926 Resident 11 weighed 103 pounds, a loss of 7 pounds and 6.3%. On 2/25/2026, Resident 11 weighed 103 pounds. On 3/2/2026, Resident 11 weighed 104 pounds. On 3/9/2026, Resident 11 weighed 102.2 pounds, an additional loss of 1.8 pounds for a total loss of 8.8 pounds or 7.26% in 1 month.The facility could provide no documentation to indicate the severe weight loss had been identified or any interventions were put into place between 2/17/26 and 3/11/26 when the dietician identified the weight loss. Resident 11's current care plan indicated the resident had a problem of potential nutritional risk related to a diagnosis of dehydration, UTI, acute kidney failure and severe sepsis, with a goal Resident 11 would not exhibit significant weight loss through the next review, with a goal date of 5/20/2026. Interventions included registered dietitian (RD) to evaluate and make diet change recommendations as needed, weights as ordered/indicated and notify medical doctor (MD) of significant weight changes.Physician orders dated, 2/9/2026 at 6:05 PM, indicated Resident 11 had a regular diet order, regular texture and thin consistency. The order indicated Resident 11 was to receive fortified cereal at breakfast.Resident 11's record indicated from 2/16/2026, when Resident 11 weighed 110.0 pounds, to 2/17/2926 and 2/25/2026, when Resident 11 weighed 103 pounds, the facility did not implement or identify any interventions in response to the weight loss. A progress note, dated 3/11/2026 at 3:26 PM, by Dietary indicated Resident 11 was reviewed for significant weight. The progress note indicated the root cause for Resident 11's weight loss was unknown, as meal intakes were recorded at 76-100%. The progress note indicated Resident 11 received fortified cereal at breakfast for calorie support. The progress note indicated the weight loss was not desired, as body mass index (BMI) was underweight. The progress note indicated a recommendation to start Ensure plus HP 237mililiters daily. Resident 11's breakfast meal ticket, dated3/18/2026, indicated Resident 11 received juice of choice, pumpkin spice oatmeal, sausage gravy, scrambled egg, biscuit, margarine, 2% milk and coffee. The meal ticket indicated Resident 11 had a diet of regular, regular texture, and thin consistency. The meal ticket did not indicate Resident 11 received fortified cereal.A review of Resident 11's physician orders was completed on 03/17/2026 and no orders for Ensure plus HP 237 milliliters were located.A review of Resident 11's progress notes was completed on 3/18/2026 and no documentation indicating the MD was notified regarding Resident 11's weight was located.A review of Resident 11's progress notes was completed on 3/18/2026 and no additional documentation regarding Resident 11's weight loss or implementation of interventions was located.In an interview on, 03/18/2026 at 11:03 AM, Unit Manager (UM 11) indicated she had just called and notified Resident 11's family of the weight loss and had entered a progress note. UM 11 indicated she had also just called the MD and notified them of Resident 11's weight loss and the recommendation from the RD to begin Ensure. UM 11 indicated the NP had not been notified of the weight loss or recommendation for Ensure prior to the call on 3/18/2026. UM 11 indicated the NP would be putting in an order for Ensure. UM 11 indicated Resident 11 was being reviewed weekly however, there were no IDT or progress notes provided to show that Resident 11's weight was being reviewed.In an interview, on 03/19/2026 at 9:40 AM, the Dietary Manager indicated Resident 11's meal ticket did not have fortified cereal however, indicated they had a fortified list the resident was on.In an interview, on 03/19/2026 at 9:53 AM, the Dietary Manager indicated they were unsure if Resident 11 received fortified cereal that morning, as it was not on the meal ticket.In an interview, on 03/19/2026 at 10:00 AM, Registered Nurse (RN) 12 and Certified Nursing Assistant (CNA) 13 indicated Resident 11 did not receive cereal with her breakfast.2. Resident 50's record was reviewed on 3/17/2026 at 1:08 PM. Diagnosis included psychotic disorder with delusions, unspecified dementia severe, depression and alcohol dependence.Resident 50's weights indicated on 12/5/2025, Resident 50 weighed 176 pounds. On 1/8/2026, Resident 50 weighed 170 pounds. On 2/5/2026, Resident 50 weighed 168 pounds. On 3/12/2026, Resident 50 weighed 157.2 pounds. Resident 50 experienced a weight loss of -10.68% from 12/5/2025 to 3/12/2026.Resident 50's current care plan indicated Resident 50 had a problem of potential for nutritional risk related to elevated BMI due to a diagnosis of psychosis, dementia, depression, and alcohol abuse, with a goal Resident 50 would not exhibit significant weight loss through the next review, with a goal date of 4/8/2026. Interventions included RD to evaluate and make diet change recommendations as needed, weights as ordered/indicated and notify MD of significant weight changes.A progress note dated, 2/2/2026 at 7:36 AM, by Nursing indicated the interdisciplinary team (IDT) monitored the resident for weight loss during a risk management meeting. The progress note indicated restorative staff were to obtain monthly weights and if weight loss was noted, the writer would follow up with RD for supplements.A review of Resident 50's progress notes was completed on 3/19/2026 and no additional documentation regarding Resident 50's weight loss or implementation of interventions was located.A review of Resident 50's progress notes was completed on 3/19/2026 and no documentation indicating the MD was notified regarding Resident 50's weight was located.In an interview, on 03/20/2026 at 9:45 AM, RNCD indicated they were unable to locate any additional weight loss progress notes or interventions for Resident 50.In an interview, on 03/20/2026 at 11:20 AM, RNCD indicated they were unable to find any documentation that the physician was notified of Resident 50's weight loss.A current policy titled Change in Condition/ Physician Notification, dated 4/1/2025, provided by RNCD indicated, The nurse will notify the physician/NP/PA and the resident/resident representative when abnormal labs, weight or vital signs. Notification will be attempted within 24 hours unless in the case of an emergency.If a significant change in condition occurs, a comprehensive assessment of the resident's/patient's condition will be conducted as outlined in the MDS RAI Instruction Manual.410 IAC (Indiana Administrative Code) 16.2-3.1-46 (a)(1)410 IAC (Indiana Administrative Code) 16.2-3.1-46 (a)(2)

Based on interview and record review the facility failed to ensure resident pain medication was secured to prevent misappropriation for 4 of 16 residents reviewed. (Resident 2, Resident 53, Resident 64, and Resident 92)Findings include: 1) Resident 2's record review began on 3/20/26 at 10:06am. Resident 2's diagnosis included necrotizing fasciitis, end stage renal disease, and heart disease. Resident 2's physician order, dated 2/25/26, indicated to give oxycodone 10mg one tablet every 6 hours for pain management. A review of Resident 2's March Medication Administration Record (MAR) compared with his controlled count sheet determined the following dates and times Oxycodone 10mg tabs were taken from Resident 2's controlled substance supply and not documented on the MAR or progress notes as administered to Resident 2:3/2/26 at 7:30 (am or pm was not specified)3/3/26 at 8:10 (am or pm was not specified)3/4/26 at 8:30 (am or pm was not specified)3/6/26 at 7:35 (am or pm was not specified)3/7/26 at 8:15 (am or pm was not specified)3/7/26 at 11:27 (am or pm was not specified)3/8/26 at 8:35 (am or pm was not specified)3/9/26 at 6:55am3/11/26 at 8:10am3/12/26 at 8:00am3/13/26 at 7:13am3/15/26 at 7:12am3/16/26 at 7:15am3/17/26 at 8:05amA total of 14 Oxycodone tablets taken from Resident 2's controlled substance supply was not documented on the MAR or progress notes as administered to Resident 2. 2) Resident 53's record review began on 3/20/26 at 9:26AM. Resident 53's diagnosis included end stage renal disease, diabetes, and heart disease. Resident 53's physician order, dated 3/5/26, indicated to give hydrocodone/APAP 5/325 one tablet as needed every 8 hours for pain. Resident 53's March controlled count sheets in comparison to his March MAR indicated the following dates and times hydrocodone/APAP 5/325 was taken from Resident 53's controlled substance supply but not documented in MAR or progress notes as administered to the resident:3/11/26 7:30 (am or pm was not specified)3/12/26 10:00am3/13/26 1:30am3/13/26 7:30am3/13/26 3:30 (am or pm was not specified)3/16/26 4:00am3/17/26 12:26am3/17/26 8:30amA total of 8 doses of hydrocodone/APAP 5/325 was taken from Resident 53's controlled substance supply and not documented on the MAR or progress notes as administered to Resident 53. 3) Resident 64's record was reviewed on 3/20/26 at 10:32AM. Resident 64's diagnosis included respiratory failure, diabetes, and fibromyalgia. Resident 64's physician's order, dated 8/1/25, indicated to give hydromorphone 8mg tablet 1 tablet every 4 hours as needed for chronic pain. A review of Resident 64's March MAR compared to her controlled substance count sheet determined the following dates and times medications were removed from her controlled substance supply and not documented in MAR or progress notes as administered to Resident 64:3/13/26 9:30 (am or pm not specified)3/13/26 1:30 (am or pm not specified) 3/13/26 6:00pm3/16/26 10:00am3/16/26 2:00pm3/16/26 4:22pm3/17/26 2:25am3/17/26 5:55am3/17/26 9:20amA total of 9 hydromorphone 8mg tablets were taken from Resident 64's controlled substance supply were not documented on the MAR or in the progress notes as administered to her. 4) Resident 92's record review began on 03/18/2026 at 9:52AM. Diagnosis included end stage renal disease, diabetes, and heart disease.Resident 92 had the following orders for Dilaudid (hydromorphone) 4mg tablets. 1) Hydromorphone HCL oral tablet give 1 tablet every 4 hours as needed for pain above a 5 dated 12/4/26 through 1/22/26.2) Hydromorphone HCL oral tablet give 1 tablet every 4 hours as needed for pain. dated 2/8/26-2/27/26.3) Dilaudid (Hydromorphone) 4mg tablet every 4 hours for pain 2/27/26-3/9/26. Resident 92's controlled count sheets compared with the MARs, dated January and February 2026, indicated the following dates and times were signed out without being accounted for on the MAR's in the months dated January and February 2026:1/9/26 at 11:15AM1/10/26 at 9:00 (did not indicate am or pm)1/11/26 at 10:50 (did not indicate am or pm)1/12/26 at 11:00 (did not indicate am or pm) 1/13/26 at 8:15AM 1/13/26 at 5;30PM2/9/26 at 2:31PM2/9/26 at 8:30PM2/10/26 at 7:30AM2/10/26 at 7:00PM2/11/26 at 4:10AM2/11/26 at 12:00PM2/13/26 at 2:13 PM2/14/26 at 9:00AM2/15/26 at 6:00am2/15/26 at 11:00am2/15/26 at 6:00pm2/16/26 at 7:35am2/16/26 at 11:40am2/17/26 at 5:21am2/18/26 at 7:00am2/18/26 at 11:00am2/19/26 at 7:15am2/19/26 at 4:00pm2/20/26 at 7:30am2/20/26 at 8:10pm2/21/26 at 12:00am2/21/26 at 4:00am2/21/26 at 8:00am2/21/26 at 12:00pm2/21/26 at 4:30pm2/22/26 at 8:35am2/22/26 at 12:31pm2/23/26 at 11:55am2/23/26 at 10:00pm2/24/26 at 2:00am2/24/26 at 7:00am2/24/26 at 11:00am2/24/26 at 3:00pm2/24/26 at 7:00pm2/25/26 at 8:00am2/25/26 at 12:00pm2/25/26 at 5:30pm2/26/26 at 5:34am2/26/26 at 9:30 (did not indicate am or pm)2/26/26 at 1:30pm2/26/26 at 4:30 pm2/27/26 at 7:00am2/27/26 at 11:00amA total of 45 Dilaudid (hydromorphone) 4mg tablets were signed out on the controlled substance count sheet but not documented on Resident 92's MAR or in the progress notes. The controlled substance count sheet, provided by pharmacy, indicated each dose administered must be charted. In an interview, on 03/19/2026 at 7:27 AM, Licensed Practical Nurse (LPN) 2 indicated when she had an order for an as needed medication but only had the routine medication in stock, she would attempt to get the medication from the emergency drug supply or contact her supervisor to get advisement and document in progress notes. LPN 2 indicated in order to complete administration of medication the staff mark it off on the MAR as given to ensure right documentation. LPN 2 indicated when the medication was not documented as administered on the MAR, there was no way to know the medication had been given. In an interview, on 3/19/26, an anonymous resident indicated they could not get their controlled substance pain medications when needed due to being told they have to wait until able to have it again even when they haven't had it all day even when the medication was scheduled to be given every few hours as needed. In an interview, on 03/20/2026 at 12:22 PM, LPN 10 indicated when a medication was given it was to be documented in the MAR. When the medication was not documented on the MAR, then there was no way to determine the mediation had been given. 410 IAC (Indiana Administrative Code) 16.2-3.1-28(a)

Based on interview and record review the facility failed to provide nonpharmacological interventions to 4 of 4 residents reviewed. (Resident 1, Resident 2, Resident 64, and Resident 92)Findings include: 1) In an interview, on [DATE] at 9:59 AM, Resident 1 indicated the facility only provided medication for pain management. Resident 1 indicated knowledge massages could be helpful from use in physical therapy. Resident denied any massages, ice, or other non-pharmacological interventions were given prior to as needed pain medication administration. Resident 1's record was reviewed [DATE] at 9:16 AM. Diagnosis included heart disease, lung disease, and depression. Resident 1's physician order, dated [DATE], indicated to give oxycodone-Acetaminophen 5-325mg 1 tablet by mouth every 4 hours as needed for pain. Resident 1's [DATE] Medication Administration Record (MAR) indicated he received the pain medication without any documentation of non-pharmacological interventions in the MAR as follows:[DATE] at 7:11pm[DATE] at 12:05pm and 5:20pm[DATE] at 4:28pm[DATE] at 6:15pm[DATE] at 4:20am, 12:16pm, and 6:48pm[DATE] at 7:55am and 3:11pm[DATE] at 7:30pm[DATE] at 4:26pm[DATE] at 11:21am[DATE] at 4:25pm[DATE] at 3:19pm and 8:47pm[DATE] at 1:09pm and 5:28pm[DATE] at 4:17pm[DATE] at 12:26am, 4:13pm, and 9:06pm[DATE] at 1:32am, 10:15am, 4:12pm, and 8:43pm A review of Resident 1's progress notes did not indicate any non-pharmacological interventions had been completed on any of the above dates or times. Resident 1's current care plan, dated [DATE], indicated to offer nonpharmacological interventions such as position change, relaxation, quiet environment, back rub, and diversional activity. A record review of Resident 1's March MAR and progress notes indicated no nonpharmacological measures were provided prior when oxycodone was administered. In an interview, on [DATE] at 12:22 PM, Licensed Practical Nurse LPN) 2 indicated when nonpharmacological interventions were not effective medication could be given, but nonpharmacological interventions were to be documented. LPN 2 indicated when nonpharmacological interventions were not charted, then there was no way to tell the interventions were attempted. 2) Resident 2's record was reviewed on [DATE] at 10:24 AM diagnosis included necrotizing fasciitis, end stage renal disease, and depression. Resident 2's physician order, dated [DATE], indicated to give oxycodone 10mg oral tablet 1 tablet by mouth every 6 hours as needed for pain Resident 2's [DATE] Medication Administration Record (MAR) indicated he received the pain medication without any documentation of nonpharmacological interventions in the MAR as follows:[DATE] at 7:46pm[DATE] at 4:46am[DATE] at 5:22pm[DATE] 10:17pm[DATE] at 7:32am[DATE] at 7:51am In Resident 2's [DATE] MAR was an area for documenting nonpharmacological nursing measures offered to resident prior to giving as needed pain medication. This area was blank, without any documentation. A review of Resident 2's progress notes did not indicate any nonpharmacological interventions on any of the above dates or times. A record review of Resident 2's [DATE] MAR and progress notes indicated no nonpharmacological measures were completed prior to oxycodone being administered. 3) Resident 64's record was reviewed, on [DATE] at 10:42am. Diagnosis included respiratory failure, diabetes, and fibromyalgia. Resident 64's physician order, dated [DATE], to give hydromorphone 8mg tablet, 1 tablet as needed every 4 hours for chronic pain. A review of Resident 64's [DATE] MAR indicated Resident 64 received the hydromorphone without documentation of nonpharmacological interventions on the following dates and times:[DATE] at 12:22pm[DATE] at 12:25am and 5:08pm[DATE] at 5:00pm[DATE] at 1:09am, 4:18pm, and 8:32pm[DATE] at 12:37am, 4:42am, 9:45am, 4:06pm, and 7:29pm[DATE] at 5:03pm[DATE] at 1:07am[DATE] at 4:51pm and 9:31pm[DATE] at 1:16am, 11:40am, and 8:44pm[DATE] at 5:30pm[DATE] at 1:08am, and 5:13am[DATE] at 12:05am and 6:35am[DATE] at 1:19am, 5:23am, and 10:07pm[DATE] at 2:29am, 8:47am, 5:21pm, and 9:21pm[DATE] at 5:26am, 9:59am, 2:30pm, and 9:39pm[DATE] at 2:00am and 6:22pm[DATE] at 1:45pm, 6:09pm, and 10:30pm[DATE] at 2:30am, 7:57am, 1:27pm, 6:22pm, and 11:15pm[DATE] at 3:27am, 8:17am, 1:46pm, 5:36pm, and 11:00pm[DATE] at 7:45am In Resident 64's [DATE] MAR to an area for documenting nonpharmacological nursing measures offered to resident prior to giving as needed pain medication. This area was blank, without any documentation. A review of Resident 64's progress notes did not indicate any nonpharmacological interventions on any of the above dates or times. A record review of Resident 64's [DATE] MAR and progress notes indicated no nonpharmacological measures were taken prior to hydromorphone being administered. 4) Resident 92's record was reviewed on [DATE] at 11:08am. Diagnosis included respiratory disease, diabetes, and end stage renal disease. Resident 92's physician order, dated [DATE], indicated to give hydromorphone 4mg 1 tablet as needed every 4 hours for pain. The order expired on [DATE]. A review of Resident 92's February 2026 MAR indicated Resident 92 received the hydromorphone on the following dates and times:[DATE] at 9:16pm[DATE] at 1:51am and 6:38am[DATE] at 4:30am[DATE] at 4:08am and 4:45pm[DATE] at 5:05am and 6:18pm[DATE] at 3:23am, 7:59am, 2:12pm, and 7:03pm[DATE] at 5:30am and 9:25pm[DATE] at 3:34am and 9:59pm[DATE] at 11:02am[DATE] at 5:48pm:50am[DATE] at 2:52am and 11:30am[DATE] at 12:25am, 11:29am, and 4:32pm[DATE] at 12:00am and 9:28pm[DATE] at 4:33am and 9:28pm[DATE] at 3:50am and 7:50am[DATE] at 11:06pm[DATE] at 4:16am and 9:32pm[DATE] at 1:34am and 4:26pm[DATE] at 4:22am. A review of Resident 92's progress notes did not indicate any nonpharmacological interventions on any of the above dates or times. Resident 92's [DATE] MAR and progress notes indicated no nonpharmacological measures were taken prior when hydromorphone was administered. In an interview, on [DATE] at 10:12 am, the Executive Director and the Regional Nurse Consultant indicated Resident 1, Resident 2, Resident 64, and Resident 92 did not have nonpharmacological interventions prior to administration of as needed pain medication. A policy titled, Pain Management, reviewed [DATE], was provided by the Executive Director on [DATE] at 11:10AM. The policy indicated the following:6. Non-pharmacological interventions will include but are not limited to:a. Environmental comfort measures such as adjusting room temperature, smoothing linens,comfortable seating, assistive devices or pressure redistributing mattress and positioning.b. Loosening any constrictive bandage, clothing or devicec. Applying splinting such as pillow or folded blanket.d. Physical modalities such as cold compress, warm shower/bath, massage, turning andrepositioning.e. Exercises to address stiffness and prevent contractures as well as restorative nursing programsto maintain joint mobilityf. Cognitive/behavioral interventions such as music, relaxation techniques, activities, diversions,spiritual and comfort support, teaching the resident coping techniques and education aboutpain. 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on interview and record review, the facility failed to ensure a neurological evaluation was completed after a blow to the eye for 1 of 3 residents reviewed. (Resident 55)Findings Include:A progress note, dated 3/10/2026 at 10:19 PM, indicated Resident 55 was sitting on their bed. The progress note indicated Resident 55 stated another resident hit him near his eye and upon assessment, Resident 55 was noted to have bruising to their left eye and a scratch under his right eye.A progress note dated 3/11/2026 at 5:18 PM, indicated the Interdisciplinary Team (IDT) met to review the incident on 3/10/2026 around 10 PM. The progress note indicated Resident 55 was in his room sitting on his bed when a nurse was called to the unit, as another resident had made contact with Resident 55 in the face.A 15-minute check on 3/13/2026 at 10:50 AM indicated Resident 55 was resting in bed with left eye bruising/swelling.A 15-minute charting on 3/15/2026 at 11:50 AM indicated Resident 55's bruising continued to heal.A 15-minute charting on 3/16/2026 at 1:02 PM indicated Resident 55's bruising continued to heal.A 15-minute charting on 3/18/2026 at 12:14 PM indicated Resident 55's bruising continued to heal.A 15-minute charting on 3/19/2026 at 11:23 AM indicated Resident 55's bruising continued to heal.In an interview, on 03/18/2026 at 1:48 PM, the Regional [NAME] President of Operations (RVPO) indicated the facility did not complete neurological checks.In an interview, on 03/20/2026 at 11:20 AM, the Regional Nurse Consultant (RNC) indicated the facility did not complete a neurological assessment.A current policy titled Head Injury, dated 1/2/2024, provided by the RNC indicated, Assess resident following a known, suspected or verbalized head injury. The assessment shall include at a minimum: . Neurological evaluation for changes in: physical function, behavior, cognition, level of consciousness, dizziness, nausea, irritability, slurred speech or slow to answer question. perform neuro checks as indicated or specified by the physician.This citation is related to intake 2802197410 IAC (Indiana Administrative Code) 16.2-3.1-45 (a)(1)

Based on record review and interview the facility failed to destroy a deceased resident's controlled substance in a timely manner for 1 of 1 resident reviewed. (Resident 92)Findings include: Resident 92's record review began on [DATE] at 2:10 PM. Diagnosis included end stage renal disease, diabetes, and heart disease.Progress notes confirmed Resident 92's respiration had ceased on [DATE] at 10:53am.Resident 92's controlled count sheet for hydromorphone (Dilaudid) 4mg tablets indicated a tablet was signed out at 1:00pm, 5:00pm, and 9:00pm on [DATE]. After Resident 92 was no longer alive. Licensed Practical Nurse (LPN)11's time card verified she did not work on [DATE]. Her initials were documented on [DATE] at the times 1:00pm, 5:00pm, and 9:00pm indicated on the controlled count sheet for hydromorphone (DIlaudid) 4mg tablets.Resident 92's controlled count sheet for hydromorphone 4mg tablets entries dated [DATE] at 1:00pm, 5:00pm, and 9:00pm were not questioned until [DATE]-5 days later. These medications were counted by several nurses but not destroyed timely after the death of Resident 92. In an interview, on [DATE] at 11:10am, the Regional Nurse Consultant indicated the medications should have been destroyed in a timely manner. A policy titled, Medication Administration dated [DATE] reviewed [DATE], provided by Regional Nurse Consultant on [DATE] at 12.Controlled medications remaining in the facility after discontinued were destroyed by 2 licensed nurses, or otherwise directed by law, in a timely manner. 410 IAC (Indiana Administrative Code) 16.2-3.1-25 (a)

Based on interview and record review, the facility failed to ensure physician orders for wound treatment were completed for 1 of 2 residents reviewed with pressure ulcers (Resident E). Findings include:On 2/4/26 at 11:36 A.M., Resident E's record was reviewed. Diagnoses included schizophrenia, dementia, anxiety disorder, and hip fracture.A significant change Minimum Data Set (MDS) assessment, dated 1/6/26, indicated a Brief Interview Mental Status (BIMS) of 9 indicating Resident E had moderately impaired cognition with delusions. She had 1 unstageable pressure ulcer and 2 unstageable pressure injuries.A care plan, dated 1/16/26, indicated Resident E had been re-admitted to the facility with an unstageable pressure ulcer to her sacrum/coccyx. Interventions included providing wound treatment as ordered.A physician order, dated 1/14/26, indicated to administer Dakins (1/4 strength) External Solution 0.125% (Sodium Hypochlorite)- Apply to coccyx every shift. Cleanse coccyx with Dakins dampened Kerlix, apply Therahoney to the sacrum and cover with Mepilex dressing.A Medication Administration Record (MAR), dated January 2026, indicated treatment to Resident D's coccyx wound was not completed, as ordered as evidenced by an absence of completion initials on 1/22, 1/24, and 1/25/26.On 2/5/26 at 1:19 P.M., Qualified Medication Aide (QMA) 2 was interviewed. She indicated documentation of medications or treatments was completed on the MAR, not initialed indicated the treatment had not been completed.On 2/5/26 at 1:22 P.M., Licensed Practical Nurse (LPN) 4 was interviewed. She indicated medications and treatments were to be completed as ordered by the physician and initialed on the MAR or treatment administration record (TAR), she indicated a lack of documentation on either record indicated the treatment had not been completed.On 2/5/26 at 2:15 p.m., the Administrator provided a current facility policy regarding completing care as ordered by the physician. The policy indicated care and services were to be provided as ordered by the physician.This Citation relates to Intake 2715286.3.1-40

Based on interview and record review, the facility failed to ensure residents were free from exploitation related to personal funds for 1 of 1 resident reviewed (Resident E).Findings include:On 11/24/25 at 1:10 P.M., Resident E's record was reviewed. Diagnoses included diabetes, anxiety, and depression.A quarterly Minimum Data Set (MDS) assessment, dated 10/21/25, indicated Resident E was cognitively intact and able to make decisions.A Report of Concern, dated 10/12/25, indicated Resident E reported, Certified Nurse Aide (CNA) 5 had asked him to lend her money about 1 month prior. CNA 5 indicated she was short on funds and needed the money to pay bills. Resident E loaned her 400 dollars with the agreement the CNA would pay back. Since giving her the money, CNA 5 avoided him and didn't pay back any money.An investigation of the concern indicated CNA 5 was placed on suspension. While suspended, CNA 5 refused to take calls or be part of the investigation. An undated written note from CNA 5 to Resident E, indicated the CNA just got her paycheck, the check wouldn't cover bills due that day, and services could be disconnected. The CNA wrote she had been in her car crying because she hadn't known what to do. The note indicated 400 dollars was loaned to CNA 5.On 11/24/25 at 1:27 P.M., the Administrator was interviewed. He indicated the allegation was confirmed after reviewing Resident E's withdrawals of cash from his account approximately 1 month prior to the reported incident. Resident E had withdrawn 400 dollars. The Administrator indicated Resident E didn't wanted to report it, but the CNA didn't pay back the money and seemed to be avoiding him. The resident hadn't wanted the CNA to get in trouble, but he was getting ready to discharge from the facility and needed to purchase items for his new apartment. The Administrator indicated after the investigation was completed, the facility replaced the money and gave Resident E a check for 400 dollars.A current facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation was provided by the Administrator on 11/24/25 at 1:45 P.M. The policy indicated residents had a right to be free from exploitation, defined as taking advantage of a resident for personal gain through manipulation, intimidation, threats, or coercion. Residents had a right to be free from misappropriation of property, defined as deliberate misplacement, exploitation, or wrongful use of a resident's belongings or money without resident consent.This Citation relates to Intake 2641578.3.1-28(a)

Based on observation, interview, and record review, the facility failed to ensure opportunities to participate in the care planning process and inclusion in decisions about care and treatment for 1 of 3 residents reviewed for resident rights (Resident H). Findings include:A report, dated 10/1/25 at 10:30 a.m., alleged Resident H had been verbally and physically abused by Licensed Practical Nurse (LPN) 2. He alleged LPN 2 refused to let him have things his care plan indicated he was allowed. Resident H reported this to the Administrator and the Ombudsman. Resident H was allegedly told LPN 2 would no longer be assigned to care for him. The resident alleged he was being retaliated against for filing a police report against LPN 2 and the facility for alleged neglect. The report alleged someone from another facility, in another town, an hour from the current one, came to see the resident to assess him for possible discharge to their facility. Resident H had not requested nor given permission to be assessed by the other facility and had no intention of moving out of the current facility. On 10/14/25 at 11:23 A.M., Resident H's record was reviewed. Diagnoses included high blood pressure, diabetes, depression, and history of alcohol abuse.On 10/14/25 at 2:00 P.M., Resident H was observed in his room. He lay in bed and had several personal items sitting within his reach on 2 overbed tables next to him. A small refrigerator sat on a bedside stand next to the overbed tables which could not be accessed when lying in bed. An opened case of beer sat on the other side of the room on a bedside stand. A camo-colored cooler sat on his bed. Resident H indicated the cooler held some cans of beer. Beside his bed, on the right side, was a tall cabinet with an open lock on the door. He indicated on 9/20/25, LPN 2 had been standing at the end of his bed when he reached out to get his cup of ice with his left hand and alleged LPN 2 reached across the end of the bed and smacked his hand. When the incident occurred, he called the police to file a report against the nurse. After the incident, Resident H spoke with the Ombudsman and a meeting between the resident, Ombudsman, and staff was arranged for 9/24/25. He indicated the meeting had been held as planned and during the meeting, he had requested LPN 2 not care for him nor come into his room. He alleged LPN 2 was retaliating against him for calling the police by denying his request for alcohol, refusing to assist him when he put on the call light and hanging up on him when he tried to call the nurses station to have someone answer his light. He indicated, since the incident, he had asked several times for LPN 2 not to come into his room, but she continued to work on his hall and provide him care. He alleged LPN 2 was told to avoid him, yet she continued to be his nurse despite management being aware of his concerns with the nurse smacking his hand. He indicated about a week ago, a man from a facility in [NAME] came to him to talk about him moving to [NAME] and living at another facility. The resident indicated he had been very angry because he had not requested anyone from any other facility come speak with him about moving. He indicated his family lived here in town and he wasn't moving to a facility an hour away. He indicated the facility was his home and he wasn't leaving.A Social Service Progress Review for MDS (Minimum Data Set assessment), dated 9/23/25, indicated Resident H had no impaired cognition and was responsible for himself.Care plans indicated Resident H was able to keep alcohol in his room within a locked storage area. He had a physician order for 2 beers at bedside within 24 hours but would request additional cans of beer. He was to store his alcoholic beverages safely behind his bed in a locked cabinet. His care plan indicated his wishes were to stay long term at the facility. Care plans did not indicate Resident H had requested LPN 2 not be assigned to care for him or not come into his room.An Interdisciplinary Team (IDT) note, dated 10/9/25 at 3:08 p.m., indicated the Social Services Designee (SSD) and Memory Care Facilitator (MCF) went to Resident H's room to let him know there was a gentleman from another facility who wanted to speak with him about possibly coming to live at their facility. Resident H became angry, yelling, and cursing at the SSD and MCF. He indicated he would not talk with anyone at any time. He believed staff were trying to hoodwink him. The MCF indicated Resident H had expressed on numerous occasions, he was unhappy at the facility so they found another facility with things he might enjoy. Resident H asked if this is coming from the administrator or higher up and was told, everyone was just trying to make him happy. The resident refused to speak with the visitor. He continued to curse at staff and indicated he would not go anywhere unless he chose to do so as it was his decision to make.On 10/14/25 at 10:04 A.M., the Ombudsman was interviewed. She indicated Resident H had not been given a 30-day discharge and was unclear why facility staff had invited another facility to visit and assess him to move to their facility, an hour away. Resident H had not initiated the assessment and had no plans to leave the facility. The Ombudsman indicated she had been present for a meeting on 9/24/25 with Resident H, the Administrator, and Director of Nursing (DON). During the meeting, the resident requested LPN 2 not care for him or come into his room. Resident H had alleged the nurse had slapped his hand and was being retaliated against for filing a police report. The Ombudsman indicated Resident H reported to her, LPN 2 continued to be assigned to care for him and come into his room despite his wishes.Progress notes, completed by LPN 2 and dated after the meeting on 9/24/25, indicated:-9/27/25 at 7:15 p.m., staff reported the resident requested beers for himself and roommate.-9/29/25 at 6:02 p.m., staff reported to LPN 2, Resident H was giving beers to his roommate and was reported to the Unit Manager. The resident's orders were for his beer to be kept locked up and have only 1 beer daily. At 8:49 p.m., the Qualified Medication Aide (QMA) reported the resident had 3 beers. He indicated he could do what he wanted and f--- the NP and LPN 2. The QMA reminded him of the order and he began yelling at her.-9/30/25 at 4:05 a.m., Resident H turned on his call light and asked 2 Certified Nurse Aides (CNA) to get him beer. He was told he already had beers on his table which angered him and he began yelling and cursing about LPN 2. He was combative and verbally attacked staff for following physician orders.-10/4/25 at 2:25 p.m., Resident H refused to allow staff to enter his room and perform patient care. At 4:38 p.m., LPN 2 answered 2 phone calls from Resident H's friend who asked if someone could go to resident's room because he kept calling them, stating no one would come to his room to assist him, and he was going to call 911. The friend was informed, several staff had made attempts to assist the resident, but he had refused. LPN 2 and a CNA tried to answer the resident's call light but he refused and said he was calling the police to report neglect. Resident H was observed dumping his urine bucket on himself while lying in bed. Both staff members left the room. -10/6/25 at 3:53 p.m., the medical Nurse Practitioner (NP) visited and asked LPN 2 to go with him into Resident H's room. When they entered the room, the resident informed the NP and nurse he was recording anyone who came into his room and was reporting to the Indiana Department of Health. He began to verbalize accusations against LPN 2. At 7:28 p.m., Resident H continued to make false accusations against staff and recorded staff without their permission.An NP progress note, dated 10/6/25, indicated the NP was accompanied by LPN 2 during his visit. Resident H turned conversation towards LPN 2 and began to raise his voice, making accusations against the nurse. He accused LPN 2 of hitting him which he had reported to the state Department of Health. The exam was deferred with the resident due to his body language, verbal behaviors, and resident recording visit. The NP and LPN 2 exited the room.LPN 2 continued to provide care to Resident H on 9/27, 9/29, 9/30, 10/4, 10/6, and 10/7/25 following the resident's meeting with the Ombudsman, Administrator, and DON on 9/24/25, when he requested LPN 2 not care for him or come into his room.On 10/16/25 at 10:35 A.M., the Administrator and DON were interviewed. The Administrator indicated he had been present during the meeting with the Ombudsman on 9/24/25 but couldn't recall the resident requesting LPN 2 not be assigned to care for him. The DON indicated she had been in and out of the room during the meeting but while in the resident's room, hadn't heard him say he hadn't wanted the nurse to care for him. When asked about the resident relocating to another facility and having someone from the other facility assess him, both indicated the resident had verbalized in the past, he wanted out of their building and would go anywhere to get away from the facility.A current policy, titled Resident Rights was provided by the Administrator on 10/16/25 at 11:00 A.M. The policy indicated residents had the right to be informed of and participate in his/her treatment including the development and implementation of his/her person-centered plan of care. Residents had the right to participate in the planning process, the right to request revisions to the person-centered plan, the right to establish goals and outcomes of care, and the right to be informed in advance of changes to the plan of care.This Citation relates to Intake 2633029.3.1-3(n)(3)

Based on interview and record review, the facility failed to ensure an allegation of physical abuse was reported timely for 1 of 3 residents reviewed for abuse (Resident H). Findings include:A report, dated 9/23/25 at 6:53 p.m., indicated Resident H alleged Licensed Practical Nurse (LPN) 2 struck him on his hand after the resident allegedly kicked LPN 2. A Certified Nurse Aide had been present during the incident and indicated they witnessed Resident H kick LPN 2 but hadn't seen LPN 2 strike the resident on the hand. A nurse progress note, dated 9/20/25 at 10:44 p.m., indicated Resident H became upset with LPN 2 over a physician order he hadn't agreed with. The resident became verbally aggressive and allegedly kicked LPN 2 in the face. Staff left the room to allow Resident H to calm down. After staff left the room, a police officer showed up at the facility after a 911 call, placed by Resident H, who alleged LPN 2 had struck him on the hand.On 10/16/25 at 10:35 A.M., the Administrator was interviewed. He indicated he had been notified of the incident on 9/20/25 (unknown time) but had not reported the incident until 9/23/25. He indicated he should have reported the incident within 24 hours after determining the resident had no injury or within 2 hours of the incident if an injury had occurred.A current facility policy, titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation was provided by the Administrator on 10/14/25 at 10:00 A.M., which indicated: All incidents and allegations of abuse, neglect, exploitation, mistreatment and misappropriation of resident and injuries of unknown source were to be reported immediately to the Administrator.If any form of abuse is alleged or serious bodily injury has occurred related to the allegation, the Administrator was to notify the Indiana Department of Health immediately but no later than 2 hours.All other allegations were to be reported immediately but no later that 24 hours from the time the incident/allegation was made known to staff.This Citation relates to Intake 2633029.3.1-28(c)

Based on observation, interview and record review, the facility failed to thoroughly investigate an allegation of abuse and ensure measures were in place to prevent further abuse while the investigation was in process for 1 of 3 residents reviewed for abuse (Resident H).Findings include:A report, dated 10/1/25 at 10:30 a.m., alleged Resident H had been verbally and physically abused by Licensed Practical Nurse (LPN) 2. He alleged LPN 2 refused to let him have things his care plan indicated he was allowed and alleged she had smacked his hand. LPN 2 continued to work with him and on his unit despite his request to have her removed from his care. Resident H alleged LPN 2 was retaliating against him due to a police report he had filed against her. The alleged retaliation included delays in his call light being answered after being soiled, refusals to provide him with alcohol allowed per his care plan, and being hung up on by LPN 2 when trying to reach staff by phone, to answer his call light. On 10/14/25 at 2:00 P.M., Resident H was observed in his room. He lay in bed and had several personal items sitting within his reach on 2 overbed tables next to him. A small refrigerator sat on a bedside stand next to the overbed tables. The refrigerator could not be accessed when lying in bed. He indicated, on 9/20/25, LPN 2 had been standing at the end of his bed when he reached out to get his cup of ice with his left hand and alleged LPN 2 reached across the end of the bed and smacked his hand. He indicated he had an involuntary reaction and his foot went up in the air and grazed the nurse. He indicated he had been angry with her but had not intentionally kicked her. Resident H indicated he had asked several times for LPN 2 not to provide care to him but she continued to do so. He alleged LPN 2 was told to avoid him yet she continued to be his nurse despite management being aware of his concerns with the nurse smacking his hand.On 10/14/25 at 11:23 A.M., Resident H's record was reviewed. Diagnoses included high blood pressure, diabetes, depression, and history of alcohol abuse.A Social Service Progress Review for MDS (Minimum Data Set assessment), dated 9/23/25, indicated Resident H had no impaired cognition and was responsible for himself. A nurse progress note, dated 9/20/25 at 10:44 p.m., indicated Resident H became upset with LPN 2 over a physician order he hadn't agreed with. The resident became verbally aggressive and allegedly kicked LPN 2 in the face. Staff left the room to allow Resident H to calm down. After staff left the room, a police officer showed up at the facility after a 911 call, placed by Resident H, who alleged LPN 2 had struck him on the hand.On 10/14/25 at 3:35 P.M., the facilities investigation of the alleged abuse was reviewed. A statement by LPN 2 indicated, on 9/20/25 around 3:30 p.m., she had answered Resident H's call light. The resident requested she get him some pop, 2 cups of ice and several cans of beer. She told him he could only have one beer because the physician order was for 1 beer only. Resident H became angry, yelled and cursed at her so she left the room. She asked another staff member, a Certified Nurse Aide (CNA) to go back into the room with her when she took him back his 2 cups of ice and medication. CNA 3 went with LPN 2 back into the resident's room where she alleged, the resident continued yelling at her and threw the medication cup with pills in it onto the floor. LPN 2 indicated she was standing at the bottom of his bed when he kicked her in the face with his foot, witnessed by CNA 3. She left his room and went outside to calm herself down when she was notified a police officer was at the facility responding to a 911 call from Resident H. An undated statement by CNA 3, indicated she had witnessed Resident H yelling, cursing at LPN 2 and throwing his medication on the floor. She witnessed the resident kick LPN 2 but hadn't seen her smack his hand as alleged.There was no documentation completed following the incident on 9/20/25 until 9/23/25 at 2:18 p.m. The 9/23/25 documentation indicated Resident H had no aggressive behaviors during the day shift. There was no documentation to indicate Resident H had been assessed for injury after alleging LPN 2 had struck his left hand. LPN 2 continued working her evening shift and night shift as scheduled on 9/20/25. There was no documentation to indicate the Administrator had been notified of the incident on 9/20/25. LPN 2 continued to provide care to Resident H on 9/20, 9/21, 9/27, 9/29, 9/30, 10/4, 10/6, and 10/7/25. On 10/16/25 at 10:35 A.M., the Administrator was interviewed. He indicated he had been notified of the incident on 9/20/25 (unknown time) but had not reported the incident immediately. He indicated he had gotten Resident H's statement and statements by LPN 2 and CNA 3. He indicated CNA 3 was present and witnessed the resident kick the nurse in the face but had not seen the nurse hit the resident's hand. The investigation had been concluded at the time because there was a witness to the incident. When asked, the Administrator couldn't recall the resident asking to not have LPN 2 care for him. There had been no further interviews completed with other residents or staff to determine if there had been any other concerns with care provided by LPN 2. A current facility policy, titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation was provided by the Administrator on 10/14/25 at 10:00 A.M., which indicated: When notified of an allegation of abuse, staff were to report and protect the resident from further harm. The nurse was responsible for performing an initial assessment of the resident which included a full body assessment for possible injuries. If staff were involved in the allegation of abuse, the staff member was to be removed from the facility and suspended pending outcome of the investigation. Social Services were to be notified of the incident, so appropriate interventions are put in place for the residents psychosocial needs. The physician was to be notified of the allegation/incident and documentation completed in the nurse notes to include results of the full body assessment, notification to physician and family (if appropriate) and any treatment provided as a result of the incident.This Citation relates to Intake 2633029.3.1-28(d)

Based on observation, and interview, the facility failed to ensure the daily report of nursing staff directly responsible for resident care was accurately posted. This had the potential to effect 74 of 74 residents. Findings include: During an observation, on 4/6/25 at 9:01 AM, next to the front desk on the wall, visible to all. There was a plastic slot with several daily staffing postings inside. The date of the visible sheet was 4/3/25. The daily posting behind was dated for 4/2/25. The third one was dated 3/28/25. The last one was dated 3/6/25. There were several staff members observed to pass by the daily postings. In an interview, on 4/6/25 at 9:15 AM, the Maintenance Director indicated, he was not sure who was supposed to change the daily posts, he thought it might be the receptionist changed them every day she worked. The manager on duty was Medical Records. In an interview, on 4/6/25 at 9:31 AM, Medical Records indicated the scheduler changed the daily posting every day, she was inthe building and would be asked to change the staffing posting. In an interview, on 4/6/25 at 11:21 AM, the scheduler indicated the postings were filled out, placed into a binder, and when she was not at the building, the staff were supposed to replace them. She did not indicate which staff were responsible for changing the postings. A current facility policy, Posting direct care daily staffing Numbers, dated 7/2016, was provided by the Regional Nurse Consultant on 4/9/25 at 8:27 AM. The policy indicated . Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents .1. within two (2) hours of the beginning of each shift, the number of Licensed Nurses ( RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location ( accessible to residents and visitors) and in a clear and readable format

Based on observation, record review, and interview, the facility failed to maintian sanitary conditions related to kitchen equipment, hand hygiene while serving a meal, and use proper labeling. 74 of 74 residents who resided in the facility ate food received from kitchen. Findings include: During an initial observation of the kitchen on 4/6/25 at 9:00 AM, the following was observed: At the handwashing sink, inside was brown and yellow food debris. The paper towel dispenser was broken at handwashing sink. No paper towels were avilable to dry staff hands. In the dry storage, there was a cardboard box of thicker open to air. On the kitchen floor, there were spills of red and yellow liquid. terry cloth Towels were observed on the floor. The floor was greasy, visible, were large and small debris of white, black and grey pieces of food on the ground. Inside the walk-in refrigerator, there was a metal can of mustard opened with seran wrap covering the entire open top. There were 3 containers of brown liquid with no label or date. There was fruit with a date of 10/20. Inside the walk-freezer, there was ice on the floor. Also visible were peas, cardboard, asparagus and smaller unidentifiable debris on the floor. The stoves, and the grill trap was full of hot unidentifiable liquid. There were tiles missing on the wall behind the stove. At the dish washing station, there were pans, bowls, plates turned facing upside, preventing protection from debris. One the garbage can was missing a lid. During a second observation of kitchen, on 04/06/25 11:08 AM, the Dietary Manager was preparing foods for 13 resident with special diets. The Dietary Manager was observed with ungloved hands, placing meat into the grinder, then wiping her hands on her pants. A review of the cleaning schedules, dated 2/16, 2/17, 2/18, 2/19, 2/20, 2/21, and 2/22/2025 indicated there were different stations to clean on AM and PM shifts. Only 2 dates (2/18 and 2/19/25) had initials all cleaning tasks were complete. On 2/20/25 only one initial for one task was completed. The rest of the dates,had no initials to indicate the tasks were completed. The cleaning schedules dated 2/23, 2/24, 2/25, 2/26, 2/27, 2/28, and 3/1/25 indicted only one date (2/25) was initialed with one task completed. There were no other initials to indicate the tasks were completed. The cleaning schedules dated 3/2, 3/3, 3/4, 3/5, 3/6, 3/7, and 3/8/25 indicated there were no initials to indicate the tasks were completed. The cleaning schedules dated 3/9, 3/10, 3/11, 3/12, 3/13, 3/14, and 3/15/25 indicated there were no initials to indicate the tasks were completed. The cleaning schedules dated 3/16, 3/17, 3/18, 3/19, 3/20, 3/21, and 3/22/25 indicated there were no initials to indicate the tasks were completed. The cleaning schedules dated 3/23, 3/24, 3/25, 3/26, 3/27, 3/28, and 3/29/25 indicated there were no initials to indicate the tasks were completed. The cleaning schedules dated 3/30, 3/31, 4/1, 4/2, 4/3, 4/4, and 4/5/25 indicated there were no initials to indicate the tasks were completed. In an interview, on 04/07/25 at 09:18 AM, the Administrator indicated everyone residing in the facility [NAME] food prepared in the kitchen. A current facility policy, Environment, was provided by the Administrator on 4/7/25 at 9:32 AM. The policy indicated . All food preparation areas, food service areas, and dinning areas will be maintained in a clean and sanitary condition .The dinning services director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceiling, lightings, and ventilation .The dinning 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 food contact surfaces will be cleaned and sanitized after each use .The dinning service director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces .All trash will be contained in covered, leak-proof containers that prevent cross contamination 3.1-21(i)(1) and (3)

Based on observation and interview the facility failed to ensure dignity was mainatined for 1 of 18 residents reviewed. (Resident 38) Findings include: During an observation, on 4/7/25 at 12:33 PM, in the dinning room on the men's memory unit, Certified Nursing Assistant (CNA) 2 was heard yelling from Resident 38's room. CNA 2 yelled down to other staff, I need a brief, pants, linens, and towels. I just don't want him walking down the hall. In an interview, on 4/7/25 at 12:50 PM, CNA 2 indicated I should have waved someone down to me. I was thinking safety over dignity. I didn't even think to use the call light. Yelling down the hall is a dignity issue. Resident 38's record review began on 4/8/25 at 8:47 AM. Diagonsis included Alzheimer's diease, unspecified. A current policy, titled Dignity dated 12/12/2024, indicated . 10. Speak respectfully to residents; avoid discussions about residents that may be overheard .12. Maintain resident privacy . 3.1-3(a)

Based on interview and record review, the facility failed to ensure medications were available for resident use as directed by the physician for 1 of 1 residents reviewed. (Resident S) Findings include: In an interview on 12/4/24 at 9:05 AM, LPN 2 indicated when staff administered medications, they were to check the 5 rights of the resident to prevent medication errors. She indicated when a medication was not available staff were to call the pharmacy and get authorization to use the onsite medication dispensing machine. If the machine did not have the medication, the physician and family were to be notified for further direction. In an interview on 12/4/2024 at 2:10 PM, Resident S indicated the medication he was prescribed for weight loss (Ozempic) was not being given. Resident S indicated medication was to start in August, but had not been given as directed because the facility would not obtain the medication for him. Resident S's record review began on 12/4/24 at 3:58 PM. Diagnoses included diabetes and morbid obesity. Resident S's Physicians orders dated 8/8/24 indicated to give Ozempic 0.5 mg every Thursday between 8/8 and 8/31, then give 1 mg every Thursday between 9/1 and 9/30, then give 2 mg every Thursday thereafter. Resident S's Medication Administration Record (MAR) indicated the following: Dated August 2024 indicated there was no documentation the Ozempic was given on 8/15/24. Dated November 2024 indicated Ozempic had not been given on 11/7/24 Progress notes dated 8/14/24 through 8/16/24 did not indicate the reason the Ozempic was not given, and did not include physician or family notification. Progress notes, dated 11/6/24 through 11/8/24, did not indicate the reason the Ozempic was not given, and did not include physician or family notification. In an interview, on 12/4/24 at 4:33 PM, the Director of Nursing indicated the pharmacy had supply issues with obtaining the Ozempic. She indicated the Endocrinologist had wanted the resident to only be on Ozempic, but the medication had been difficult to obtain. She indicated the facility tried to offer alternative medications suggested by the pharmacy, but the resident and physician refused the alternatives. She indicated the facility was able to finally receive a multi-dose/use pen and was administering Ozempic to the resident as prescribed. She was unable to proved documentation of the pharmacy supply issue. This Federal citation is related to complaint IN00447546. 3.1-25(a)

Based on interview and record review, the facility failed to ensure a resident was treated with respect and dignity for 1 of 3 residents reviewed. (Resident F) Findings include: A record review began on 5/22/24 at 10:30 AM of an incident that occurred between Resident F and Certified Nurses Aide 6 (CNA). On 4/18/24, no time specified, CNA 6 was observed having a disagreement with Resident F. Resident F was also on the phone with a family member at the time. CNA 6, heard the resident mention something regarding CNA 6 to the family member. Then CNA 6 put their middle finger up and gestured toward the resident. The immediate action from facility: CNA 6 was immediately suspended pending investigation. Physician, Pysch services, and family were notified. On 5/22/24 at 10:45 AM, Resident F's record was reviewed. Diagnoses included, Chronic Obstructive Pulmonary disease with acute exacerbation. A quarterly MDS (Minimum Data Set) assessment, dated 4/12/24, brief mental status interview indicated Resident F had no cognitive impairment. In an interview on 05/22/24 at 2:08 PM, Resident F indicated CNA 6 put a finger in their face. The resident indicated she had never been scared of her and wasn't then. The resident was beyond pissed off, not intimidated, scared, or fearful. The resident was so mad she hung up the phone on her niece who called right back. In an interview on 05/23/24 at 7:59 AM, the Executive Director indicated CNA 6 was employed by the facility 26 yrs with no prior incidents or issues and was well liked. Resident F showed no signs of distress following the incident with no further complaints. The Executive Director confirmed the incident did apparently happen regarding Resident F being flipped off. The employee was terminated. A current facility policy, Resident's Right, date 10/19 was provided by the Regional Clinical Nurse on 5/23/24 at 12:30 PM. The policy indicated . All care team members recognize the rights of residents at all times and residents assume their responsibilities to enable dignity, respect, and proper delivery of care This Federal citation is related to complaint IN00432880. 3.1-3(a)

Based on observation, interview, and record review the facility failed to ensure labeling of open date for 1 of 3 carts reviewed affecting 3 residents. (Resident 9, Resident 14, Resident 92). Findings include: During an observation with interview on 05/21/24 at 9:33 AM on [NAME] Hall with QMA 3 (Qualified Medical Assistant), the medication room and medication cart was well labeled. QMA 3 indicated all meds were to be labeled with an open date when opened and a discard or expiration date. During an observation with interview on 05/22/24 at 01:12 PM in the East Hall medication room and medication cart. The East Hall cart had three opened medications without an open date. The medications were as follows: Resident 9 cough syrup liquid the silver seal was punctured. Resident 14 polyethylene glycol powder the seal was removed; about a half a bottle remained. Resident 92 milk of magnesia the seal was removed. QMA 4 was labeling Resident 14's and Resident 92's medication bottles with the date 5/15/24. QMA 4 indicated one of the 2 residents was a recent admit and she was aware the other resident's meds came near the same time. 1) Resident 9's record was reviewed on 5/23/24 at 9:03AM. Her diagnosis included lung disease and muscle weakness. Resident 9' s MAR (Medication Administration Record) indicated cough syrup was not administered in the month of May 2024. The bottle of cough syrup was labeled during observation with an open date of 5/15/24. The order for cough syrup was as needed every 4 hours. 2) Resident 14's record was reviewed on 5/23/24 at 9:32AM. His diagnosis included chronic kidney disease and constipation. An order for polyethylene glycol powder was dated 4/29/23. The polyethylene glycol powder for constipation was last administered 5/22/24. 3 )Resident 92's record was reviewed on 5/23/24 at 9:40AM. Her diagnosis included adult failure to thrive and cognitive impairment. An order for milk of magnesia every 24 hours as needed for constipation if no bowel movement for 3 days; was dated 4/26/24. Milk of Magnesia was not administered from May 1 to May 22, 2024, according to a review of the May MAR (Medication Administration Record). The bottle of Milk of Magnesia should not have been opened on 5/15/24 as Resident 92 record indicated she was not administered the medication on 5/15/24. In an interview on 5/23/24 at 10:07AM the Regional Nurse Consultant indicated they were doing quality measures with cart audits. A review of the cart audits indicated ongoing issues of medications without dates from February, March, and April 2024. The May audit was not available for review. A policy titled, Medication Storage, was not dated. The policy did not indicate the labeling of medications in the cart in multiple use packaging. Including labeling with open and discard date. No other policy was made available at the time of exit. 3.1-25(j)(m)(n)

Based on interview and record review the facility failed to ensure residents were free from significant medication errors for 2 of 4 residents reviewed for medication errors. The deficient practice resulted in Resident B experiencing altered mental status that required emergent treatment at the facility for opioid overdose and hospitalization for chest pain. The deficient practice resulted in Resident C experiencing altered mental status with lethargy that required hospitalization . (Resident B, Resident C). 1. An Indiana Department of Health (IDOH) facility-reported incident report was provided by the Administrator on 2/13/24 at 1:00 P.M. The report indicated Resident B had returned from the pain management clinic on 1/19/24 with a new medication order for Suboxone 2.0-0.5 milligram one tablet SL every eight hours for pain. The report indicated the Assistant Director of Nursing (ADON) entered the new order into the electronic medication administration record (EMAR). The report indicated the correct amount of tablets for administration had been inaccurately transcribed into the EMAR as eight and LPN 5 incorrectly administered eight tablets of the opioid medication on 1/19/24 at 9:00 P.M. and 1/20/24 at 5:00 A.M. The report indicated Resident B required a rescue dose of Narcan (an antagonist medication to reverse an opioid overdose) and emergent transfer to the hospital for treatment of altered mental status. The incident report indicated LPN 6 questioned the amount of tablets during medication preparation activities, on 1/20/24 at 1:00 P.M. and held the dose. Resident B's record was reviewed on 2/13/24 at 1:00 P.M. Diagnoses included congestive heart failure, end stage renal disease and chronic pain syndrome. A Quarterly MDS (Minimum Data Set) assessment dated [DATE], indicated Resident B had no cognitive impairment, was able to understand and able to make himself understood. A pain management visit note, dated 01/18/2024, indicated Resident B received a new medication order to refill Suboxone (brand name for buprenorphine/naloxone) (an opioid pain medication) 2.0-0.5 milligram (mg) one tablet sublingual (SL) every eight hours for pain. A nursing note, dated 1/20/24 at 1:00 P.M., indicated staff noted Resident B was lethargic and was unable to speak. The nurse indicated the resident had a medication order for Suboxone 8 tablets. The note indicated Narcan was administered three minutes apart. An order to send to the emergency room was obtained. The note also indicated Resident B had refused to go to the emergency room . A nursing note, dated 1/20/24 at 9:30 PM, indicated Resident B was very lethargic with garbled speech. The note indicated Narcan was given twice and the resident had clear speech after 15 minutes. The note indicated Resident B expressed chest pain and was sent to the hospital. The Medication Administration Record (MAR), dated 1/19/24 - 1/20/24 indicated Resident B received eight tablets of Suboxone on 1/19/24 at 9:00 P.M. and 1/20/24 at 5:00 A.M. During an interview on 2/14/24 at 11:30 AM, the Administrator indicated Resident B had returned from the pain management doctor with a new prescription for Suboxone. The Administrator indicated the ADON (Assistant Director of Nursing) assisted nursing staff by entering the order into the resident's MAR, but the ADON entered the order incorrectly. The Administrator indicated the order from the pain management doctor was to administer 1 tablet of Suboxone 2-0.5 mg every 8 hours for pain, but the ADON incorrectly entered the amount of tablets as eight. The Administrator indicated the medication was inaccurately administered on 01/19/24 at 9:00 P.M. and 01/20/24 at 5:00 A.M. and LPN 6 identified the error on 01/20/24 at 1:00 P.M. The Administrator indicated Resident B was sent to the emergency room . According to drugs.com, in the event of overdose, the respiratory and cardiac status of the patient should be monitored carefully. When respiratory or cardiac functions are depressed, primary attention should be given to the re-establishment of adequate respiratory exchange through provision of a patent airway and institution of assisted or controlled ventilation. Oxygen, IV fluids, vasopressors, and other supportive measures should be employed as indicated. 2. In a confidential interview on 2/13/24 at 1:45 P.M., a family member indicated Resident C had received three times the ordered dosage of gabapentin (an anticonvulsant medication) and the wrong dosage of Depakote (divalproex sodium) (an anticonvulsant medication). The family indicated Resident C was in the hospital for 3 days. Resident C's record was reviewed on 2/13/24 at 2 PM. Diagnoses included end stage renal disease, bipolar disorder, schizophrenia, behavioral disturbances, and seizures. A nursing note, dated 1/11/24, entered by LPN 3, indicated a new order was received for gabapentin 300 mg TID (three times a day) and Depakote 500mg BID (two times a day) for behavioral disturbances, seizures, and bipolar disorder. An untimed neurology physician's order, dated 1/11/24, indicated Resident C should receive gabapentin 300 mg one capsule at hs (bedtime). (total 300 mg daily) The January 2024 MAR indicated Resident C received gabapentin 300 mg as follows: 01/12/24- 9:00 AM, 1:00 P.M., and 5:00 P.M. 01/13/24- 9:00 AM, 1:00 P.M., and 5:00 P.M. 01/14/24- 9:00 AM, 1:00 P.M., and 5:00 P.M. An untimed neurology physician's order, dated 1/11/24, indicated Resident C should receive Depakote ER (extended release) 500 mg two tablets twice daily. (total 2,000 mg daily) The January 2024 MAR indicated Resident C received Depakote 500 mg one tablet as follows: 01/12/24- 7:00 A.M. and 6:00 P.M. 01/13/24- 7:00 A.M. and 6:00 P.M. 01/14/24- 7:00 A.M. and 6:00 P.M. The MAR indicated Resident C received 1000 mg of the anticonvulsant medication daily for three days. A nursing note, dated 1/15/24, indicated Resident C had an altered mental status, was lethargic, and was sent to the hospital. During an interview on 2/14/24 at 1:09 P.M., LPN 2 indicated when a new order was received from the physician, he would verify the order and enter the data into the computer. LPN 2 indicated if he didn't have time the unit manager entered orders. LPN 2 indicated when while entering and/or administering medication he would verify the order with the Nurse Practitioner if anything seemed odd. During an interview on 2/14/24 at 1:14 P.M., Qualified Medication Aide (QMA) 4 indicated new orders were entered into the patient's chart by the nurse or unit manager. QMA 4 indicated it is her usual practice to doublecheck an order with the nurse, unit manager, or MDS Coordinator when she has questions while preparing medication for administration. QMA 4 also indicated nurses are not to enter orders of medication changes without permission from the nurse practitioner and/or prescribing doctor. According to Mayoclinic.org, Depakote levels need to be kept within therapeutic levels to prevent seizure activity. The website indicated the medication should be taken exactly as ordered. Taking inadequate dosages of the medication Depakote could result in intractable seizures (seizures that cannot be stopped easily). According to Drugs.com, Gabapentin side effects may result in dizziness, sleepinesss, and weakness. If overdose is suspected, poison control should be called right away and medical care should be started immediately. The website indicated to be ready to tell or show what was taken, how much and when it happened. A policy, dated 10/2023, titled Medication Errors, was provided by the Regional Consultant on 2/14/24 at 1:34 PM. The policy indicated medications are administrated per the physician's orders. The policy also indicated when dosage orders were written and not within the usual dosages/frequency range, the nurse was to clarify the orders with the physician and/or NP. The facility corrected the deficient practice prior to the beginning of the current survey, on 2/1/2024, after completing review of all orders of residents who received orders from the pain management clinic, progress notes, educating staff on questioning orders outside of dosage/ frequency range, and monitoring new orders daily x 4 weeks, then every weekday x 5 months. This citation relates to Complaints IN00426663 and IN00426877. 3.1-48(c)(2)

Based on interview and record review the facility failed to ensure residents were free from verbal abuse for 1 of 6 residents reviewed (Resident F). Findings include: A facility reported incident was provided by the Administrator on 2/13/24 at 1 PM. The report indicated Resident F had reported to the staff about an incident with Licensed Practical Nurse 3. The report indicated on 1/22/24, LPN 3 had made the comment you mean, miserable man - people like you in my country, we cut their heads off. An investigation file was provided by the Administrator on 2/14/24 at 11:30 AM. The filed statements indicated the following: - Dated 1/23/24 by Resident F indicated on 1/22/24 LPN 3 had assisted with setting up Resident F's breathing treatment and LPN 3 had knocked a few things off the resident's night stand. The statement indicated Resident F stated to LPN 3 you just don't know what you are doing, do you? LPN 3 responded Im African, people like you get their heads cut off in my country. - Dated 1/29/24 by LPN 3 indicated on 1/22/24 LPN 3 while setting up Resident F's breathing treatment, Resident F stated 'you just don't know what you are doing, do you? The statement indicated Resident F then called LPN 3 a stupid Africian. LPN 3 indicated he responded I'm am trying to get along with you. LPN 3 indicated he stated I'm African, people like you get their heads cut off in my country. During an interview on 2/14/24 at 11:30 AM, the Administrator indicated Resident F had reported an incident with LPN 3. Resident F indicated LPN 3 made inappropriate comments to the resident, such as I'm African, people like you in my country, we chopped their heads off. The Administrator indicated he interviewed Resident F and LPN 3 and found the statements to be accurate. The Administator indicated LPN 3 was terminated. A policy, dated 2/2018, titled Abuse prevention program, was provided by the Regional Consultant on 2/14/24 at 1:34 PM. The policy indicated verbal abuse was the use of any oral, written or gestured language that willfully included disparaging and derogatory terms to the residents and/or families regardless of age, ability to comprehend or disability. This citation relates to Complaint IN00426890. 3.1-27(b)

Based on interview and record review, the facility failed to notify the physician and family when a resident had a significant change in condition and weight loss which resulted in hospitalization for 1 of 3 residents reviewed (Resident B). Findings include: On 5/5/22 at 2:47 P.M., Resident B's record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS (Minimum Data Set) assessment, dated 1/14/22, indicated the resident had a BIMS (Brief Interview Mental Status) score of 7-severely impaired cognition. Resident B required cueing and supervision for eating and limited assistance for locomotion while up in her wheelchair. Care plans indicated the following: -Needs assistance with ADL's (3/22/21) with goal of continuing with her current level of ADL function. She was independent with eating. Nursing documentation from 4/1-4/10/22 indicated Resident B required supervision to total dependence on staff for eating. -Altered nutrition with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions were to monitor her weight, give nutritional supplements as ordered, and Registered Dietician evaluation as needed. -At risk for dehydration with goal of being free from symptoms of dehydration (3/21/21). Interventions were to observe, document, and report any signs or symptoms of dehydration such as increased pulse, new onset confusion, fatigue/weakness, decreased or no urine output, concentrated urine, tenting skin, dizziness, fever, thirst, recent or sudden weight loss, and sunken eyes. -DNR (Do not Resuscitate) if the resident stopped breathing or heart stopped beating. Interventions included, but were not limited to, follow advanced directives as depicted in the residents chart, honor choices made by resident and/or POA, and notify physician of changes. Advance Directives/Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Hospital notes, dated 4/10/22, indicated the resident had been admitted to the hospital for weakness, altered mental status, dehydration with acute kidney injury, high blood sodium, urinary tract infection, and severe protein-calorie malnutrition with a weight of 119.7 pounds. On 5/4/22 at 12:23 P.M., Resident B's Power of Attorney (POA) was interviewed. She indicated she received a call from the facility on 4/10/22 from a nurse who stated the resident was not eating and the facility was trying to keep her comfortable as she was a DNR-do not resuscitate. When questioned by the POA, the nurse indicated the facility hadn't done any blood work or assessment of pain which could've been the cause of resident not eating due to history of mouth pain. The POA was told the resident was no longer talking and didn't want to get out of bed. The POA came to the facility and found the resident lying in a fetal position in bed. Her skin looked abnormal, she was very thin, non-verbal, congested, had dried mucous in her eyes and nose, and her call light was on the floor where it couldn't be reached. The POA asked for the resident to be transported to the hospital for treatment. The POA indicated she had not been notified the resident had lost so much weight, hadn't been eating, drinking or talking, and had a significant change in her condition. She'd last seen the resident in person in February. The resident had advanced directives which indicated she had wanted artificial nutrition if needed. Review of past weights were as follows: -1/12/22-169 pounds -There was no February weight completed. -3/2/22-136 pounds. There was no immediate re-weight done. -3/11/22-161 pounds -4/4/22-159 pounds A Physician order, dated 10/24/21, was for a fruit beverage supplement given 2 times per day. Nurse Practitioner (NP) Progress Notes indicated the following: -3/9/22 at 9:55 p.m., resident was a DNR with comfort care. She had a significant weight loss of 33 pounds and would like to get a re-weight. She was not weighed in February. She did have an overall decline with decreased appetite. Assessment and Plan was abnormal weight loss and monitor/follow-up as needed. -3/30/22 at 8:24 a.m., resident was seen for altered mental status. She was observed lying in bed curled up in a ball and refusing to eat and drink. She answered questions appropriately and appeared at baseline mental status at time of visit. She was a DNR/comfort measures. Staff were to continue to monitor and offer feedings. She'd had notable weight loss which had been consistent over the last several months. Assessment and Plan was fatigue and monitor. Progress notes/Skilled Care Nursing Documentation and Food/Fluid intakes were as follows: -4/1/22 at 2:29 a.m., resident was alert and oriented to person; breathing was non-labored; pulse regular at 72 beats per minute (bpm); nothing recorded for food or fluid intake at meals; per MAR (Medication Administration Record), nurses gave the resident her fruit supplement 2 times for a total of 474 milliliters of fluid. -4/2/22 at 9:13 a.m., resident was alert and oriented to person; breathing was non-labored; pulse irregular at 73 bpm; nothing recorded for food or fluid intake at meals; nurses gave the resident her fruit supplement 2 times for a total of 474 milliliters of fluid. -4/3/22 at 9:31 a.m., resident was alert and oriented to person; breathing was non-labored; pulse irregular at 73 bpm; she ate 51-75% of 1 meal, drank 240 ml of fluid, and was given her fruit supplement 2 times as ordered. -4/4/22 at 1:31 a.m., resident was alert; breathing was non-labored; pulse regular at 75 bpm; she at 25-50% of 1 meal, drank 325 ml of fluid, and was given her fruit supplement 2 times as ordered. -4/5/22 at 3:50 a.m., upon bed check, the resident had been covered in diarrheal stool and while being cleaned up, continued with diarrhea and began vomiting. She had been given some applesauce but had thrown it up. At 12:03 p.m., she was alert to person; breathing was non-labored; pulse regular at 75 bpm; she ate 0-25% of 1 meal, drank 240 ml of fluid, and per MAR, nurses gave the resident her fruit supplement 1 time in the morning. At 9:32 p.m., Resident B was lethargic and her pulse was regular at 98 bpm. There was no documentation the physician or NP had been notified of this change. -4/6/22 at 12:38 p.m., the resident had no further emesis or diarrhea. She ate 76-100% of 1 meal and refused the other 2; drank 240 ml of fluid, and was given her fruit supplement 1 time in the morning. -4/7/22 at 5:05 a.m., resident had been in bed all shift and was closely monitored. She slept and was able to drink some apple juice without vomiting. She refused breakfast, ate 0-25% of lunch and 76-100% of supper; drank 700 ml of fluid, and was given her fruit supplement 1 time in the morning. -4/8/22 at 1:49 a.m., resident was alert and oriented to person; her breathing was labored with activity and when lying flat; pulse was irregular at 84 bpm; she ate 76-100% of breakfast and lunch, and ate 0-25% of supper; drank 780 ml of fluid, and was given her fruit supplement 2 times as ordered. -4/9/22 at 3:41 a.m., the resident was alert and oriented to person and place; her breathing was labored with activity and when lying flat; her blood pressure and pulse were not obtained; she ate 0-25% of 1 meal; drank 480 ml of fluid, and was given her fruit supplement 2 times as ordered. -4/10/22 at 4:59 a.m., the resident was alert and oriented to person; breathing was labored with activity and when lying flat; her blood pressure and pulse were not obtained; she refused breakfast and lunch but was given her fruit supplement in the morning. At 1:32 p.m., the progress note indicated the resident had been sleeping constantly, hadn't wanted to get out of bed, hadn't wanted to be moved even to get her brief changed, and was unable to be roused. Her blood pressure was 137/63, pulse was regular at 60 bpm, respirations 16, temperature 98.7, and last weight from 4/4/22 was 159 pounds. The NP was notified and no orders were given. The POA was called and a voice message left for a return call to the facility. At 5:05 p.m., the POA was at the facility and wanted the resident sent to the hospital for treatment. The NP was notified, orders given, and the resident sent to the hospital for evaluation and treatment. There was no documentation that the POA had been notified of the resident's overall decline, decreased appetite, refusals to eat/drink, and weight loss as documented by the NP on 3/9/22, and again, on 3/30/22. The POA was not notified of the resident's acute illness of vomiting/diarrhea, decreased food and fluid intake, and resident no longer talking. On 5/4/22 at 1:54 P.M., the Director of Nursing (DON) was interviewed. She indicated the physician/NP and family/POA's were to be notified of acute changes in condition regardless of the residents advance directives or code status. Physician/NP's and resident's family/POA were to be notified of significant changes in weight, appetite, and ADL abilities. Residents with a monthly weight change of +/- 5 pounds were to be re-weighed and if verified as a significant weight change, were to be followed by the Nutrition Risk IDT (Interdisciplinary Team) and weights obtained and monitored weekly. On 5/4/22 at 1:55 P.M., the DON provided current copies of the following policies which stated: 1. Change in Condition: Acute Medical Change-any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician .the responsible party will be notified there has been a change in the resident's condition and what steps are being taken 2. Advance Directives: Residents have the right to formulate and issue advance directives to be followed should the resident become incapacitated 3. Resident Weight Monitoring: All residents will be weighed at admission and routinely thereafter. Weights will be followed by the IDT and reviewed as needed .Monthly weights should be taken by the 5th of the month .Residents will be re-weighed/verified if a weight change of +/- 5 pounds in a month is noted. Re-weighs should be completed by the 6th of the month This Federal tag relates to Complaint IN 379. 3.1-37

Based on interview and record review, the facility failed to provide appropriate transfer for 1 of 2 residents reviewed. This resulted in anxiety and fear for the resident. (Resident B) Findings include: The record review for Resident B began on 7-27-2020 at 3:56 p.m. [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) discharge with anticipated return dated 6-6-2020 for the 5-22-2020 discharge indicated a discharge status in box A2100 of Community. Resident B's BIMS (Brief Interview for Mental Status) was 15/15, which indicated the resident's mental status was cognitively intact. The May 2020 social service progress notes were reviewed. The notes on May 1, 2020 indicated no physical or verbal behaviors for any symptoms directed towards others, no behavioral symptoms directed toward self and no behaviors putting resident at risk for injury or illness. The current discharge plan indicated that Resident B had a discharge plan to move to an apartment but needed a waiver and an apartment to open. A Social Services progress note dated 5-12-2020, indicated Resident B played cards and smoked. Resident B was waiting for assisted living apartment to open after Covid-19 ended. A progress note written by Social Services dated 5-22-2020 at 6:54 p.m., indicated Resident B went to a single woman's shelter. The resident took all of her medications with her and several bags of personal clothes. She was dropped off and taken into the building at 6:25 p.m. A progress note dated 5-26-2020 at 6:47 p.m., indicated Resident B had verbal behavioral symptoms occurred 1 to 3 days as she yelled at staff. The summary indicated Resident B left to go to a shelter per staff due to non-compliance smoking in her bathroom. There was no documentation available for review to indicate Residnet B had been smoking in her room prior to her 5-22-2020 discharge. An interview with Resident B on 7-28-2020 at 11:00 a.m., indicated the Former Social Services Designee drove her to a shelter which had no sleeping facilities in the staff member's car . She indicated CNA 2 (Certified Nurse Aide) went with them. Resident B indicated she told CNA 2 that she did not smoke in her room and the Former Social Services said to her I did not say you did it. Resident B indicated she was asked about how this discharge to a shelter came about and she indicated they accused her of smoking in her room. She indicated one day, the Former Social Services came down to her room [ROOM NUMBER] times and told her, you need to get out. She indicated the Former Social Services indicated she was going to an assisted living, then told her she was going to a homeless shelter as the assisted living would not take her. She indicated the police came and asked her why she wanted to stay here where they did not want her here. Resident B indicated she had no where else to go. The police indicated she had to leave and that's when the Former Social Services drove her to the homeless shelter. An interview with Resident B's POA (Power of Attorney) on 7-28-2020 at 1:06 p.m., indicated the facility lead the POA to believe Resident B would be taken care of when discharged from the facility. The POA indicated she was aware of previous warnings regarding smoking. The facility discharged the resident without notifying her of the discharge, or why the resident was being discharged . The POA indicated she was never given a reason for the discharge and never given a chance to appeal it. An interview with the Administrator on 7-31-2020 at 10:05 a.m., indicated she was asked who was notified about the smoking incident and about Resident B going to a shelter. The Administrator indicated the Former Social Services notified her the resident had been smoking in her room and she could discharge Resident B to a homeless shelter. The Administrator indicated she was unable to provide any documentation of this, as she gave her notes to the Former Social Services for safe keeping and the Interim Social Services was unable to locate any of the documentation. The Administrator was asked if the resident was provided with a Notice of Transfer or Discharge and if she had the opportunity appeal the discharge or to contact the ombudsman. The Administrator indicated the resident should have been provided the Notice of Transfer or Discharge and with the opportunity to appeal and contact the Ombudsman. She indicated she was not aware that the homeless shelter did not provide a place to stay during the day, did not provide food and only provided a motel to stay for the night. She indicated if she would have know that, Resident B would not have been discharged there as it was not a safe discharge. A nurse progress note on 5-26-2020 at 7:41 p.m., indicated Resident B was readmitted to the facility and arrived to facility via a private vehicle per the POA. Resident B's personal fund statement dated May 2020 was provided by the Receptionist on 7-29- at 11:59 a.m. A review of the personal fund statement indicated Resident B had $17.05 in her account as of 5-20-2020, and no money had been withdrawn at the time of discharge on 5-22-2020. A copy of Discharge Instructions for Resident B dated 5-22-2020 at 4:05 p.m., was provided by Medical Records on 7-28-2020 at 3:20 p.m. The Discharge Instructions were not completely filled out. The only documentation on the form included the resident's weight, vital signs, oxygen saturation, pain level, and allergies [REDACTED]. The form was not signed by Resident B. An interview with Resident B on 7-28-2020 at 11:00 a.m., indicated Social Services drove her to a shelter on 5-22-2020 and dumped her there. An interview with Nurse 1 on 7-29-2020 at 10:22 a.m., indicated she saw Resident B leave with the Former Social Services person on 5-22-2020. She indicated the resident took her medications with her. Nurse 1 indicated she did not fill out any paperwork for a discharge.When a person discharged from the facility, the resident would get a discharge summary, a form which has their profile, medications listed, a bed hold form, and a transfer/discharge report. Nurse 1 indicated she had never had any reason to suspect Resident had smoked in the facility at any time. An interview with the Interim Social Services Designee (SSD) on 7-30-2020 at 9:42 a.m., indicated there were concerns regarding the lack of records for Resident B. This included discharge planning and documentation. The Interim SSD indicated she had been going through the Social Services office and had not found any documentation or notes regarding any paperwork given to Resident B at the time of her discharge. The Interim SSD was made aware Resident B's records lacked a physician order [REDACTED]. A current, undated policy/procedure Discharge/Transfer of Resident was provided by the Administrator on 7-30-2020 at 8:15 a.m. The purpose: .To provide safe departure from the facility .To provide for continuity of care and treatment .Equipment .Clinical Record .Discharge Notice, Transfer form (other than death) .Wheelchair .Discharge Against Medical Advice Form (as applicable) .Procedure 1. Explain discharge procedure to resident and family. Provide additional health education or medication instruction information for resident or family as indicated in lay terms. Review and adhere to current federal regulations as found in Resident Rights and Transfer and Discharge Policies. 2. An attending physician order [REDACTED]. Initiate measures for follow-care as indicated (Social Services, Home Health Care, ect.) 3. Inform all departments of anticipated and actual discharge . 7. Complete Transfer Form accurately and completely including vital signs. Ensure that resident's current physical and psycho/social assessment, medications and current treatment is completely described and available to the receiving facility upon transfer. Assure required 'notices' (DNR, Will, POA) are sent with the resident. Note time of leaving 10. Thoroughly assess resident prior to discharge/transfer. 11. Document discharge summary. Include notes on specific instructions given (medications dressings, ect.) to resident and responsible parties in lay terminology This Federal tag relates to Complaint IN 757. 3.1-12(a)(3)

Based on interview and record review, the facility failed to ensure medically-related social services were provided for 3 of 3 residents reviewd for safe discharge. This resulted in fear, anxiety, and a lack of coordination of medical supplies and care residents after discharge. (Resident B, Resident C, and Resident D) Findings include: 1. The Record Review for Resident B began on 7-27-2020 at 3:56 p.m. [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) discharge with anticipated return assessment was dated 6-6-2020 for the 5-22-2020 discharge. The discharge status in box A2100 was marked Community. Resident B's BIMS (Brief Interview for Mental Status) was 15/15, which indicated the resident's mental status was cognitively intact. The PHQ-9 (Patient Health Questionnaire for Depression) score was 21. A score greater than 20 indicated [MEDICAL CONDITION]. In section E, Behavior, the potential indicators for [MEDICAL CONDITION] was marked, B for delusions. No other behaviors were marked. The discharge plan for active discharge planning area indicated resident return to the community was no and the question regarding a referral being made to the Local Contact Agency was answered no. The MDS entry tracking record was dated 6-6-2020 for a re-admission date of [DATE]. Resident B was marked as entering from the community. The May 2020 social service progress notes were reviewed. The notes dated May 1, 2020 indicated no physical or verbal behaviors for any symptom directed towards others, no behavioral symptoms directed toward self and no behaviors putting resident at risk for injury or illness. The current discharge plan indicated that Resident B had a discharge plan to move to an apartment but needed a waiver and an apartment to open. A Social Services progress note dated 5-12-2020, indicated Resident B played cards and smoked. Resident B was waiting for assisted living apartment to open after Covid-19 ended. A Social Services progress note dated 5-22-2020 at 6:54 p.m., indicated Resident B went to a single woman's shelter. The resident took all of her medications with her and several bags of personal clothes. She was dropped off and taken into the building at 6:25 p.m. A Social Services progress note dated 5-26-2020 at 6:47 p.m., indicated Resident B was marked yes for verbal behavioral symptoms that occurred 1 to 3 days as she yelled at staff. In the summary, the Social Worker indicated Resident B left the facility to go to a shelter per staff due to non-compliance smoking in her bathroom. A nurse progress note on 5-26-2020 at 7:41 p.m., indicated Resident B was readmitted to the facility and arrived to facility via a private vehicle per the POA. A social service progress note dated 5-29-2020, indicated Resident B had hazardous behavior with smoking products. Resident B's personal fund statement for May 2020 was provided by the Receptionist on 7-29- at 11:59 a.m. A review of the personal fund statement indicated Resident B had $17.05 in the account as of 5-20-2020, and no money had been withdrawn at the time of discharge on 5-22-2020. A copy of the Discharge Instructions for Resident B dated 5-22-2020 at 4:05 p.m., and was provided by Medical Records on 7-28-2020 at 3:20 p.m. The Discharge Instructions were not completely filled out. The only documentation included the resident's weight, vital signs, oxygen saturation, pain level, and allergies [REDACTED]. The form was not signed by Resident B. Further review of Resident B's record indicated there was not a physician order [REDACTED]. A copy of Resident B's care plans were obtained from Medical Records on 7-28-2020 at 4:18 p.m. Care plans had not been developed regarding discharge planning, making up stories, nor for non-compliance with smoking materials. A Smoking Safety Risk Assessment for Resident B was completed on 5-26-2020. Potential for safe smoking problem following the facility Smoking Policy had been initiated. An Abuse/Neglect Screening for Resident B was completed on 6-1-2020. indicated the resident was at The screening indicated the resident was at high risk for self abuse or neglect. A Screening Assessment for Evaluation of Self Harm/Suicide for Resident B dated 6-1-2020, indicated a score of 8. A score of 6 - 10 indicated a moderate risk for self harm/suicide and in the comment section, the notes indicated resident was at high risk for self harm, wiithout further explanation. An interview with Resident B on 7-28-2020 at 11:00 a.m., indicated the Former Social Services drove her in the staff person's personal car to a shelter which had no sleeping facilities. She indicated CNA 2 (Certified Nurse Aide) went with them. Resident B indicated she told CNA 2 that she did not smoke in her room and the Former Social Services replyed with I did not say you did it. Resident B indicated the facility just dumped her at the shelter who then put her on a bus and took her to a motel. She indicated she had to be out of the motel by 7:00 a.m. the next day. She indicated she had no where to go during the day, that she went to the park, mostly cried and was petrified. She indicated she had no money, as the facility kept her money. She indicated the shelter gave her crackers and a sandwich. Resident B indicated she was asked about how the discharge to a shelter came about and she indicated they accused her of smoking in her room. She indicated one day, the Former Social Services came down to her room [ROOM NUMBER] times and told her, you need to get out. She indicated the Former Social Services indicated she was going to an assisted living, then told her she was going to a homeless shelter as the assisted living would not take her. She indicated the police came and asked her why she wanted to stay here where they did not want her. Resident B indicated she had no where else to go. The police indicated she had to leave and that's when the Former Social Services drove her to the homeless shelter. An interview with Resident B's POA (Power of Attorney) on 7-28-2020 at 1:06 p.m., indicated the facility led the POA to believe Resident B would be taken care of when discharged from the facility. The POA indicated she was aware of previous warnings regarding smoking. The facility discharged the resident without notifying her of the discharge, without any money, food or water. The POA indicated Resident B was taken to a homeless shelter that only provided lodging for the night and no place for her during the day from 7:00 a.m. until check in at the shelter at 6:00 p.m. An interview with Nurse 1 on 7-29-2020 at 10:22 a.m., indicated she saw Resident B leave with the Former Social Services on 5-22-2020 and she was not sure why. Nurse 1 indicated the resident took her medications with her and Nurse 1 indicated she did not prepare any paperwork for a discharge. She indicated the resident had been compliant with smoking since returning to the facility. An interview with CNA 2 (Certified Nurse Aide) on 7-29-2020 at 10:48 a.m., indicated on 5-22-2020, she was pulled off the behavioral unit and asked to go with the Former Social Services to take Resident B in the staff member's car. CNA 2 indicated she did not know what happened and why she was being asked to go in the car with Former Social Services. She indicated she went to Resident B's room and the police were there. She indicated the Former Social Services was observed to be yelling at Resident B and her room was in shambles with clothing and items strewn about. CNA 2 indicated the resident's bags were packed and Resident B gave CNA 2 her jewelry. CNA 2 indicated she inventoried the jewelry, placed it in a sealed bag and gave to the Administrator. CNA 2 indicated she rode in the back seat with Resident B and when they arrived at the homeless shelter, Former Social Services went inside. CNA 2 indicated when Former Social Services came out, Resident B asked her why she was doing this and Former Social Services yelled at her that she was non-compliant. On 7-29-2020 9:26 a.m., the Case Manager at the homeless shelter was interviewed. She indicated the nursing home dropped of a woman (Resident B). They tried to give her Resident B's medical records, but the Case Manager indicated she could not take them. She indicated this shelter was for single women who came for intake between 6:00 p.m. and 7:00 p.m. She indicated a bus would transport the women to a motel for the night and they had to be out by 7:00 a.m. in the morning. The Case Manager indicated the bus did not run on Sundays, but she could not remember if the bus ran on Saturdays during the pandemic. On 7-30-2020 at 4:35 p.m., a letter was received from the Case Manager which indicated Resident B was brought to the homeless shelter on 5-22-2020 due to reported smoking in her room. The shelter was the intake site for an emergency women's program from mid-May to July 8th, 2020. The intake was 6:00 p.m. to 7:00 p.m. and then they were transported to the local hotel where they could stay until 7:00 a.m. the next day. The letter indicated it was their responsibility to transport themselves back to the named homeless shelter for intake the next evening. The letter indicated those checking into the homeless shelter should not arrive prior to 5:00 p.m. The letter indicated Resident B returned to the site on 5-23-2020 and 5-24-2020. Resident B was last seen at the shelter on 5-24-2020. The letter indicated someone contacted the shelter to let them know Resident B was going to the emergency roiagnom on [DATE]. Additional information received from the homeless shelter indicated the shelter was not open at all during the daytime hours for food or water. They were strictly the intake site from 6-7pm. The hotel stay was strictly from 7pm-7am. On 7-29-2020 at 9:46 a.m., the local Police Department was contacted for a copy of the police report. A copy of the police report was provided on 7-29-2020 at 10:32 a.m. The report indicated on May 22nd, 2020 at approximately 1725 hours (5:25 p.m.) the police responded to the facility inreference an unwanted party. The officers spoke to the Former Social Worker who advised that they currently had a patient, Resident B, who had been discharged due to smoking in the room. The Former Social Worker advised that they had attempted to have Resident B exit the facility and had provided her with a new place to stay located at another address in the same city. The officer advised that they would not transport individuals and the Former Social Worker advised she would be willing to transport Resident B. The officer spoke to the resident and indicated she could no longer stay at the facility. He explained where her new living situation would be if she were willing and the Former Social Worker would be willing to transport her. Resident B indicated she did not think it was fair she had to leave the facility, however stated she would be willing to be transported by the Former Social Worker to the shelter. The note indicated Resident B gathered some of her belongings and made a plan to get the rest of her belongings at a later date. The Former Social worker transported to Resident B to the homeless shelter. An interview with the Administrator on 7-29-2020 at 11:34 a.m., indicated Resident B was discharged because she was smoking in her room with another resident who was on oxygen. The Administrator indicated this should have been documented in the resident's record. The Administrator was notified there was no documentation found in the record regarding this incident or any other smoking incident involving Resident B. The Administrator indicated that did not surprise her. The Administrator indicated Resident B was non-compliant with smoking and other issues which she cannot remember. She indicated the Former Social Services notified the POA of the situation regarding Resident B's smoking in her room with another resident who was on oxygen. The POA was on board with a homeless shelter the Former Social Services had found to take Resident B. The Administrator indicated Resident B was agreeable to go. The Administrator was asked about the police call on 5-22-2020 to assist with Resident B's discharge. She indicated she couldn't remember why the police were called. She indicated 3 days later, she was notified Resident B was in the hospital emergency room . The Administrator indicated Resident B's POA had contacted the Corporate Supervisor and the hospital social worker had also contacted the facility about taking the resident back. The Administrator indicated she was in the facility when the Former Social Services transported Resident B to the homeless shelter. The Administrator indicated she assumed this was like any other homeless shelter where you stayed there, had a bunk, worked there and were provided with food and water. The Administrator indicated she did not know the homeless shelter did not have a place for them to sleep, sent them off with in a bus to a mote,l and had a bus token for return after 7:00 a.m. the next day. The Administrator indicated she was not sure when Resident B left the facility what items were in her possession. She indicated she was not sure if the resident had eaten dinner prior to leaving the facility and did not know if the resident was provided any food and water to take with her from the facility, or money from her resident fund account. The Administrator indicated Resident B should have had a State Notice of Discharge or Transfer form, and discharge instructions with her including her medication list and would not expect her to get a bed hold since she was discharged to the community. The Administrator was asked if Resident B had been given written warnings for her smoking non-compliance.She indicated she thought the Former Social Services was documenting this in the resident record. She indicated the Interim Social Worker was going through the Former Social Worker's office files to find the missing documentation. The Administrator provided what she had in her paper file. This included a copy of the progress notes with the note on 5-22-2020 that Resident B was dropped off at homeless shelter, a Nursing Home to Hospital Transfer Form which was dated for a previous hospitalization , Discharge Instructions dated 5-22-2020, a copy of the [MEDICATION NAME] controlled substance record showing 4 [MEDICATION NAME] left on the card, the emergency room visit notes and a note that APS (Adult Protective Services) had been notified. On 7-29-2020 at 1:02 p.m., APS was contacted. The Case Manager indicated she was sort of behind the scenes in this case with Resident B. The Case Manager indicated she was notified by Former Social Services that this resident had a safe discharge to a homeless shelter and the police were involved. The APS Case Manager indicated the Former Social Services indicated the facility had been working with Resident B since August of 2019 regarding her non-compliance with smoking safely and in her room. The Case Manager indicated she questioned the Former Social Services, how could being discharged to a homeless shelter be a safe discharge, given the previous length of stay of Resident B. The Case Manager indicated she was contacted by Resident B's POA as the resident was found wandering around in a park and was unable to manage on her own. The Case Manager indicated she advised the POA to take the resident to the hospital emergency room . The Case Manager indicated she was notified by the hospital emergency room they were working with the facility to have the resident return to the facility. On 7-28-2020 at 4:15 p.m., Resident B was re-interviewed and was asked about what she did each day and what she had to eat each day after being dropped off at the homeless shelter. She indicated she could not remember if she ate supper prior to leaving the facility on 5-22-2020 around 6:00 p.m. She indicated she was just dropped off at the shelter with no food, no water and no money. She indicated she had 4 pain pills and she had what was left of her other medications and a day's worth of clothing. She indicated the shelter provided the transportation to the motel on 5-22-2020.The next morning her POA's family got her some breakfast through a fast food drive through. She indicated on Saturday and Sunday, there was not a bus to take her back to the homeless shelter and indicated it was too far for her to walk. She can't remember about having anything to eat except for the breakfast. She indicated she was very scared as she did not know this town. She indicated on Monday morning she took the bus back to the homeless shelter and they let her sit in the grass in front and provided her ice water, a sack lunch and a bathroom. She remembered spending one day on the weekend in a park, but could not remember where. She indicated she was dragging around her prescriptions and a couple of females at the motel asked her if she had prescriptions. She indicated she was afraid they were going to attack her, so she told them no. Resident B indicated on Tuesday, 5-26-2020, the POA took her to the hospital emergency room . She indicated she went back to the facility on Tuesday evening (5-26-2020). An interview with the Administrator on 7-31-2020 at 10:05 a.m., indicated the Former Social Services indicated to her that she could discharge Resident B related to unsafe smoking to a homeless shelter. The Administrator indicated the POA and the Nurse Practitioner were aware and in agreement with the discharge. The Administrator indicated she was unable to provide any documentation of this, as she gave her notes to the Former Social Services for safe keeping and the Interim Social Services was unable to locate any of the documentation. The Administrator indicated she was not aware that the homeless shelter did not provide a place to stay or food during the day and only provided a motel to stay for the night. She indicated if she would have know that, Resident B would not have been discharged there as it was not a safe discharge. The Administrator was asked if the resident was provided with a Notice of Discharge or Transfer and if she had the opportunity to contact the state or the ombudsman regarding the discharge. The Administrator indicated the resident should have been provided the Notice of Discharge or Transfer and had the opportunity to contact the state or the Ombudsman. The Administrator indicated she was aware discharge planning and the appropriate paperwork was not being done at the facility. The Administrator indicated the facility had tried to educate the nurses about what to do when a resident discharged as well as the use of forms and documentation. She indicated the staff were still picking and choosing what forms to use and they hadn't been making copies of the forms for the records. The Administrator indicated the Former Social Services was placed on suspension as she was not doing her job with following through with discharge planning and documentation. Then, two days later the Former Social Services resigned. 2. The record review for Resident C began on 7-27-2020 at 2:11 p.m. The resident was admitted on [DATE] and billing stopped on 2-24-2020. [DIAGNOSES REDACTED]. The admission MDS assessment dated [DATE], indicated Resident C had a BIMS of 15/15, which indicated the resident was cognitively intact. The PHQ-9 score was 14, which indicated the resident had minor depression. There were no behaviors marked. The resident required an extensive assist of 1 person for bed mobility, transfers, walk in room, walk in corridor happened one time, locomotion on unit and dressing, toileting and personal hygiene. The resident required supervision of one person for the locomotion off unit and eating. There was no impairment of the upper or lower extremities and the resident used a walker and wheelchair. The resident was 66 inches tall, 294 pounds and was marked as having a [DEVICE] (gastrostomy tube, a way to feed a person liquids who could not eat by swallowing their food). The resident had surgical wounds marked and was getting [MEDICAL CONDITION] care and oxygen. A discharge MDS assessment with no anticipated return for Resident C was completed on 2-27-2020 and indicated the discharge was planned. The resident had a BIMS of 14/15 and had no behaviors marked. The resident needed limited assist with bed mobility, transfers, walking in room/corridor, locomotion on/off unit, toileting, dressing, and personal hygiene. For eating, the resident required an extensive assist. The [DEVICE] was checked no. The resident had Physical and Occupational Therapy services which ended on 2-24-2020. The resident had Speech Therapy services which ended on 2-18-2020. The MDS assessment indicated a discharge plan was made and no referrals were needed. A review of physician orders [REDACTED]. A review of the Social Services progress notes indicated three entries on 1-13-2020. The notes included a social history, an assessment and a room move. The assessment indicated the resident planned to discharge to home, but had no discharge plans at this time. No further documentation by the Former Social Services regarding any discharge planning was found in the progress notes. The care plans for Resident C were reviewed. There were no a care plans regarding discharge planning, the gastrostomy tube, and the care plan for regular diet was updated on 3-10-2020, after the resident discharged on [DATE]. A nurse progress note dated 2-23-2020 at 1:08 p.m., indicated Resident C's family came to take the resident out for a leave of absence to her home. Resident C and her family indicated she would be discharging to home on Monday 2-24-2020. There were no further discharge notes in the resident's record to indicate she was discharged or when she left. A Discharge Summary for Resident C with an effective date of 2-24-2020 at 10:52 a.m., was completed. The Discharge Summary, indicated vitals were completed on 2-24-2020 in the morning for the blood pressure, pulse, respirations and pain level. The last weight was documented on 2-7-2020 and the last temperature was taken on 2-23-2020. The resident's allergies [REDACTED]. The section to be completed by Social Services indicated the resident had a walker and no services or referrals were needed. None of the medications, the dosage amounts or times to be given were entered on the discharge form. The diet orders indicated Resident C was fed by gastrostomy tube feeding with no amounts or how often the feedings should be done. The Activities of Daily living were entered as the resident was independent and used a walker. The education Resident C received was marked as medication administration, blood pressure monitoring, oxygen therapy, aerosol/nebulizer, [MEDICAL CONDITION] care, wound care/dressing changes, tube feeding administration and care of site. Two wounds were listed with instructions for care. There was no indication the resident received a copy of these instructions. An interview with Medical Records on 7-28-2020 at 3:20 p.m., indicated neither the Notice of Discharge or Transfer or the bed hold policy was found in the Resident C's file or in her stacks of papers to be filed. A confidential interview with Resident C's family indicated when she was discharged , there were no medication orders to get her medications nor instructions telling her when to administer the medications. The family did not know how to go about getting the feeding for the [DEVICE] as the resident did not take anything by mouth. The facility only sent home 4 cans of the feeding, which was less than one day's supply. The family indicated they were not set up with any type of home health referral for care, supplies for the [MEDICAL CONDITION], nor support to ensure the transition from the facility to home went smoothly. The family indicated the Former Social Services promised all kinds of things to them, including a meeting to assist them to figure out the needs of the resident prior to discharge. No meeting had been attempted and none of it was done. The family indicated the resident came home with a paper which indicated may discharge to home. 3. The Record review for Resident D began on 7-29-2020 at 2:00 p.m. [DIAGNOSES REDACTED]. An admission MDS assessment for Resident D dated 6-5-2020, indicated Resident D's BIMS was 9/15, which indicated the resident was mildly, cognitively impaired. The PHQ-9 score was 16 which indicated the resident had moderately severe depression. There were no behaviors marked. Resident D required a limited assist of 1 person for bed mobility, eating, toilet use and personal hygiene. The resident required supervision with set up help only for walk in room/corridor and locomotion on/off unit. The resident required supervision of one staff for transfers and dressing. Resident D had no limitations on his upper or lower extremities and no mobility devices marked. The resident and family or significant other participated in the assessment and there were no discharge plans as the resident planned to stay at the facility. The MDS discharge with return not anticipated assessment for Resident D was dated 7-8-2020 and indicated a BIMS of 9/15. The resident needed limited assist for bed mobility, transfers, locomotion on/off unit, dressing, eating, toilet use and personal hygiene. The walk in room/corridor occurred only once or twice. The resident was marked for taking antipsychotics and an antidepressant. The discharge plan question was marked as returning to community with no referral needed. A confidential interview with Resident D's family was done on 7-28-2020 at 1:19 p.m The family member indicated she was the POA. She indicated the facility did not notify her regarding admission paperwork. The facility had Resident D sign a form for a full code when the resident was a DNR (Do Not Resuscitate). The facility did not notify her of a room move from the Harmony (Behavioral) unit to a regular room with a roommate. The family indicated they tried to communicate withthe facility regarding this, but there was no follow up from the facility on anything. The family indicated the current facility did not notify the receiving facility the time of departure, and when the resident arrived, there was not a discharge summary provided to assist in the transition of care. A review of a social service evaluation in the progress notes indicated on 6-1-2020, the Former Social Services documented Resident D was a full code. A copy of Resident D's Post form was provided by Medical Records on 7-29-2020 at 3:23 p.m. Resident D's Post form dated 5-29-2020 indicated the resident had signed the form and dated it with a date of 3-23-2020. The physician signed and dated the Post form on 3-27-2020. The history and physical dated 5-13-2020 for Resident D from the transferring hospital indicated the patient was a Do Not Resuscitate per Indiana Post Form. A review of the social service note dated 6-10-2020 by the Former Social Services indicated a care plan meeting was to be held on 6-25-2020 at 1:30 p.m. The note indicated the care plan invite was sent to the resident on 6-10-2020. A review of progress notes indicated there was no entry regarding a room move for Resident D and no notification of the resident's representative was documented. A copy of the clinical census for Resident D was provided by Medical Records on 7-30-2020 at 11:30 a.m., and indicated the resident was moved on 5-29-2020 from room [ROOM NUMBER] in the Harmony unit to the West unit room [ROOM NUMBER]A. There were no further social services notes to indicate the resident was followed up for any issues regarding the room move. A review of Resident D's care plans indicated, there was not a care plan addressing discharge planning developed. A review of the progress notes indicated the NP made a visit on 7-7-2020 and her plan was to continue with the current psych plan of care. There were no further progress notes provided to indicate Resident D was discharged , where he was discharged to or whether any type of paperwork prepared or sent with him. A review of the physician orders [REDACTED]. An interview with the MDS Coordinator on 7-29-2020 at 3:35 p.m., indicated there should have been discharge planning care plans for residents in place prior to their discharge. An interview with Medical Records on 7-29-2020 at 3:37 p.m., indicated there was not a Bed Hold, a Notice of Discharge or Transfer form, or discharge instructions in the records. An interview with Nurse 1 on 7-29-2020 at 4:16 p.m., indicated when a person discharged from the facility, the resident would get a discharge summary, a form which has their profile, medications listed, the bed hold, and transfer/discharge report. She indicated she did not know what the state form Notice of Transfer or Discharge was. An interview with the Administrator on 7-29-2020 at 4:32 p.m., indicated the facility social services program would be described in the social worker's job description. An interview with the Interim Social Services on 7-30-2020 at 9:42 a.m., indicated there were concerns regarding the lack of records for Resident B, Resident C and Resident D, which included discharge planning and documentation. The Interim Social Services indicated she had been going through the Former Social Services office, boxes of papers, and had not found any notes or documentation to back up any of the accusations/warnings given to Resident B. She indicated there were no notes found regarding any paperwork she may have given to Resident B at the time of her discharge on 5-22-2020. The Interim Social Services was made aware Resident B's records lacked a physician order [REDACTED]. She would have had a physician's orders [REDACTED].Resident D, with a BIMS 9/15, the Interim Social Services would not have him sign a Post form to designate the Advanced Directives he had chosen, due to the resident's BIMS score of 9. She indicated in theory, when a resident was admitted to the facility during Covid-19 and with limited family visitation, social services should have contacted the resident representative to get information and social history. She indicated for residents that were admitted for short term rehab stays, discharge planning should have begun within 1-2 weeksof admission with ongoing evaluation for the future. She indicated when a resident was being transferred to another facility, she would expect the following paperwork to be sent with the resident to the receiving facility (TRUNCATED)

Based on observation, interview and record review the facility failed to ensure adequate supervision to prevent unsupervised exit for 1 of 1 residents reviewed. (Resident B) The resident exited the building for a period of approximately an hour and emergency room evaluation was needed. The Immediate Jeopardy began on 1/9/2020 at approximately 5:00 pm when the resident exited the building without supervision. The resident was outside the building for over an hour. The Administrator was notified of the Immediate Jeopardy on 1/15/2020 at 5:11 pm . Findings include: On 1/14/2020 at 2:00 p.m. review of the clinical record for Resident B was admitted to the facility with [DIAGNOSES REDACTED]. Resident B resided on the Harmony unit, a locked behavioral unit. Review of Resident B's plan of care indicated he was an elopement risk due to wandering and resided on the locked unit. Interventions included placement on the locked unit and to engage resident in activities of interest. A review of Resident B's record indicated he had a previous exit from the facility on 12/13/19 at 9:54 a.m. Resident B was found outside walking around in the parking lot by therapy, resident was redirected and assisted back inside. No visible injuries, denies pain. DON (Director of Nursing) and Admin (Administrator) notified. The resident was placed on the locked unit. Review of a reported incident for Resident B indicated on 1/9/2020 at approximately 5:40 p.m., the resident was not in the building and staff started searching for the resident. Resident B was found outside of the building in a parking lot area by staff at 6:20 pm. The resident was sitting on a curb. Interview with Nurse 1 on 1/15/2020 at 2:30 p.m. indicated he had been called to the Harmony Unit on 1/9/20 at about 4:50 p.m. to do a new admission assessment. Nurse 1 indicated he was in a room towards the end of the hall when staff came and told him Resident B was missing. He and staff started searching room to room and could not find the resident. Staff called the Administrator and 911. He got in his car and went across the street to the mall area and searched for the resident. When Nurse 1 returned to the facility, the resident had been found outside by staff, the police and EMS had been called. The resident was without a [NAME]et, had slipper socks on and slippers on his feet. The resident was transported to the hospital for an evaluation. On 1/15/2020 at 2:45 p.m. in an interview, the Admission Coordinator indicated she found the resident sitting on the curb in the front parking lot on the west end. She indicated the resident had on a long sleeved shirt, pants, slipper socks and slippers. The resident also had a chair cushion next to him, she put it on the ground and had the resident lay down on it. She then saw the police and motioned them to the area. This was at approximately 6:30 to 6:45 p.m. when the resident was found. Resident B was cold and slightly pale when found. A review from the National Weather Service of the ambient temperature in Fort Wayne, Indiana indicated at 5 p.m. on 1/9/2020 the temperature was 55 degrees. On 1/15/2020 at 3:45 p.m., an interview with Therapy Staff 2 indicated on 1/9/2020 she had seen Resident B attempting to go out the door and had returned him to the unit. She had not informed the staff Resident B was exit seeking. The door alarm had been sounding when she redirected him. She did not know the resident had exited the facility later in the day. An interview with the Administrator on 1/15/2020 at 4:15 p.m. indicated she was notified immediately Resident B was missing. The resident was found in the front parking lot by staff and she observed the resident with his coat on prior to being transported to the hospital for an evaluation. The Harmony Unit had been having a music activity which was loud and the staff may have not heard a door alarm sounding. The nurse was normally stationed at the desk to hear the alarm but was instead down the hall doing an assessment. During an observation of the Harmony Unit doors on 1/15/2020 at 4:00 p.m. with the Maintenance Director an initial alarm sounded which could be heard only half way down the hallway. A secondary alarm sounded when the door opened that could be heard down the hall but not in resident rooms. A current policy titled Missing Resident/Elopement effective 11/15/17 indicated he following: All personnel are responsible for reporting a cognitively impaired resident attempting to leave the premises. The Immediate Jeopardy that began on 1/9/2020 was removed on 1/16/2020 when the facility reeducated staff on elopement risk assessment and installed a new annunciator panel, but the noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy because monitoring and tracking the new system had not been completed. This federal tag is related to complaint IN 001 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to develop and implement a plan to manage behaviors for 1 of 3 residents reviewed (Resident J). This deficient practice resulted in feelings of self harm and hospitalization . Findings include: On 12/11/19 at 1:54 P.M., Resident J's record was reviewed. [DIAGNOSES REDACTED]. He resided on the facility's secured behavioral health unit. A quarterly MDS assessment, dated 11/20/19, indicated the resident had a BIMS score of 14 which signified he had no cognitive impairment. The assessment indicated he had an increase in mood issues since his prior MDS which were: having little interest/pleasure in doing things-12-14 days during the assessment period; feeling down, depressed, restless-12-14 days; feeling tired or having little energy-12-14 days; feeling bad about himself or being a failure, letting self and others down-12-14 days; trouble concentrating on things such as newspaper or TV-12-14 days; feeling fidgety/restless-12-14 days; and thoughts of being better off dead-2-6 days. He had no behaviors towards himself or others. He was able to ambulate in his room and in the corridors without aids and with supervision. A care plan, dated 8/27/19 and revised 9/9/19, indicated the resident had a behavior problem related to outburst. He was a slow eater. The goal was there would be no evidence of behavior problems due to not having enough time to eat his food. Interventions were: Administer medications as ordered and monitor for side effects and effectiveness; allow resident adequate time to eat meals in his room; educate the resident/family/caregivers on successful coping and interaction strategies. The resident needs encouragement and active support; praise any indication of the resident's progress/improvement in behavior. A care plan, dated 8/27/19 and revised on 8/29/19, indicated the resident had outburst that caused him to yell and curse at staff and other residents. He liked to run nude in the hallway. The goals were he would use coping skills to help de-escalate his angry feelings and would talk to staff which seemed to help calm his nerves. Interventions were: listen to music; read a magazine; and work on a puzzle. There were no other plans of care to address the resident's need for a secure environment or timely medication regimen A report, submitted to the Indiana State Department of Health on 12/7/19 at 6:20 p.m., indicated Resident J had allegedly grabbed a female resident. The report indicated the resident's were separated and Resident J was taken to the hospital for a psychiatric evaluation and then returned to the facility. After returning to the facility, family members picked him up and he went home for a LOA-leave of absence. After returning from the LOA, he was moved back onto the locked behavioral unit and placed on 1:1 supervision. On 12/11/19 at 1:36 p.m., Resident J was observed laying in his bed in a room on the locked behavioral health unit. The lights were off and he was covered with a sheet. A CNA (Certified Nurse Assistant) was seated in a chair in the corner of the room. A Psychiatric Rehabilitation Services Coordinator (PRSC) came into the room and asked the resident if it would be alright to have a visitor. He indicated it would and he sat up in bed. When interviewed, he was quiet, reserved, and calm appearing. He indicated he couldn't talk about the incident that had allegedly occurred with another resident. When questioned, he indicated he couldn't remember the incident. He indicated he was feeling ok and didn't have any immediate needs. A Social Service Note, dated 8/24/19 at 1:58 p.m., indicated the resident admitted with several mood issues. The note indicated he had a credible history of mistreatment towards him but had none towards others. He had [MEDICAL CONDITION] and [MEDICAL CONDITION] disorders and a history of substance abuse. The resident was expected to be long term placement. There were no notes to indicate the resident needed a secure environment or a regular and timely medication regimen. A Psychiatric NP (Nurse Practitioner) progress note, dated 8/26/19 at 12:07 p.m., indicated the resident was seen for follow up to [MEDICAL CONDITION] disorder, dementia, depression, anxiety, restlessness/agitation, and [MEDICAL CONDITION]. The note indicated the resident had been refusing medication intermittently and had been difficult to redirect. The resident was visited in his room where he'd had good eye contact. He told the NP that he would take his medications when he felt like it. He appeared comfortable and was alert to himself. His mood and affect were flat and his attention span short; paranoia was present and he had poor insight/judgement, and impaired long and short term memory issues. The plan was to continue on his psychiatric medications and staff were to notify the NP of any psych related questions or changes. Nurse Progress notes indicated the resident displayed several behaviors which included, but were not limited to, the following: 8/27/19 at 5:45 a.m., 11:57 a.m., and 3:05 p.m., the resident refused his medications which included medications to assist with his behaviors. At 5:47 p.m., the SSD notified the resident's family of his refusals to take his medications. The SSD went to his room and knocked on the door and the resident yelled out for her to go away. The resident's family member was going to visit the following day. There was no note to indicate the SSD had returned to attempt commuinication with the resident. The resident continued to refuse his medications on 8/28, 8/29, and 9/1/19. There was no indication the facility notified the SSD or physician of his medication refusals. A Psychiatric NP (Nurse Practitioner) progress note, dated 9/3/19 at 1:55 p.m., indicated the resident was seen for a follow up visit. He was visited in his room where he made no eye contact. His speech was monotone and he told the NP he was fine when asked questions. There was no documentation found that the NP was aware the resident continued to not take his medications. There were no new orders and the plan was to continue with the same medications. On 9/4/19 at 8:56 p.m., the resident became very agitated, yelling at staff when asked to take his medications. He refused the medications that day. There was no note the SSD had been informed of the resident's refusals. On 9/5 and 9/6/19, Resident J refused his medications. On 9/7 and 9/8/19, the resident went out of the facility with family for LO[NAME] On 9/13/19 at 5:01 p.m., a follow-up behavior note indicated the resident usually remained in his room during the shift but had asked for a shower, then some popcorn and pop. At dinner time, he went to the dining room, collected his tray and took it to his room where he ate his meal and then returned his tray. He was pleasant and cooperative with taking his medications and receiving care. He had no behaviors while in the common room. There was no documentation found regarding the behavior that triggered a follow up behavior note. There were no changes made to the care plan, and no note the SSD had interacted with the resident. A Physician order, dated 9/16/19 at 11:52 a.m., was for the resident to be referred for psychological counseling services. The SSD was notified of the new order for referral. On 9/16/19 at 3:56 p.m., a Social Service note indicated there had been a phone conference with the resident's family member regarding the resident's care which included the resident having 3 pillows and a blanket with the American flag on it, possibly having a refrigerator in his room to help with health issues, adding anti-anxiety medication on an as needed schedule, the need for 1:1 with a Psychologist, and setting up an appointment with an orthopedic specialist for pain in the resident's right knee. During the phone call, the family had expressed some concerns about the resident's medical care. All questions were answered and the family felt better about the resident's care. The family would be waiting for a call back from the SSD on the list of issues. There was no note the SSD had followed up with the family. A Psychiatric NP progress note, dated 9/16/19 at 10:12 p.m., indicated the NP had been notified by staff that the resident was having [MEDICAL CONDITION] but no plan. Orders were given to administer his evening medications early, place the resident on 15 minute checks and call the NP back at 9:00 p.m. The note indicated the staff nurse called back at 9:15 p.m. and indicated the resident was doing better and that the resident had received his [MEDICATION NAME][MEDICATION NAME] injection earlier in the day. There was no documentation completed by facility staff to indicate the resident had [MEDICAL CONDITION] or monitoring that was put into place. The MAR indicated [REDACTED]. There were no changes made to the care plan regarding his [MEDICAL CONDITION]. A Nurse Progress Note, dated 9/21/19 at 3:59 p.m., indicated Resident J was pacing the hallways and making negative comments about wanting to die. He indicated he didn't know why God put him through this misery. He kept asking how he could make it stop. He then began talking about feelings of wanting to hurt huimself. He continued to pace the hallways, went back and forth from his room to the nurse's station and kept repeating comments about hurting himself. He kept stating he did bad things in my life and now God was punishing him. The resident was assisted to do deep breathing and a little exercise. The nurse walked back and forth with the resident and continued with deep breathing. The resident was assisted to take a warm shower and was administered his medications. He eventually calmed down and went back into his room. The resident was placed on safety checks every hour.There was no note the SSD had been notified of the increased anxiety. A Nurse Progress Note, dated 9/22/19 at 4:29 p.m., indicated the resident was pacing the halls asking for medication for his anxiety. Resident is aware he does not have any prn (as needed). The family came in to be with the resident. The note did not indicate the SSD or physician had been called for this behavior increase. An IDT (Interdisciplinary Team) note, dated 9/23/19 at 9:15 a.m., indicated the IDT met to review documentation and forms related to incident of the resident requesting a blade to injure himself. There was a medication error noted for [MEDICATION NAME] with no IM order which the NP was made aware of. The IDT reviewed the current interventions for behavioral approaches and supported current interventions/redirection which were in place at the time. There were no changes found to the care plan. There was no indication the NP had been made aware of the resident's medication refusals or of other missed doses. A Psychiatric NP progress note, dated 9/23/19 at 11:52 a.m., indicated the resident was seen for an acute visit due to increase in negativity, restlessness and rapid mood changes. Over the weekend, the resident was noted with an increase in agitation, restlessness, and rapid mood swings. The resident was observed walking in the hallway, his speech was clear, he made no eye contact and was agitated, restless, and anxious with a flat affect. He indicated he had been more on edge, feeling like he wanted to be mean towards people at times; denied [MEDICAL CONDITION] and homicidal ideations at the time of the visit. He was positive for paranoia. The plan was to continue [MEDICATION NAME][MEDICATION NAME](anti-psychotic medication) 50 mg IM every 2 weeks and start [MEDICATION NAME] (anti-psychotic) 1 mg by mouth at bedtime for an increase in rapid mood changes and feelings of overwhelming negativity. The progress note did not indicate if the resident had received his [MEDICATION NAME] injections as ordered. A Social Service note, dated 9/30/19 at 11:30 a.m., indicated a care plan meeting had been held with the family. The note indicated it had been a productive meeting regarding the resident's care. Family asked about getting an order to see an orthopedic doctor regarding his right knee (see note on 9/16/19). Family informed facility that resident would be going on LOA for the day and night and would return the following day around 3:00 p.m. There was no note to indicate the SSD had addressed increased anxiety with the family. On 10/6 and 10/7/19, the progess notes indicated the resident refused his medications. There was no note the SSD had been informed of the refusals. A Progress note, dated 10/9/19 at 2:53 p.m., indicated the resident had seemed irritated the last few days. The resident had indicated he was not happy about a possible room change. The resident was on LOA with family from 10/10-10/13/19. A Social Service Group note, dated 10/15/19 at 4:48 p.m., indicated the resident was to be checked on every 30 minutes for a safety issue. There was no documentation found to indicate what safety issues there were. A Social Service Group note, dated 10/16/19 at 3:27 p.m., indicated the resident was very laid back today. He had been very emotional on 10/15/19 and seemed to have had a stressful day. A Social Service note, dated 10/17/19 at 1:54 p.m., indicated the resident had requested to call the Help Prevention line. Follow up was needed. The PRSC indicated he would check on the resident more often to make sure he was okay. There were no further notes to indicate hw the resident responded. A Nurse Progress note, dated 10/17/19 at 8:02 p.m., indicated the resident had come out into the hallway multiple times and stated I can't do this and I'm tired of faking it. He was pacing up and down the hallways. The psychiatric NP was notified and orders received to give an extra dose of the resident's mood stabilizing medication ([MEDICATION NAME]). The resident was administered the medication and then went to sleep in his room. The resident went on LOA with family from 10/18-10/21/19. A Medical NP progress note, dated 10/25/19 at 10:31 a.m., indicated the resident was seen at the request of family for continued anxiety which was worse in the afternoon. The resident stated he was fine but the family reported he shut himself in his room for a few hours every afternoon and was highly anxious. The note indicated the assessment or plan was to have a psych practitioner to follow. There were no medication changes made. An Intrafacility room transfer notification form, dated 10/25/19 at unknown time, indicated the resident was moved off of the locked behavior unit and into a room on an unsecured hallway in the facility. The form indicated the resident wanted to have things in his room but was unable to do so on the locked behavior unit. Family members had mentioned at a care plan meeting that they would like the resident to come off the locked behavior unit onto an open unit where he could come and go as desired. The note indicated the resident had been doing better with less behaviors so the staff wanted to give it a chance to see if he would do well on the open unit. The family assisted with the move. There was no documentation in the progress notes that the room move had occurred nor changes made on the care plan. There were no notes to indicate the SSD had reviewed the pending room move with the resident or pur any interventions in place to assist him with relocation concerns. Resident J went LOA with family from 10/25-10/28, 11/1-11/4 11/8-11/11, 11/15-11/18, 11/22-11/25, and 11/23-12/1/19. On 12/2/19 at 6:55 p.m., A Social Service note indicated the resident had come out of his room saying he wanted to kill himself. The SSD talked with him to see what staff could do to help him feel better. The POA was notified of the resident's behavior. The psychiatric NP was notified who ordered the resident to be transferred out of the facility for evaluation. There was no care plan put into place regarding the residnet's self harm statements. Resident J was not transferred to the hospital for evaluation of [MEDICAL CONDITION]. There was no further documentation completed on the resident until 12/7/19 when the resident had an alleged altercation with another resident. An Intrafacility room transfer notification form, dated 12/3/19 at unknown time, indicated the facility needed a double room for male residents and the resident refused to have a roommate therefore, he was moved to another room with the help of staff. The new room was a private room and was located at the end of a hallway furthest from the nurses station. There was no indication the room move had been discussed with the resident or a plan put into place to assist with his relocation concerns. A Psychiatric NP progress note, dated 12/7/19 at 10:56 p.m., indicated the NP had been notified by the facility that Resident J had been involved in an altercation with another resident in the facility. An order was given to send the resident to the ER for further psychiatric evaluation and treatment. A Nurse note, dated 12/8/19 at 12:36 a.m., indicated the resident returned from the hospital with no new orders. His family member collected his medications through the weekend and took him home for LO[NAME] Upon his return to the facility, the resident was moved back onto the secured behavioral health unit with 1:1 supervision. On 12/11/19 at 1:30 P.M., the PRSC and RN 3 (Registered Nurse) were interviewed. During the interview, both indicated it was very important that Resident J got his medications on time and as prescribed. The PRSC indicated the resident told him that when his room was off the locked unit, he didn't get his medications as ordered and in a timely manner. The PRSC indicated the resident would report increased agitation and anxiety within a short period of time if his medications were late. The resident would even tell the nurses he needed his medications if they were late. The PRSC indicated he had not seen the resident have behavior issues with others on the unit. He was unaware of why the resident was to be moved off the unit because he was doing so well there and the resident had expressed that he didn't want to move off the locked unit. RN 3 indicated the resident's medications on the unit were administered an hour before or after the time scheduled and staff had to be very prompt in providing his medication as ordered. On 12/11/19 at 3:55 P.M., the SSD (Social Service Director) was interviewed. During the interview, she indicated she had cared for the resident at a previous facility, was aware of his behaviors and believed he was appropriately placed onto the secured behavioral health unit. She indicated she had not been aware the resident was not consistently taking his medications prescribed to manage his behaviors but the POA had indicated it was very important for the resident to receive his prescribed medications as ordered, on time and the same time each day for management of his behaviors. This information was not found on the care plan. She had been aware of the residents statements on 12/2/19 that he wanted to kill himself. She indicated she had contacted a local neuropsychiatric inpatient unit and had faxed papers over to them late that evening. The following morning, she was told the inpatient unit wouldn't accept him and she was trying to find another facility for him. She indicated she thought there was follow up documentation but was unable to locate any. When questioned, she indicated the resident was supposed to be seen by the facility's contracted psychology counselors but that the counselor that came to the facility, came only on Saturdays and the resident was usually on LOA with family. She didn't know if the family had been made aware that the counselor only came on Saturdays so accommodations could be made for him to be seen by the counselor prior to leaving for LOA's. She indicated the resident had not been seen by the psychologist for counseling since being admitted to the facility in (MONTH) 2019. During the interview, she indicated residents were placed onto and taken off the secured behavior unit according to facility criteria. She indicated Resident J had improvements in his behaviors and the family believed he would do better off the secured unit where he could have certain items in his room and more freedom. There were no changes made to the care plan when the resident was moved into a room on the open unsecured hallway of the facility . The SSD indicated she was aware the care plan had not been updated to reflect changes that had occurred in his behaviors. The resident was placed back onto the secured behavioral health unit upon return from the hospital on [DATE] following the alleged altercation with another resident. He was to have 1:1 supervision on the unit until another facility could be found that would accept the resident for transfer. On 12/12/19 at 9:30 [NAME]M., the Administrator indicated Resident J had been sent to the neuropsychiatric hospital the following evening due to the resident being agitated and anxious. He had made comments that he wanted to kill himself. The family was notified that the resident was going to hurt himself and needed to be transferred to the hospital. He was transferred to a local neuropsychiatric hospital for inpatient treatment. On 12/12/19 at 1:30 P.M., the Administrator provided a current copy of the facility policy titled Behavior Management Program which stated the following: Purpose: To establish a system for identifying behaviors and implementing appropriate interventions consistent with the individualized plan of care and to ensure that each resident receives appropriate treatment and services to attain the highest practicable mental and psychosocial well-being .Mental health rehabilitative services and behavior management programs for Mental Illness and Intellectual Disabilities may include, but are not limited to: Consistent implementation during the resident's daily routine and across settings, of systematic plans which are designed to change inappropriate behaviors; Medications prescribed to change inappropriate behavior or to alter manifestations of psychiatric illness; Provision of a structured environment for those individuals who are determined to need such structure (e.g., structured socialization activities to diminish tendencies toward isolation and withdrawal) .Crisis intervention service; Individual, group, and family psychotherapy .Formal behavior modification programs; 'Behavioral interventions' are individualized non-pharmacological approaches (including direct care and activities) that are provided as part of a supportive physical and psychosocial environment, and are directed toward preventing, relieving, and/or accommodating a resident's distressed behavior; 'Distressed behavior' is behavior that reflects individual discomfort or emotional strain. It may present as crying, apathetic or withdrawn behavior, or as verbal or physical actions such as: pacing, cursing, hitting, kicking, pushing, scratching, tearing things, or grabbing others. Distress behavior may be treated with medications but should also be address through nonpharmacological approaches .Monitoring of Behaviors and Effectiveness of Interventions: The following are examples of measures that may be taken to monitor behaviors and the effectiveness of interventions. These measures may include, but are not limited to: Review of behaviors and interventions implemented during daily or weekly clinical review meetings; Implementing 72 hour monitoring following a new or worsening behavior or behavior crisis .Review of CAA triggers for mood, behavior and/or [MEDICAL CONDITION] medications; review of care plan .Development and Review of Care Plan .The care plan should include a well-defined problem-statement and should outline the goals of care. It should include measurable objectives and timetables for individualized interventions. It should also identify the responsibilities of various staff to implement the approaches effectively. The care plan should reflect: Baseline and ongoing details of common behavioral expressions and expected response to interventions; Specific goals for and monitoring all interventions for effectiveness in responding to target behaviors/expressions of distress; For any medications, indication/rationale for use, specific target behaviors and expected outcomes, dosage, duration, monitoring for efficacy and/or adverse consequences and plans for gradual dose reduction if an antipsychotic medication is used .The plan of care shall be reviewed and/or updated at least quarterly and with a change in condition such as a new or worsening behavior or a behavior event requiring increased monitoring, reporting to Risk Management or State agencies, or implementation of new interventions This Federal tag relates to Complaint IN 044. 3.1-37

Based on observation, interview, and record review, the facility failed to ensure long acting [MEDICAL CONDITION] medication was administered per physician orders [REDACTED]. The deficient practice resulted in increased behaviors, potential danger to self, and hospitalization . Findings include: On 12/11/19 at 1:54 P.M., Resident J's record was reviewed. [DIAGNOSES REDACTED]. An admission MDS (Minimum Data Set) assessment, dated 8/26/19, indicated the resident had a BIMS (Brief Interview Mental Status) score of 13 which signified he had no cognitive impairment. The assessment indicated he had the following mood issues and number of days noted during the assessment: having little interest/pleasure in doing things-2-6 days during the assessment period; feeling down, depressed, restless-2-6 days; feeling tired or having little energy-2-6; feeling bad about himself or being a failure, letting self and others down-2-6 days; trouble concentrating on things such as newspaper or TV-2-6 days; and feeling fidgety/restless-2-6 days. A quarterly MDS assessment, dated 11/20/19, indicated the resident had a BIMS score of 14 which signified he had no cognitive impairment. The assessment indicated he had an increase in mood issues since his prior MDS which were: having little interest/pleasure in doing things-12-14 days during the assessment period; feeling down, depressed, restless-12-14 days; feeling tired or having little energy-12-14 days; feeling bad about himself or being a failure, letting self and others down-12-14 days; trouble concentrating on things such as newspaper or TV-12-14 days; feeling fidgety/restless-12-14 days; and thoughts of being better off dead-2-6 days. On 12/11/19 at 1:36 p.m., Resident J was observed laying in his bed in a room on the locked behavioral health unit. The lights were off and he was covered with a sheet. A CNA (Certified Nurse Assistant) was seated in a chair in the corner of the room. A Psychiatric Rehabilitation Services Coordinator (PRSC) came into the room and asked the resident if it would be alright to have a visitor. He indicated it would and he sat up in bed. When interviewed, he was quiet, reserved, and calm appearing. He indicated he couldn't talk about an incident that allegedly occurred with another resident. When questioned, he indicated he couldn't remember the incident. He indicated he was feeling ok and didn't have any immediate needs. A physician order, with a start date of 8/28/19, was for [MEDICATION NAME][MEDICATION NAME] (anti-psychotic)-inject 50 mg (milligrams) intramuscularly (IM) in the morning every 14 days. Review of the MARs (Medication Administration Records) and progress notes indicated the following: August 2019 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. 8/27/19 at 5:45 a.m., 11:57 a.m., and 3:05 p.m., the resident refused his medications which included medications to assist with his behaviors. At 5:47 p.m., the SSD notified the resident's family of his refusals to take his medications. The SSD went to his room and knocked on the door and the resident yelled out for her to go away. The resident's family member was going to visit the following day. The progress notes indicated the resident refused his medications on 8/28, 8/29, and 9/1/19. September 2019 MAR indicated [REDACTED]. A progress note for 9/15/19, indicated the nurse was unable to give the medication because it was not available. The pharmacy was notified and the medication was to be sent out and received by the facility during the evening medication delivery. There were no further entries on the (MONTH) MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A Psychiatric NP progress note, dated 9/16/19 at 10:12 p.m., indicated the NP had been notified by staff that the resident was having [MEDICAL CONDITION] but no plan. Orders were given to administer his evening medications early, place on 15 minute checks and call the NP back at 9:00 p.m. The note indicated the nurse called at 9:15 p.m. and indicated the resident was doing better and that the resident had received his [MEDICATION NAME][MEDICATION NAME] injection earlier in the day. There was no documentation completed by facility staff to indicate the resident had [MEDICAL CONDITION] or monitoring that was put into place. The MAR indicated [REDACTED]. A Nurse Progress Note, dated 9/21/19 at 3:59 p.m., indicated Resident J was pacing the hallways and making negative comments about wanting to die. He indicated he didn't know why God put him through this misery. He kept asking how he could make it stop. He then began talking about feelings of wanting to hurt himself. He continued to pace the hallways, went back and forth from his room to the nurse's station and kept repeating comments about hurting himself. He kept stating he did bad things in my life and now God was punishing him. He eventually calmed down and went back into his room. A Nurse Progress Note, dated 9/22/19 at 4:29 p.m., indicated the resident was pacing the halls asking for medication for his anxiety. Resident is aware he does not have any prn (as needed). The family came in to be with the resident. The note did not indicate the physician had been called for this behavior increase. An IDT (Interdisciplinary Team) note, dated 9/23/19 at 9:15 a.m., indicated the IDT met to review documentation and forms related to incident of the resident requesting a blade to injure himself. There was a medication error noted for [MEDICATION NAME] with no IM order which the NP was made aware of. The IDT reviewed the current interventions for behavioral approaches and supported current interventions/redirection which were in place at the time. There was no documentation to indicate the team reviewed the frequency of missed medications. A Psychiatric NP progress note, dated 9/23/19 at 11:52 p.m., indicated the resident was seen for an acute visit due to increase in negativity, restlessness and rapid mood changes. Over the weekend, the resident was noted with an increase in agitation, restlessness, and rapid mood swings. The resident was noted walking in the hallway, his speech was clear, he made no eye contact and was agitated, restless, and anxious with a flat affect. He indicated he had been more on edge, feeling like he wanted to be mean towards people at times; denied [MEDICAL CONDITION] and homicidal ideations at the time of interview. The report indicated the NP felt the resident had some paranoia. The plan was to continue [MEDICATION NAME][MEDICATION NAME] mg IM every 2 weeks and start [MEDICATION NAME] 1 mg by mouth at bedtime for an increase in rapid mood changes and feelings of overwhelming negativity. The progress note did not indicate if the resident had received his [MEDICATION NAME] injections as ordered, or if the NP had been made aware of missed doses. An (MONTH) 2019 MAR indicated [REDACTED]. On 10/6 and 10/7/19, the progess notes indicated the resident refused his medications. A Progress note, dated 10/9/19 at 2:53 p.m., indicated the resident had seemed irritated the last few days. The resident had indicated he was not happy about a possible room change to a more open unit. The note indicated the resident wanted to remain on the locked unit as it gave him a sense of security. The resident was on LOA with family from 10/10-10/13/19. The (MONTH) 2019 MAR indicated [REDACTED]. An administration note, dated 10/15/19 at 4:24 p.m., indicated [MEDICATION NAME][MEDICATION NAME] was unavailable on the due date and was given on this date. It is unknown what date the [MEDICATION NAME] was to have been administered on. A Nurse Progress note, dated 10/17/19 at 8:02 p.m., indicated the resident had come out into the hallway multiple times and stated I can't do this and I'm tired of faking it. He was pacing up and down the hallways. The psychiatric NP was notified and orders received to give an extra dose of the resident's mood stabilizing medication ([MEDICATION NAME]). The resident was administered the medication and then went to sleep in his room. The resident went on LOA with family from 10/18-10/21/19. A Medical NP progress note, dated 10/25/19 at 10:31 a.m., indicated the resident was seen at the request of family for continued anxiety which was worse in the afternoon. The resident stated he was fine but the family reported he shut himself in his room for a few hours every afternoon and was highly anxious. The note indicated the assessment or plan was to have a psych practitioner to follow. There were no medication changes made. An Intrafacility room transfer notification form, dated 10/25/19 at unknown time, indicated the resident was moved off of the locked behavior unit and into a room on an unsecured hallway in the facility. The form indicated the resident wanted to have things in his room but was unable to do so on the locked behavior unit. Family members had mentioned at a care plan meeting that they would like the resident to come off the locked behavior unit onto an open unit where he could come and go as desired. The note indicated the resident had been doing better with less behaviors so the staff wanted to give it a chance to see if he would do well on the open unit. The family assisted with the move. There was no documentation in the progress notes that the room move had occurred nor changes made to the care plan. The progress notes indicated Resident J went LOA with family from 10/25-10/28. A Nurse Progress note, dated 10/30/19 at 4:52 p.m., indicated the resident was supposed to have received his [MEDICATION NAME] injection on 10/29/19 but the medication had not been sent by the pharmacy. The pharmacy was made aware the medication was to be given every 14 days and the schedule would have to be changed to accommodate the medication not being delivered. On 10/30/19 at 6:49 p.m., the nurse documented the [MEDICATION NAME] injection had been delivered and would be given as ordered. The (MONTH) 2019 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. There was no documentation to indicate why the medication had not been given on the scheduled day. The resident's next scheduled dose of [MEDICATION NAME] was due on 11/29/19. The MAR indicated [REDACTED]. There was no documentation the NP or physician had been notified of the missed dose of medication. Nurs's progress notes indicated Resident J went LOA with family from 11/1-11/4 11/8-11/11, 11/15-11/18, 11/22-11/25, and 11/23-12/1/19. There was no indication the facility had made arrangements for the resident to receive his medication while absent from the facility. A Social Service note, dated 12/2/19 at 5:51 p.m., indicated the resident was saying that he wanted to kill himself. The Psychiatric NP was notified and she indicated to send him out for evaluation. The resident was not sent out of the facility as ordered on [DATE]. On 12/7/19 at 6:45 p.m., Resident J allegedly touched another resident. He was sent to the hospital for evaluation and returned to the facility on [DATE] where he was placed on 1:1 supervision. On 12/11/19 at 8:13 p.m., the resident was agitated and restless and stated he felt like killing himself. The resident was transferred to a neuropsychiatric hospital for evaluation and treatment. On 12/11/19 at 1:30 P.M., the PRSC and RN 3 (Registered Nurse) were interviewed. During the interview, both indicated it was very important that Resident J got his medications on time and as prescribed. The PRSC indicated the resident told him that when his room was off the locked unit, he didn't get his medications as ordered and in a timely manner. The PRSC indicated the resident would report increased agitation and anxiety within a short period of time if his medications were late. The resident would tell the nurses he needed his medications if they were late. RN 3 indicated the resident's medications on the unit were administered an hour before or after the time scheduled and staff had to be very prompt in providing his medication as ordered. On 12/11/19 at 3:55 P.M., the SSD (Social Service Director) was interviewed. During the interview, she indicated per the resident's POA (Power of Attorney), it was very important for the resident to receive his prescribed medications as ordered, on time and the same time each day for management of his behaviors. On 12/11/19 at 5:15 P.M., the DON (Director of Nursing) was interviewed. During the interview, she indicated she had only been with the facility for a short time and was not aware of the resident's care prior to her employment. She indicated there was some type of medication error that occurred with his [MEDICATION NAME][MEDICATION NAME] but was unable to provide any specific information. She indicated the resident should've received his medications as ordered by the physician. This Federal tag relates to Complaint IN 044. 3.1-25(b)(9)

Based on observation, interview, and record review, the facility failed to implement a plan of care for pressure ulcers for 1 of 2 residents reviewed for pressure ulcers. The facility's failure resulted in development of an unstageable pressure ulcer (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) for Resident H. Findings include: On 10/11/18 at 11:45 A.M., Resident H's record was reviewed. [DIAGNOSES REDACTED]. The resident was hospitalized prior to admission with the following Diagnoses: [REDACTED]. He was admitted to the facility for rehabilitation services. A Hospital Transfer form, dated 8/24/18 at 1:15 p.m., indicated the resident had reddened skin to his buttocks and inner thighs. The form did not indicate he had any skin issues on his right heel. An Admission Nursing Assessment, dated 8/24/18 at 9:43 p.m., indicated Resident H had [MEDICAL CONDITION] to his feet. He had bruises on his right and left arm and an area on his right heel. There was no description of the area on his right heel or measurements completed. An admission MDS (Minimum Data Set) assessment, dated 8/31/18, indicated the resident had a BIMS (Brief Interview Mental Status) score of 6 which signified the resident had severely impaired cognition. He required extensive assistance of 2 staff members for for bed mobility, transfers, and toileting and was non-ambulatory. The MDS indicated he had no pressure ulcers or other skin issues. A Care Area Assessment (CAA), triggered by information on the MDS, indicated the resident was at risk for skin breakdown due to impaired mobility, incontinence of bowel, use of an indwelling urinary catheter, non-ambulatory status, and need for extensive assistance with repositioning. The CAA indicated the last skin assessment was completed on 8/31/18, his skin was intact and there were no skin issues or concerns noted at that time. A skin integrity care plan was put in place with a goal of no new areas of pressure would develop thru the next review. Staff were to provide catheter care, incontinence management, routine skin care, and perform weekly skin inspections to prevent pressure areas from occurring. A Care Plan, initiated 9/2/18 and revised 9/5/18, indicated the resident had the potential for impaired skin integrity related to impaired mobility and incontinence. The goal was the resident would have no complications from skin issues through the review date. Interventions, all dated 8/24/18, were: evaluate skin weekly, labs as ordered, medications as ordered, notify doctor promptly of skin breakdown, observe skin integrity during morning and evening care, pressure redistribution mattress to bed, provide diet as ordered, and reposition every 2 hours when in bed. There was no care plan written or that addressed deep tissue injury to the residents right heel, nor was it identified on his admission MDS assessment. On 10/11/18 at 12:10 P.M., Resident H was observed eating lunch in his room. He was sitting in a wheelchair with his feet resting on foot pedals that were low to the ground. He was observed wearing sandals. His right foot and ankle were wrapped with kerlix dressing and a piece of tape with initials was over the dressing. There was no date on the tape or dressing to indicate when the dressing had been put on the residents foot. His toes and exposed portion of his right calf appeared dark red to purple colored. A Prevalon off-loading (pressure relieving) boot was sitting on the floor by his closet. An alternating pressure mattress was on his bed. On 10/11/18 at 12:53 P.M., LPN (Licensed Practical Nurse) 3 was interviewed. During the interview, he indicated the resident had a pressure area on his right foot but he was not aware of when the residents wound had been identified. He indicated he changes the dressing daily but the facility wound nurse was responsible for the weekly measurements. He indicated he had not changed the dressing yet today. On 10/11/18 at 1:41 P.M., Resident H was observed lying in bed with both feet elevated on pillows. LPN 9 removed the kerlix dressing to the residents right foot. The tape that had secured the dressing had initials and a date written on it which indicated it was last changed on 10/10/18. LPN 9 measured the wound which was 5.5 cm (centimeters) by 5 cm. The wound was 100% eschar with an area in the center which appeared moist and colored dark grey to green. The wound covered the bottom of the heel and extended up the back of the heel. The outer edges of the wound on the lateral side was dry and the skin tissue was starting to loosen. LPN 9 indicated the resident was to wear his Prevalon off-loading boot when lying in bed. Review of resident Progress Notes indicated the following: 8/24/18 through 9/12/18 did not indicate the resident had any skin issues on his right foot. 9/13/18 at 9:36 p.m., indicated the resident had the Prevalon boot on his right foot at this time. A Wound Assessment, dated 8/28/18 at unknown time and completed by the facility's designated wound nurse, indicated the resident was admitted to the facility on [DATE] with a pressure area to his right heel. The physician and family were notified of the area on 8/24/18. The form indicated the area was designated as a suspected deep tissue injury (intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue). The area was dry and measured 4.5 cm by 5.0 cm. The assessment was signed and dated 9/12/18. There was no information regarding treatment or implemented interventions put into place. An (MONTH) (YEAR) TAR (Treatment Administration Record) did not indicate the resident had a deep tissue injury to his right heel. There were no treatments administered to the wound and there was no monitoring of the wound completed. A Wound Assessment, dated 9/4/18 at unknown time and completed by the facility's designated wound nurse, indicated the residents wound continued to measure 4.5 cm by 5.0 cm and remained designated as a suspected deep tissue injury. The physician and family were notified of the area on 8/24/18. There was no information regarding treatment or implemented interventions put into place. The assessment was signed and dated 9/12/18. A Wound Assessment, dated 9/11/18 at unknown time and completed by the facility's designated wound nurse, indicated the residents wound continued to measure 4.5 cm by 5.0 cm and remained designated as a suspected deep tissue injury. The physician and family were notified of the area on 8/24/18. There was no information regarding treatment or implemented interventions put into place. The assessment was signed and dated 9/12/18. A History and Physical, dated 9/14/18 at unknown time, indicated the wound NP (Nurse Practitioner) saw the resident at the facility for wound care evaluation of the right heel pressure ulcer. The note indicated the resident had recently been hospitalized , there had been no documentation of his ulcer there, and he had a Prevalon off-loading boot. The wound was an unstageable pressure ulcer (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar). The wound base was 100% necrotic (dead) tissue. The current treatment was skin prep. Physical examination indicated the resident had pedal pulses to both feet, no [MEDICAL CONDITION], and no cyanosis. His right lower extremity was a dark brawny discoloration and the posterior heel ulcer measured 4.5 cm by 5 cm, covered with black eschar with some fluctuance (area of skin with a wave-like or boggy feeling upon palpation) in the center. Orders were to wash the wound daily with baby magic soap, paint the right heel ulcer with [MEDICATION NAME] daily and cover with dry gauze and no pressure to the heel at any time. A Wound Assessment, dated 9/18/18 at unknown time and completed by the facility's designated wound nurse, indicated the residents wound continued to measure 4.5 cm by 4.5 cm and remained designated as a suspected deep tissue injury. The physician and family were notified of the area on 8/24/18. There was no information regarding treatment or implemented interventions put into place. The assessment was signed and dated 9/21/18. A Progress Note, dated 9/21/18 at unknown time, indicated the wound NP had visited the resident for continued wound care evaluation of his right heel. The note indicated the resident had recently been hospitalized and there was no documentation of his ulcer there. He had a Prevalon off-loading boot. The wound base remained 100% necrotic tissue. The wound measured 4.5 cm by 4.5 cm. Orders were to wash the wound daily with baby magic soap, continue to paint the right heel ulcer with [MEDICATION NAME] daily and cover with dry gauze and no pressure to the heel at any time. An additional order was given to obtain an arterial doppler to the right lower extremity. A Wound Assessment, dated 9/25/18 at unknown time and completed by the facility's designated wound nurse, indicated the residents wound continued to measure 4.5 cm by 4.5 cm and designated as a deep tissue injury. The physician and family were notified of the area on 9/21/18. The form indicated there was no change to the current care plan. A Progress Note, dated 9/28/18 at unknown time, indicated the wound NP had visited the resident for continued wound care evaluation of his right heel and to continue the Prevalon off-loading boot. An arterial doppler was completed on Monday and the report was pending. The wound base remained 100% necrotic tissue. The wound measured 4.5 cm by 4.5 cm. Orders were to wash the wound daily with baby magic soap, continue to paint the right heel ulcer with [MEDICATION NAME] daily and cover with dry gauze and no pressure to the heel at any time. A Wound Assessment, dated 10/2/18 at 4:30 a.m. and completed by the facility's designated wound nurse, indicated the residents wound continued to measure 5.3 cm by 4.5 cm and was designated as a deep tissue injury. The wound base remained 100% necrotic tissue. The form indicated there was no change to the current care plan. A Progress Note, dated 10/5/18 at unknown time, indicated the wound NP had visited the resident for continued wound care evaluation of his right heel and to continue the Prevalon off-loading boot. An arterial doppler was completed and suggested [MEDICAL CONDITION] disease. The wound base remained 100% necrotic tissue. The wound measured 5.3 cm by 4.5 cm. Orders were to wash the wound daily with baby magic soap, continue to paint the right heel ulcer with [MEDICATION NAME] daily and cover with dry gauze and no pressure to the heel at any time. A Wound Assessment, dated 10/9/18 at 3:31 p.m. and completed by the facility's designated wound nurse, indicated the residents wound measured 5.0 cm by 5.0 cm and was designated as a deep tissue injury. The wound base remained 100% necrotic tissue. The form indicated there was no change to the current care plan. A (MONTH) (YEAR) TAR indicated an order, dated 9/6/18-9/14/18, was to cleanse the right heel daily with normal saline, apply skin prep and leave open to area. The TAR did not indicate, by nurse initials, that the treatment was completed on day shift on 9/10, 9/11, and 9/12/18. An order, dated 9/6/18, indicated staff were to observe the right heel for signs and symptoms of infection or worsening of the wound. An order, dated 9/14/18, was to cleanse the right heel daily with normal saline, apply [MEDICATION NAME], wrap with kerlix every day shift. The TAR did not indicate, by nurse initials, that the treatment was completed on 9/15, 9/16, 9/17, 9/21, 9/23, 9/24, 9/25, 9/26, 9/27, 9/28, 9/29, and 9/30/18. There was no indication the order to wash the area with baby magic soap had been followed. A (MONTH) (YEAR) TAR indicated an order, dated 9/14/18, was to cleanse the right heel daily with normal saline, apply [MEDICATION NAME], wrap with kerlix every day shift. The TAR did not indicate, by nurse initials, that the treatment was completed on 10/3, 10/4, 10/9, and 10/11/18. There was no indication the order to wash the area with baby magic soap had been followed. On 10/11/18 at 2:57 P.M., the facility wound nurse, LPN 9, and DON (Director of Nursing) were interviewed. During the interview, neither could indicate where the resident's Prevalon boot had come from or who had ordered it. LPN 9 indicated she did wound rounds every week on Tuesday and the wound NP did wound rounds every week on Friday. She indicated the wound NP did not usually measure the resident's wound but would use her measurements that were done on Tuesdays. LPN 9 indicated she observed the resident's wound for the first time on 8/28/18 during her weekly wound rounds. She indicated the wound NP did not observe the resident's wound until 9/14/18. LPN 9 indicated the order to cleanse the resident's right heel with normal saline and apply skin prep was the facility's standing order. She was not able to indicate why baby magic soap was not used to clean the wound as ordered by the wound NP on 9/14/18. LPN 9 and the DON indicated the wound NP did write that the resident was to have no pressure to his heel at any time on 9/14/18. On 10/11/18 at 3:52 P.M., CNA (Certified Nurse Assistant) 4 was interviewed. During the interview, she indicated the resident was to wear the Prevalon off loading boot when up in the wheelchair. She indicated when in bed, the resident was to have his heels elevated on pillows. She indicated the resident was not supposed to have sandals or any shoes on but that therapy staff would put them on for therapy and then not take them off after therapy. On 10/11/18 at 3:54 P.M., LPN 3 was interviewed. During the interview, he indicated the resident should have no pressure to the bottom of his heel and the heel was to be kept off loaded. On 10/11/18 at 4:02 P.M., RN (Registered Nurse) 2 was interviewed. During the interview, she indicated she was the admitting nurse for Resident H. She indicated, upon admission to the facility, the resident did have a discolored area to his right heel but she was unable to recall how large the area was or the color of the area. She received a telephone report from the transferring hospital nurse who indicated the resident had a skin issue on his right heel. RN 2 indicated the facility wound nurse was responsible for measuring pressure wounds and she did not measure or further assess the area. She indicated the resident did not come to the facility with the Prevalon off loading boot and did not know where the boot had come from. RN 2 did not notify the physician or family on 8/24/18 of the discolored area on his right heel because she indicated the resident came with orders and he was unaccompanied by family. August, September, and (MONTH) (YEAR) TAR's did not indicate the resident was to wear a Prevalon off-loading boot to his right ankle. There was no physician order on the chart for a Prevalon off loading boot. There was no physician order noted on the physician order summary for the resident to have no pressure to his heel at any time. The resident continued to receive physical and occupational therapy after the wound NP began to follow the resident and had indicated in her progress notes that the resident was to have no pressure to his heel at any time. On 10/11/18 at 4:58 P.M., the PTA (Physical Therapy Assistant) was interviewed. During the interview, she indicated she observed the resident's right heel the day after the Physical Therapist had completed their evaluation but did not know the date. She indicated that she was the person that gave the nurses the Prevalon boot to put on the resident due to the pressure wound to his right heel. She indicated the resident received and continues to receive physical and occupational therapy. A Physical Therapy Plan of Care, with a start date of 8/27/18 and end date of 9/13/18, indicated the resident was to receive skilled physical therapy services which included, but were not limited to, develop strength, endurance, ROM (range of motion), stair climbing, transfers related to gait, and activities to improve functional performance. Physical therapy notes indicated the resident was put back on physical therapy with Medicare part B. The note indicated the resident received physical therapy services on 9/17, 9/18, 9/19, 9/20, 9/25, 9/26, 9/27, and 9/28/18. The facility was unable to provide physical therapy treatment notes or care plan for these dates and for therapy provided in the month of (MONTH) due to a new computer system. On 10/11/18 at 5:25 P.M., the DON provided a copy of the facility policy titled Skin Integrity Standard which stated the following: .If skin integrity issues are identified post-admission the following documented information is required: 1. Wound Specifics: a. Location of wound b. Size of the wound including length, width, and depth in centimeters .4. Notification of the physician 5. Care plan up-dated to reflect current status of the wound, treatment plan, turning and positioning program, and additional interventions to promote healing This Federal tag relates to Complaint IN 792. 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure fall prevention assessment was completed for 1 of 3 residents with a change in condition relating to falls which resulted in hospitalization . (Resident O). Findings include: On 7/25/17 at 10:31 A.M., Resident O's record was reviewed. [DIAGNOSES REDACTED]. An admission MDS (Minimum Data Set) assessment, dated 6/19/17, indicated Resident O had unclear speech however, the MDS did not indicate whether the resident could make herself understood by others. Staff assessment for the resident's mental status indicated Resident O had no impairments with short or long term memory. Resident O knew the current season, location of her room, staff names and faces and that she was in a nursing home. The MDS indicated the resident had no signs of delirium such as inattention, disorganized thinking or altered level of consciousness. The MDS indicated that Resident O required extensive assistance of 1 staff member for transfers, was non-ambulatory, and was independent with wheelchair locomotion on and off the unit. Also, Resident O was continent of bowel and bladder. A Plan of Care, revised on 6/13/17, indicated Resident O was at risk for falls related to weakness. The goal, dated 6/29/17, was that the resident would be free from minor and serious injury and free from falls. Interventions included, but were not limited to the following: anticipate and meet the resident's needs, assist the resident to toilet every 2 hours and prn (as needed), keep call light within reach and staff to provide prompt response to requests for assistance, low bed, and non skid foot wear. An SBAR (Situation Background Appearance Review and Notify) communication form, dated 7/16/17 at 3:45 P.M., indicated Resident O had increased confusion, increased crying, resident uncontrollable crying, unable to console resident, resident looking around room/unit doesn't recognize where she is and resident with pain which is new (no description of where the pain is), occasional labored breathing, short period of hyperventilation, repeated troubled calling out, loud moaning or groaning, crying, sad, frightened, frown. NP (nurse practitioner) 2 was notified and order received for UA C&S (urinalysis with culture and sensitivity). Medicare/HMO documentation, dated 7/17/17 at 11:40 P.M., indicated Resident O's vital signs were taken at 10:23 P.M. and were as follows: temperature (T): 97.9, pulse (P): 68, respirations (R): 16, and blood pressure (B/P) 118/68. Documentation indicated Resident O was alert to person, no changes to mood or behavior, and incontinent of bladder and bowel. There was no other nursing documentation completed on 7/17/17. The UA C&S ordered on [DATE] was not obtained. An SBAR-Fall Report of Incident form, dated 7/18/17 at 12:00 A.M., indicated Resident O had an unwitnessed fall. Writer heard a loud bump in resident room and went to check on her and found the resident on the floor. The resident was alert and oriented to herself. The SBAR-Fall Report of Incident form indicated an Episodic Fall Care Plan: The resident has had an actual fall. Interventions included, but were not limited to, neurochecks per protocol, vital signs every shift for 72 hours, and monitor/document/report signs or symptoms of pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture, agitation. An SBAR-Physical Injury Report of Incident form, dated 7/18/17 at 12:00 A.M., indicated Resident O had an area of swelling, bruise or discoloration and was located left eye. The facial bruising measured .5 inches by 1 inch (1.3 centimeters by 2.5 centimeters). On 7/18/17 at 2:00 A.M., NP 2 was notified of Resident O's fall. There were no new orders. there was no indication the NP had been notified of the facial swelling or changes in behavior on 7/17/17 and 7/18/17. A Neurocheck form was initiated which indicated neurochecks to be done every 15 minutes for 4 times, then every 30 minutes for 4 times, then every 60 minutes for 2 times. Neurochecks were completed on 7/18/17 at 12:00 A.M., 2:23 A.M. for two times, 2:50 A.M., 3:20 A.M., 3:50 A.M., 4:20 A.M., and 5:30 A.M. The Neurocheck form included vital signs to be completed with each neurocheck. Vital signs were obtained on 7/18/17 at 12:00 A.M. with the initial assessment of Resident O's fall. No vital signs were obtained until a neurocheck was completed on 7/18/17 at 7:10 A.M. The Neurocheck form, dated 7/18/17 at 7:10 A.M., indicated Resident O was oriented to person and place, was alert but drowsy. The last neurocheck was completed on 7/18/17 at 8:00 A.M, but did not indicate if the resident was alert ororiented. Vital signs were T: 98.0, P: 72, R: 18, B/P: 118/68. A Plan of Care, dated 7/18/17, titled Acute Physical Injury hadbeen initiated for Resident O. The goal was that the injury will heal without signs or symptoms of infection/complications in 14 days. Interventions included, but were not limited to, neurological checks for 72 hours. The Plan of Care did not indicate the type or location of the injury. A History and Physical form, dated 7/18/17 at 3:30 P.M., indicated NP 1 visited Resident O who sustained fall in room with no injuries. noted to be less motivated today and increase in lethargy. res aphasic, hard to communicate needs and wants. no fevers or chills .hx of CVA and DVT's, on Coumadin therapy. Plan: check CBC and BMP next lab day UA ordered-c&s if indicated monitor vitals fall precautions notify if s/s worsen or change. A Wound Assessment form, dated 7/19/17 (no time), indicated Resident O had a dark bruise noted post fall whose location was documented as; left eye; and measured 3.0 centimeters by 5.0 centimeters (1.2 inches by 2 inches) 0.9 x 1 inch larger than the initial assessment. The form indicated the date MD/Alternate Notified/Last updated was 7/18/17 (no time) when NP 2 was notified. A Nurse Progress Note, dated 7/19/17 at 2:29 A.M., indicated Resident O continues to attempt to get up by herself. At present in wheelchair with staff. A Nurse Progress Note, dated 7/19/17 at 9:57 A.M., indicated the resident's family member was updated regarding resident's condition and new orders were obtained for Rocephin (antibiotic) 1 gm (gram) now (for abnormal urinalysis), chest x-ray stat, CBC (complete blood count) and BMP (basic metabolic profile) today. Lab results for Resident O, dated 7/19/17 and printed at 2:42 P.M., indicated the resident had abnormal lab results which included, but were not limited to, low potassium, low chloride, and a low platelet count (platelets help blood clot). There was no documentation to indicate the physician or NP were notified of the abnormal lab results. A Nurse Progress Note, dated 7/19/17 at 7:17 P.M., indicated Resident O was up and down in her bed and chair all day, resident restless, resident at emergency door trying to open door 2 times, resident redirected to dining room for meal times, resident refused breakfast and lunch, resident ate dinner. A SBAR-Fall Report of Incident form, dated 7/19/17 at 8:45 P.M., indicated Resident O had an unwitnessed fall. The resident was found on opposite side of her room, on the floor. The resident was seated on her buttocks when found by staff. NP 2 was notified of the fall at 9:30 P.M. and indicated staff should monitor vital signs and observe. The form indicated Resident O's vital signs, completed 7/19/17 at 10:22 A.M., were as follows: T: 97.1, P: 87, R: 18, B/P: 144/88. After the resident's fall, she was seated near the nurses station for observation and continued to attempt unsafe ambulation. The SBAR-Fall Report of Incident form indicated an Episodic Fall Care Plan: The resident has had an actual fall. Interventions included, but were not limited to, neurochecks per protocol, vital signs every shift for 72 hours, and monitor/document/report signs or symptoms of pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture, agitation. Neurochecks and vital signs were not completed following Resident O's fall on 7/19/17 at 8:45 P.M. Medicare/HMO Documentation form, dated 7/20/17 at 8:10 A.M., indicated Resident O was not alert and required total assistance with ADL's L(activities of daily living) and transfers. Vital signs, documented on 7/20/17 at 2:30 P.M. were as follows: T: 97.3, P: 73, R: 18, and B/P: 157/80. A History and Physical Form, dated 7/20/17 at 1:21 P.M., indicated NP 1 completed an acute visit with Resident O who had altered mental status. Per nursing, resident was irritable yesterday and opening fire doors through the day. PLAN: reviewed labs receiving IVF (intravenous fluids) for dehydration res remains lethargic after lunch, responds to painful stimuli given hx (history) of falls, and altered mental status-feel it's best resident evaluated at (hospital). A Nurse Progress Note, dated 7/20/17 at 3:10 P.M., indicated Resident O was transferred to (hospital). A Nurse Progress Note, dated 7/20/17 at 5:52 P.M., indicated the facility was updated with resident's condition. Resident O's condition was critical and she would be admitted to ICU. On 7/26/17 at 10:35 A.M., the emergency room chart and summary for Resident O's visit on 7/20/17 at 3:44 P.M., indicated the following: Primary Diagnosis: [REDACTED]. CT scan (brain imaging test) indicated Resident O had multiple areas of bleeding in her brain. Resident O was admitted to the intensive care unit where she was intubated and placed on a ventilator. On 7/26/17 at 2:10 P.M., the DON (Director of Nursing) was interviewed. During the interview, she indicated the UA C&S, ordered on [DATE], for Resident O was not obtained until 7/18/17. She indicated this lab test should've been completed when ordered. The DON indicated that neurochecks for Resident O following her fall on 7/19/17 at 8:45 P.M., should have been initiated and completed but they were not done. On 7/26/17 at 3:34 P.M., the DON provided a current copy of the facility's policy titled Fall Management which indicated the following: Purpose: To evaluate risk factors and provide interventions to minimize risk, injury, and occurrences .Procedure for responding to a fall .3. Address any emergent conditions or first aide needs. Initiate neurological checks for any unwitnessed falls, and falls with actual or suspected head injury or trauma .5. Observe and document condition for a minimum of 72 hours. 6. Review, revise, and update care plan accordingly. 7. Evaluate actual or suspected causal factors to prevent recurrences The DON indicated the facility did not have a specific policy regarding neurochecks. This Federal tag relates to Complaint IN 975. 3.1-45(a)(1)(2)

Based on observation, interview and record review, the facility failed to ensure a safe environment on the memory care unit for 17 of 18 ambulatory residents who had access to a coffee pot, and failed to prevent falls with injuries for 2 of 9 residents (#124 and B) who met the criteria for falls with injury. This deficient practice resulted in falls with a fractured arm and hip, and a facial injury. Findings include: 1. On 2/4/13 at 10:47 a.m. resident #116 who resides on the memory care unit was observed to walk up to a coffee pot, which was on and had coffee in the carafe, touched the edge of the heating element and stated "that is hot". Staff were told by writer the resident had touched the coffee pot. Interview with CNA # 2 on 2/4/13 at 10:50 a.m. indicated the coffee pot is used for the staff to get coffee for the residents. The coffee pot was observed sitting on a small counter next to the washer and dryer in the kitchen area, which is open to the dining/activity area. CNA #2 was queried about the concern of residents touching and/or burning themselves and she indicated the staff redirect the residents away from the pot. On 2/4/13 at 11:00 a.m. interview with the nursing staff supervisor #1 indicated 17 of 18 residents residing on the memory care unit were ambulatory. 2. Resident B was observed on 2-6-2013 at 12:09 p.m., in the dining room, sitting in wheelchair with a chair alarm secured on the wheelchair. A cast was observed on the left lower arm. The clinical record review on 2-6-2013 at 11 a.m., indicated Resident B was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The recapitulation for January 2013 was signed by the physician on 1-3-2013 and treatment orders included "may use bed and chair alarms due to frequent falls." The fall risk evaluation completed 8-7-2012 indicated a score of 16. A score of 10 or above represented "high risk." A fall risk care plan was developed on 8-7-2012 with the following interventions: provide adequate lighting, monitor side effects of medications, keep call light in reach, encourage use of call light, keep floors free of spills and clutter, monitor for unsteady gait and balance, instruct to avoid sudden position changes; labs as ordered, assess toileting needs, provide verbal safety cues, keep assistive devices in reach - wheelchair, physical and occupational therapy evaluation and treatment, and pressure sensor pad for bed and wheelchair. The fall risk care plan was updated on the following dates: 8-14-12 - updated with "educated about locking wheelchair brakes." 8-28-2012 - changed wheelchair 9-7-2012 - rollback device on chair 9-17-2012 - gripper socks, bed alarm and chair alarm 1-9-2013 - educated to use call light due to left arm fracture. On 1-8-2013 at 9 a.m., Resident B was found on the floor with pain to the left wrist. The report of incident did not indicate use of the bed or chair alarm. The Verification of Investigation indicated the follow up actions included "alarms in place to alert staff of any attempt at self transfers." an order for [REDACTED]. Resident B was seen in the emergency department on 1-8-2013. The consulation report dated 1-10-2013 indicated the resident had a left distal raduis and ulnar fracture. On 1-10-2013 at 4:50 a.m., Resident B was found on the floor. The report of incident did not indicate the bed or chair alarms were in place. The resident was transferred to the hospital. The consultation report dated 1-10-2013 indicated a left intertrochanteric hip fracture. A review of the Verification of Investigation dated 1-9-2013 indicated the bed and chair alarms were placed as part of the follow up action to the fall on 1-8-2013. A review of the Verification of Incident Investigation report for the fall on 1-10-2013 at 4:50 a.m., did not indicate use of alarms. The Report of Incident dated 1-10-2013 at 4:50 a.m. and completed by LPN #27 indicated Resident B was found on floor with pain to the left leg. Additional circumstances that included " Alarm Activated/Sounding " and " Alarm Failure or Device Removal " were not checked on the Report of Incident form for 1-10-2013. A review of the AccuNurse (documentation computer program for CNAs) documentation provided by RN #22 on 2-6-2013 at 10:00 a.m. for CNAs indicated the prompt, " alarm checked ? " , was answered " no " for 1-8-2013 at 2:00 a.m. and 6:41 a.m. and 1-10-2013 at 1:29 a.m. and 3:45 a.m. An interview with the DON on 2-7-2013 at 9:20 a.m., indicated there were no bed or chair alarms in place prior to the fallson 1-8-13, and prior to the fall on 1-10-13 which resulted in a left hip fracture. 3. On 2/6/13 at 1:00 p.m. review of the clinical record for resident #124 indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set) assessment dated [DATE] indicated the resident had short term and long term memory problems and was non-ambulatory. On 2/6/13 at 1:30 p.m. review of the resident's "Fall Risk Assessment" dated 12/20/12 indicated the resident was a high risk for falls. Review of the physician orders [REDACTED]. Interview with the Director of Nursing on 2/4/13 at 2:30 p.m. indicated the resident fell on [DATE] at 2:40 p.m. The resident was found laying on her right side next to her bed with a bloody nose, the physician and family were notified. On 2/4/13 at 2:35 p.m. review of the fall investigation indicated the staff had not activated the resident's sensor alarm on her bed. This Federal tag is related to complaint IN 937. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident was transferred, according to their plan of care, resulting in the resident sustaining lacerations to the left leg that required 8 sutures to close. This deficiency affected 1 of 1 resident, who was injured during a transfer, in a sample of 6. (Resident #D) Findings include: On 11/26/12 at 9:30 a.m., during the orientation tour, the DON (Director of Nursing) indicated Resident #D's leg was injured during a transfer and she was sent to the hospital for treatment of [REDACTED]. The clinical record of Resident #D was reviewed on 11/27/12 at 6:30 a.m., and indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The care plan, initially dated 5/14/12 and reviewed on 11/2012, indicated Resident #D was to be transferred with two person assistance and a mechanical lift. The MDS (Minimum Data Set) Assessment, dated 11/1/12, indicated the resident had severe cognitive impairments and required extensive assistance of two for transfer. The Nursing Notes, dated 11/25/12 at 5:20 a.m., indicated the nurse was called into the Resident #D's room because her leg was bleeding. The Nursing Notes indicated "...(2) skin tears noted to LLE (Lower Left Extremity). (2x1) et (and) (4.5 x 2.5 x 1+ deep), pressure drsg (dressing) applied...N.O. (New Order) send to ER (emergency room ) to be evaluated et (and) treated...Resident unaware of how injury occurred. CNA (Certified Nursing Assistant) states "she didn't bump her leg on anything." "I looked down and saw her bleeding." Resident pant leg was down when writer entered the room et (and) blood noted on pants..." The Hospital emergency room Care Record, dated 11/25/12 at 6:22 a.m., indicated the resident had a wound/laceration to the left shin that was closed with eight, 4-0 (size) nylon sutures. On 11/27/12 at 7:40 a.m., Resident #D was observed sitting in a wheelchair. Two CNAs, the Supervisor and a mechanical lift were in the room. The Night Shift Supervisor indicated the resident had just gotten out of bed using the lift. On 11/27/12 at 10:15 a.m., LPN #10, who had worked on the night shift when Resident #D was injured, was interviewed. LPN #10 indicated that on 11/25/12, when she checked the resident's leg, adipose tissue was visible. She indicated Resident #D had been transferred from the bed to the wheelchair without a lift by CNA (Certified Nursing Assistant) #11. LPN #10 indicated, at the time of the incident, there was a sign posted above the bed indicating a lift should be used, but CNA #11 indicated he had been told that a lift was no longer needed to transfer the resident. On 11/27/12 at 11:00 a.m., Resident #D's anterior left lower leg was observed with Unit Manager #12 and the Wound Nurse. An incision measuring 4.4 cm and an adjacent incision measuring 1.8 cm, were present on the resident's left lower leg. There were a total of 8 sutures and the wounds were well approximated. On 11/28/12 at 4:00 p.m., the Incident Investigation/Administrative Summary, dated 11/27/12, provided by the DON, was reviewed. The Summary indicated, "CNA stated that resident's leg was not bleeding when he dressed her in bed....He stated that he transferred her manually without assistance and did not know she was to be transferred via Hoyer lift per plan of care. Resident has very fragile skin and history of multiple skin tears... Writer and Administrator educated CNA (CNA #11's Name) on proper procedure & (and) safe transfer with residents, as well as, how to access resident plans of care via accunurse/vocollect (sic)...." This Federal tag relates to Complaint IN 811. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure the safety of a resident, who was smoking in an outdoor smoking area and failed to prevent oxygen usage in a smoking area. This resulted in a resident being burned. This deficiency affected 1 of 3 residents reviewed, who smoked at the facility, in a sample of 8. (Resident #E) Findings include: On 7/17/12 at 9:15 a.m., during the entrance conference, the Administrator indicated there had been an incident on 7/15/12 and Resident #E had been burned on the hand while smoking in an outdoor smoking area. The Administrator indicated the incident had not been witnessed by facility staff but had been reported later to facility staff by a peer who had witnessed the incident. The Administrator indicated, after the incident, all resident who smoke, were reassessed and their care plans were reviewed. The Administrator indicated the smoking policy was revised, a schedule of designated smoking times was initiated, residents were educated regarding the need to keep smoking materials with licensed nursing staff and residents were now monitored during smoking sessions. On 7/17/12 at 9:30 a.m., Resident #E was observed in her wheelchair in her room. Her left hand was bandaged and she was asked about the injury to the hand. The resident indicated it happened just like that and she snapped her finger. Resident #E indicated she could not reach the portable oxygen control that was on the back of her wheelchair, so after the spark, she yanked the nasal canula tubing so it wasn't connected to the oxygen tank. The resident indicated she smoked independently and it was usual for her to have her oxygen with her when she went out to smoke. She indicated she would take the nasal canula off and hang it on the wheelchair while she was smoking. On 7/17/12 at 4:45 p.m., Resident #J, who witnessed and reported the incident, was interviewed. The resident indicated Resident #E had her oxygen tubing in her lap and there was a flame. Resident #J said she told Resident #E to throw the tubing on the ground but Resident #E patted the flame with her hand and jerked the tubing out of the oxygen container. On 7/18/12 at 1:30 p.m. LPN #11, who worked on Resident #E's hall was interviewed. She indicated Resident #E went out with her oxygen to smoke. The LPN indicated the resident had been told not to do this but she smoked independently and had her own supplies so it was difficult to monitor her. The clinical record of Resident #E was reviewed on 7/17/12 at 1:50 p.m. and indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Admission Nursing Assessment, dated 4/16/12, indicated the resident did not desire to smoke and as a result no additional assessment was done. Physician orders, dated 4/21/12, indicated the resident was to receive oxygen at 3 liters per nasal canula continuously. The MDS (Minimum Data Set) Assessment, dated 6/14/12, indicated the resident had no cognitive impairments, required supervision of one staff for transfer/locomotion/toileting, required extensive assistance with dressing and did not ambulate during the 7-day observation period. On 7/15/12 at 10:30 a.m., nursing notes indicated "has 1st degree burn to left palm of hand. Redness noted. Denies pain or discomfort. Area cooled w/cold water; Bacitrin (sic) & (and) bandage applied. Res (resident) refused to state what happened; peers report that res (resident) outside smoking c (with) O2 (oxygen) portable O2 tank. Res (Resident) has been told multiple times by nurses & (and) aides to take tank off before going outside to smoke. (Physician's Name) notified. Resident own POA (Power of Attorney). On 7/15/12 at 10:10 p.m., nursing notes indicated Resident #E's left hand was observed at 8:30 p.m. and she had four fluid filled blisters. On 7/16/12 at 2:30 p.m. nursing notes indicated the resident had four fluid filled blisters to palm/fingers and an open blister to the crease of the thumb on the left hand measuring as follows: 1.8 cm by 1.4 cm; 0.9 cm by 0.8 cm; 1.1 cm by 0.5 cm; 1.5 cm by 1.3 cm; and 1.7 cm by 1.8 cm There was no documentation a smoking safety assessment or smoking care plan were completed until, after the incident, on 7/16/12. The Smoking Safety Assessment, completed on 7/16/12, indicated the resident was a potentially unsafe smoker and "must be supervised and wear a protective non-flammable cover (smoking apron) when smoking." The Smoking Risk Care plan, dated 7/16/12, indicated the following: educate/enforce smoking in designated areas only, review smoking safety quarterly, provide information on smoking cessation as desired, provide safe receptacles for extinguishing ashes, reinforce safe practices, praise safe practices, staff to retain cigarettes, staff to retain lighters, and supervised smoking. Although the Smoking Safety Assessment indicated the resident must wear a smoking apron, there was no mention of the apron in the care plan. Resident #E was observed during smoking sessions on 7/17/12 at 11:00 a.m., at 7/17/12 at 3:00 p.m. and 7/18/12 at 9:00 a.m. Resident #E was monitored, the oxygen was removed prior to smoking, and smoking material were provided by staff. The outside smoking area had a fire extinguisher, a water thermos, and a safety ash receptacle. Resident #E did not wear an apron during the smoking sessions observed. On 7/17/12 at 4:00 p.m., the Administrator indicated they were unable to locate a smoking assessment or a smoking care plan for the resident prior to the incident. On 7/18/12 at 11:00 a.m., the Administrator indicated and smoking aprons had been ordered on [DATE] but had not yet been delivered, smoking aprons were being obtained from a sister facility and would be delivered on 7/18/12. The Smoking Policy, revised October 2009, that was in place prior to the incident on 7/15/12, provided by the administrator, was reviewed on 7/17/12 at 2:00 p.m. and indicated in part, "It is the policy to monitor and evaluate residents for safety related to smoking...The Interdisciplinary Team (IDT) is responsible for ensuring safety risks are evaluated, and that smoking is conducted in a safe manner... 1. The IDT will evaluate safety, physical ability, sensory issues, and the need for adaptive or safety equipment upon admission, with every significant change... and annually for resident's who express a desire to smoke. 2. Staff will control distribution of all cigarettes and lighting materials for all residents,... 3. For residents who have been determined to need supervised smoking, or are unsafe when smoking, staff will provide appropriate supervision... a. Use of adaptive equipment (smoking aprons, etc.)..... 5. Portable oxygen tanks and/or other O2 delivery systems are not allowed in designated smoking areas, even if oxygen is turned off. 6. Residents who do not adhere to facility smoking protocols and rules should be reviewed for alternate placement..... Care Plan Documentation Guidelines.... Identify measurable goals for safe smoking... List approaches to monitor and prevent complications." This Federal tag relates to Complaint IN 127. 3.1-45(a)(1) 3.1-45(a)(2)

Based on interviews and record reviews, the facility failed to ensure care and services were provided to prevent the development of diabetic ulcers and to promptly notify the Physician with a change in condition of the resident's toes that resulted in osteomylitis of the bone, and surgical amputation of the to the second toe of the right foot. This deficiency affected 1 resident, Resident C, in a sample of 3. Findings include: The clinical record of Resident C was reviewed on 12/19/11, at 1:45 p.m. and indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set(MDS) Assessment, dated 11/11/11, indicated the resident scored 15/15 on the Brief Interview for Mental Status (BIM), and required limited assistance of one person for dressing, toilet use, personal hygiene, and bathing. Review of the Nursing Admission Assessment, dated 11/1/11, indicated a skin graft to the right thigh, measuring 25 centimeters (cm) by 18 cm., and a skin graft to the penis. There were no other skin conditions identified on the assessment. Care plans were reviewed on 12/19/11. A skin integrity care plan, dated 11/7/11, indicated a potential for impaired skin integrity related to recent surgery, with problems related to impaired mobility and Diabetes Mellitus. Interventions for this problem included, but were not limited to: observe skin integrity during morning and evening care; notify the physician promptly of skin breakdown; evaluate skin weekly. Another care plan, dated 11/1/11, for self care deficit indicated the resident required limited assistance for bed mobility, transfers, ambulation, dressing, personal hygiene, bathing, and toilet use. Interventions for this problem included, but not limited to: one person physical assist for bed mobility, transfers, ambulation, locomotion, dressing, toilet use, and bathing. Review of the treatment sheet for November, 2011, indicated weekly skin assessments were completed on 11/2, 11/9, 11/17, and 11/24/11. Review of a Change of Condition Skin Sheet, dated 11/21/11 at 11:00 p.m.,indicated the following: "Res (resident) complained of toe bleeding through sock found 4 diabetic ulcers upon inspection 3 on 2nd (second) toe of res (right) foot, et (and) 1 of his 3rd (third) toe. slight amount of blood draining from OA (open area) on 2nd toe's ulcer, near toenail. Skin under toe is very pale. (No) c/o (complaints) pain. Wrapped ( with) dressing et (and) contacted Dr. (Physician's name). Prescribed [MEDICATION NAME] ( antibiotic) po (by mouth) BID (two times a day) x (times) 2 weeks, CBC (Complete Blood Count laboratory test) PT/PTT ([MEDICATION NAME] and [MEDICATION NAME] Time laboratory test) et appt (appointment) (with) wound clinic. Res aware...." A narrative nursing note, dated 11/22/11 at 2:00 p.m., indicated the dressing was changed to the 2nd and 3rd toes, the 2nd toe was swollen, bright red, and warm. The nurse's note also indicated there was 100% black area to the tip and bottom of the 2nd toe, and a small area to the top of the toe, with a moderate amount of drainage to both toes. Nursing notes, dated on 11/23/11 indicated the dressing to the toes was clean, dry, and intact, and the antibiotic was being given. There was no documentation the physician was notified regarding the black areas on the toes, until 11/24/11, at 6:30 p.m. A nursing note, dated 11/24/11, at 6:30 p.m., indicated the antibiotic treatment continued for the diabetic ulcers on the right 2nd and 3rd toes, and "ordered xeroform." There was no documentation in the note that the physician was made aware of the black toes. However, a physician's orders [REDACTED]. A nursing note, dated 11/25/11, at 10:00 a.m., indicated the dressing was changed to the 2nd and 3rd right toes, the diabetic ulcers continued to the 2nd and 3rd superior toes, the 2nd digit had an open area on the inferior toe, and the drainage was purulent with a foul odor. The note indicated the 2nd digit inferior open area was black in color with surrounding skin pink and peeling, the 2nd and 3rd superior open area's wound beds were yellow/red, and the surrounding skin peeling and pink. A nursing note, dated 11/27/11 at 1:00 a.m., indicated the resident continued on an antibiotic for infection to the right toes, there was no odor noted, but purulent drainage was noted. A narrative nursing note, on the back of the skilled documentation flow sheet, and dated 11/27/11, at 11:30 p.m., indicated the resident ambulated per self using a walker, and was independent with activities of daily living. The note indicated there was a purulent, foul smelling drainage noted, and a black area to the 3rd toe, and open area to the 2nd toe. A non pressure skin condition report, dated 11/28/11, indicated the resident had necrotizing fascitis to bilateral feet. A nursing note, dated 11/28/11 (no time) indicated the resident had necrotizing fascitis to bilateral feet, the right foot was pale with purple discoloration and streaking noted, odor noted, the left foot was pale with purple discoloration, streaking present, and an odor. The resident had no complaints of pain, the physician was notified and the resident sent to the emergency room for evaluation. Review of an acute hospital transfer record, dated 11/28/11, indicated the resident was transferred to the hospital at 10:30 a.m. on 11/28/11. A nursing note, dated 12/5/11, indicated the resident was hospitalized . A history and physical, dated 11/28/11, from the local hospital, indicated the resident had [DIAGNOSES REDACTED]. The history and physical indicated the resident was transferred from the nursing home with [MEDICAL CONDITION] and possible osteomylitis. The physical exam indicated bilateral second digit foot gangrene. Xray of the right foot showed suspicious for only findings for 2nd distal phalanx, could be related to osteomylitis and healing [MEDICAL CONDITION] of the 1st phalanx of the left foot showed [MEDICAL CONDITION] of the 2nd phalanx. Also right foot 2nd digit showed findings suggestive of osteomylitis. A physician progress notes [REDACTED]. The Director of Nursing Services (DNS), was interviewed on 12/20/11, at 9:05 a.m., and indicated the physician was notified regarding the condition of the toes on 11/24/11, and a new order was received for xeroform dressing. Resident C was interviewed, at 11:00 a.m., on 12/21/11, and indicated staff assisted him with washing his back and hair in the shower. He indicated he noticed a scab on his toes and the toes were bleeding, so he reported this to the staff. He indicated he had to have 2 of his toes ambulated after this. CNA # 1 was interviewed, at 12:03 p.m., on 12/21/11, and indicated she took care of Resident C on the day shift, but the evening shift did Resident C's showers. She indicated when she did showers on any residents, she always checked their skin and reported anything unusual to the nurse. She indicated the resident required a little assistance when he first came to the facility, but was pretty independent, and able to dress himself, and toilet himself. The DNS was interviewed, on 12/21/11 at 2:15 p.m., and indicated Resident C did not have necrotizing fascitis of his bilateral feet. She indicated the wound nurse had documented this diagnosis, but the resident was diagnosed as having osteomylitis, not necrotizing fascitis CNA # 2 was interviewed, on 12/21/11, at 2:30 p.m., and indicated she took care of Resident C on the evening shift, and showered him at least weekly. She indicated she washed his back and he was able to wash the rest of his body. She indicated she checked his skin with every shower, head to toe, and reported anything unusual to the nurse. This federal tags relates to complaint IN 272. 3.1-37(a)

Based on observation, record reviews, and interviews, the facility failed to ensure to implement a skin condition sheet completed by the Licensed Nurse to assure assessments were complete, failed to ensure the Registered Dietician was notified and a reassessment of the resident's needs was completed to ensure adequate nutrition, resulting in an unstageable pressure ulcer 7 centimeters (cm) by 6 cm with bloody drainage, slight odor and 50% slough (Resident B). The facility failed to ensure Resident D did not develop 2 pressure ulcers one was a deep tissue injury on the left foot and one was an unstageable pressure on the right foot. This deficiency affected 2 residents who developed pressure ulcers in a sample of 3 (Resident B and D) Findings include: 1. The closed record for Resident B, was reviewed at 10:55 a.m., on 12/19/11. The resident was admitted to the facility on [DATE], with diagnoses, including, but not limited to: [MEDICAL CONDITION], recurrent Urinary Tract Infections (UTIs), Hypokalemia, Gross Hematuria, [MEDICAL CONDITIONS], Urolithiasis, and History of Sacral decubitus ulcer. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of a History and Physical, dated 8/20/11, from a local hospital (hospital 1), indicated the resident had a past medical history of [REDACTED]. Review of another History and Physical, from another local hospital (hospital 2), and dated 10/6/11, indicated the resident was admitted to hospital 1 on 8/19/11 because of hematuria and urosepsis, developed perforation and had septic shock, went into [MEDICAL CONDITION] from [MEDICAL CONDITION], and had a [MEDICAL CONDITION]. The resident was transferred to hospital 2 on 10/3/11, for continued antibiotics and recuperation, had not been able to eat and was fed through a Gastrostomy tube. A nursing admission assessment, dated 11/7/11, indicated the resident had a history of [REDACTED]. The initial skin interventions listed included pressure reducing mattress, repositioning program, and incontinence management. The assessment also revealed the resident had a catheter in place and a Gastrostomy tube. A nursing note, dated 11/7/11 at 4:45 p.m., indicated the resident was admitted with a [MEDICAL CONDITION], peg tube and was to get Pivot 50 cubic centimeters (cc) an hour from 8:00 p.m., to 6:00 a.m., had a catheter, and was on a mechanical soft diet. A nutrition screening and assessment, dated 11/11/11, indicated the resident was receiving a supplement, Pivot, at 50 cc hour at night, and skin was intact. A Braden scale assessment, for predicting pressure sore risk, indicated assessments were completed on 11/7/11, 11/21/11, and 11/28/11, and indicated the resident scored "9" with a total score of 12 or less representing a high risk for pressure sore. A pressure ulcer evaluation record, dated 11/26/11, indicated the resident developed a stage 2 pressure ulcer on the right buttock, measuring 2.0 centimeters (cm) by 2.0 cm, no odor, scant serous drainage, non-granulating, and intact surrounding skin. A reassessment, completed on 11/28/11, indicated the same assessment information as was documented on 11/26/11. A nursing note, dated 11/29/11, indicated the resident was started on an antibiotic Intravenously, for 10 days, due to an abnormal urinalysis, but there was no further documentation in the nursing notes regarding the pressure ulcer on the resident's buttocks, until a nursing note, dated on 12/3/11, at 9:00 a.m., indicated the sacral wound was 50 percent slough and granulation tissue with a medium amount to bloody drainage, and had a slight odor, no signs or symptoms of infection. A nursing note, dated 12/4/11, at 9:00 a.m., indicated the resident continued to have the wound on the sacrum dressing applied as ordered, and the wound was 50 percent slough and granulation tissue, and the wound was actively bleeding and continued to have a slight odor, with wound edges attached, and no signs or symptoms of infection. Review of the ulcer evaluation record, dated 12/4/11, indicated the wound measured 7.0 cm. by 6.0 cm, had an odor, with moderate sanguineous drainage, 50 percent slough, pink surrounding skin, and was unstageable. A physician's orders [REDACTED]. The orders also indicated Vitamin C 500 milligrams twice a day for 30 days, and Zinc 220 milligrams, every day for 30 days, to promote wound healing, and a referral to the Wound Clinic. Another physician order, dated 12/4/11, indicated the Pivot tube feeding was discontinued, and the resident was to be started on [MEDICATION NAME]. A change in condition report, dated 12/4/11, at 11:00 p.m., indicated the resident was sent to the emergency room due to inability to get adequate air exchange through his [MEDICAL CONDITION]. A nursing note, dated 12/5/11, at 2:00 a.m., indicated the resident had returned from the hospital, with a new [MEDICAL CONDITION]. A nursing note, dated 12/7/11, at 4:00 p.m., indicated the resident was informed the physician had recommended treatment at the wound clinic. The note indicated the resident refused the appointment due to problems with the area on his buttocks opening from time to time. The resident indicated, "he knew his body and knew what the doctor will say, so he would rather tx (treat) like he has in the past, and will follow up c (with) wound clinic if needed after he does what the doctor has ordered in the past." Care plans, dated 11/11/11, indicated a potential for impaired skin integrity related to [MEDICAL CONDITION], impaired mobility, incontinence, pain, and history of breakdown. Interventions included, but not limited to: pressure reducing mattress to bed, pressure reducing cushion to wheelchair, observe skin integrity during am/pm care, refer to RD (registered dietician) as needed to evaluate diet/needs, evaluate skin weekly, and low loss air mattress. Review of the treatment sheet for November, 2011, indicated weekly skin assessments were to be completed with a narrative. An admission assessment, was completed on 11/7/11, however, there were blanks under the marked off dates for 11/14/11, 11/21/11, and 11/28/11 on the treatment sheet. A nutrition screening and assessment, dated 11/11/11, indicated the skin was intact. The only other nutritional progress note, dated 12/2/11, was documented by the dietary manager, and indicated the resident was on a mechanical soft diet, current weight was 210 pounds, and Pivot was used in the tube feeding. There was no dietary notes or interventions on the care plan regarding the development of the pressure sore. A discharge instruction sheet, dated 12/9/11, indicated the resident was discharged to home with home health care, and friends were to provide 24 hour care. A skin Condition report, dated 12/9/11, on discharge, indicated the resident had sacral wounds with buttocks excoriation, stage 2, on the coccyx/sacrum. The DNS was interviewed, at 2:35 p.m., on 12/19/11, and indicated the resident did not have any open areas when he was admitted , but had a history of [REDACTED]. The Rehab Nurse Manager, was interviewed, on 12/19/11, at 2:49 p.m., and indicated the resident was "pretty compliant" was transferred using the hoyer lift, was in Physical, Occupational, and Speech therapies, and had a feeding tube for nutrition, but also ate food by mouth. She also indicated the resident was alert and oriented, and made his own health care decisions. The wound nurse was interviewed on 12/19/11, at 3:00 p.m., and indicated the resident had told her he had a history of [REDACTED]. She indicated the initial nursing assessment had identified a "scar" on the resident's coccyx area. She indicated the stage 2 pressure ulcer which developed on 11/26/11, was close to the coccyx area, and she did not see scars anywhere else on the resident. She indicated the nurses did weekly skin assessments on the residents, and once a skin condition was identified, she did weekly assessments and measured the wound. She indicated between her weekly assessments, the floor nurses did the treatments and assessed the wounds. The wound nurse indicated she did the assessment on 11/26/11 for the stage 2 pressure ulcer because she was on call that weekend, and then reassessed the area on 11/28/11, her routine day for doing the wound assessments. She indicated she was weekend supervisor on 12/4/11, and reassessed the wound which measured 7.0 cm by 6 cm, and was unstageable. She indicated this was the same wound which was identified as a stage 2 pressure ulcer on 11/26 and 11/28/11, but had now become a larger area. She indicated when she assessed the area on 12/4/11, it was 50 percent slough, so was unstageable. The wound nurse indicated she talked to the resident about going to the wound clinic to make sure he had the appointment available before he was discharged from the facility, but the resident refused because he indicated he had the same thing before and knew the physician would just "slap yellow stuff" on the wound and he would just have to sit and wait at the wound clinic. The wound nurse indicated the resident had a low loss air mattress in place, and she had even checked the inflation in the air mattress to make sure there were proper preventions in place. The DNS was interviewed at 4:00 p.m., on 12/19/11, and indicated the initial skin assessment for Resident B was completed on 11/7/11 when the resident was admitted , but none of the other weekly skin assessments had been completed. The DNS indicated a corporate nurse had visited on 11/28/11, and identified a concern that the weekly skin assessments on some of the residents had not been completed, and Resident B was one of the residents identified. The DNS indicated the facility policy to turn the resident every 2 hours was followed and a low loss alternating pressure mattress offloaded pressure every 10 minutes was used. The DNS was interviewed on 12/20/11, at 9:03 a.m., and indicated there were no additional dietary progress notes documented, and the Dietary Manager was no longer employed at the facility and had resigned, with her last day worked on 12/7/11. The DNS indicated she had done an audit of the dietary progress notes on 12/14 and 12/15/11, and found the dietary notes to be out of compliance. The DNS was interviewed at 10:45 a.m., on 12/20/11, and indicated the nurses documented on the Medicare skilled flow sheet on a daily basis, on the rehab unit, and even though there was not an area to document skin assessments, it would be expected the nurses would document anything unusual. She indicated the CNAs documented anything unusual when showers were given to the residents, 2 times weekly, and also when dressing the residents,and then reported to the nurses if anything unusual was found. She indicated the nurses did skin assessments on every resident on a weekly basis, not just on residents at risk for pressure sores. Review of the "Best Practice Skin Integrity Process" policy, provided by the Director of Nursing Services (DNS), at 10:00 a.m., on 12/20/11, indicated the following: Daily communication by CNA to licensed nurse utilizing a skin condition worksheet or comparable document; Documentation of the turning and repositioning at least every two (2) hours while in bed or in a chair; Assigned shower/bed bath schedule for residents will include utilization of skin condition worksheet by the CNA with licensed nurse co-signature; Weekly "head to toe" assessment of all residents by Licensed nurses with narrative documentation of findings; Dietary support would include additional nutritional supplement or fortified diet according to the Registered Dietician's recommendations; Revise care plan as appropriate. 2. The clinical record of Resident D was reviewed on 12/19/11, at 10:00 a.m., and indicated the resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The initial admission assessment, dated 10/20/11, indicated the resident had a slight rash in the abdominal folds, a bruise to the left upper/inner arm, 3+ [MEDICAL CONDITION] to the bilateral lower extremities, left anticubital bruising, and a left hip replacement incision. A Braden Scale assessment for predicting pressure sore risk was completed on 10/27, 11/3, and 11/10/11, and indicated the resident was not at risk for pressure sores. The treatment sheet for October, 2011, indicated weekly skin assessments were completed on admission and again on 10/27/11. Treatment sheets for November, 2011, indicated weekly skin assessments were completed. A nursing note, dated 10/30/11, at 12 noon, indicated the physician was notified due to the resident having 3+[MEDICAL CONDITION] , and new orders were left for [MEDICATION NAME] to be given daily, and lab ordered for 11/1/11. The resident also indicated she just felt bad. A nursing note, dated 10/31/11, at 10:50 a.m., indicated, "dark purple dti (deep tissue injury) noted to l (left) foot, lateral arch area. Dry calloused skin surrounding. Res (resident) c/o(complained of) mild pain sensation upon exam or pressure c (with) foot weight bearing. [MEDICAL CONDITION] 3+ pitting continues bilat (bilateral) LE (lower extremities). " The Pressure Ulcer Evaluation Form, dated 10/30/11, indicated the resident had a deep tissue injury on the left foot, which measured 3 centimeters(cm) in length and 1.5 cm in width with no drainage. A change of condition report, dated 10/30/11, indicated the physician was contacted on 10/30/11 at 12 noon, regarding the new area, but left no new orders. The Pressure Evaluation Form indicated a deep tissue injury is defined as "...Purple or maroon localized area of discolored intact skin or blood- filled blister due to damage of underlying soft tissue from pressure and/or sheer...." A pressure ulcer evaluation form, dated 10/31/11, indicated an unstageable area to the left foot arch, measuring 1.2 cm by 2.5 cm, which was 100 percent eschar, and pink surrounding skin with swelling. Physician orders, dated 11/1/11, indicated cover the left lateral foot arch with a dry abdominal pad and fix with loose kerlix, change daily and as needed for loosening/soilage. Also a venous doppler study was ordered to the bilateral lower extremities, for swelling and pain to rule out [MEDICAL CONDITION]. Another physician order, dated 11/1/11, indicated bilateral extremity compression wraps with lymphatic massage was ordered due to [MEDICAL CONDITION]. A bilateral lower extremity venous ultrasound test, dated 11/2/11, indicated no evidence of [MEDICAL CONDITION] involving the lower extremities bilaterally. A pressure ulcer evaluation, dated 11/7/11, indicated the area was unstageable, 100 percent eschar, and measured 1.1 cm by 3.0 cm. An occupational therapy daily treatment note, dated 11/16/11, indicated resident labs were drawn on 11/15/11, and the therapist was withholding the compression wraps due to the abnormal lab results. A physical therapy progress report, dated 11/18/11, indicated the open area to the left foot was improving, but now noted a small pressure area laterally to the right foot, and nursing was notified. A narrative nursing note, dated 11/18/11, at 11:15 a.m., indicated a new wound sheet was completed for a small, dry, deep tissue injury to the lateral side of the right foot, measuring 2 cm by 2 cm. A pressure ulcer evaluation form, dated 11/18/11, indicated there was a deep tissue injury to the right foot, lateral side, measuring 2 cm by 2 cm, no odors, no drainage, [MEDICATION NAME], hard/scarred wound edges, and pink surrounding skin. A pressure ulcer evaluation form, dated 11/21/11, indicated the area on the right foot was unstageable, measured 0.5 by 0.8 cm, no odor or drainage, 100 percent eschar, wound edges defined, and the surrounding skin was pink. A pressure ulcer evaluation, dated 12/12/11, indicated the area was healed to the right foot. On 11/22/11 the resident was transferred to the hospital for a scheduled blood transfusion. A pressure ulcer evaluation, dated 12/19/11, indicated the area located on the left foot arch measured length was 0.8 centimeters (cm) and 1.8 cm. On 12/20/11 at 12:15 p.m. the LPN Wound Nurse was interviewed in regard to the cause of the pressure ulcers and she indicated she thought the pressure ulcers developed due to the resident had [MEDICAL CONDITION] and [MEDICAL CONDITION]. On 12/20/11 at 12:45 p.m. the Certified Occupational Therapy Assistant (COTA) was interviewed in regard to the compression wraps and indicted the resident wore the compression wraps for 23 hours a day 7 days a week. The COTA further indicated she applied the wraps through the week and Nursing applied the wraps on the week-ends and both nursing and COTA were responsible for assessing the residents bilateral legs when the wraps were removed for 1 hour a day. On 12/20/11 at 4:55 p.m. the Director Nursing Service (DNS) was interviewed in regard to the resident's pressure ulcer and she indicated the resident only wore shoes in therapy after the first pressure ulcer developed. The DNS further indicated the resident had a special pressure reduction mattress with a "heel slope" On 12/21/11 at 10:45 a.m. an observation of the resident's pressure area with RN #3 was obtained to the left foot arch and the wound bed was pink and surrounding tissue were pink and slightly swollen with a scant amount of serosanguineous drainage on the old dressing. This federal tag relates to complaint IN 272 3.1-40(a)(1) 3.1-40(a)(2)

Based on record review and interviews, the facility failed to ensure 1 of 3 residents reviewed for hydration needs in a sample of 24 was provided fluids and/or interventions to maintain proper hydration. The deficient practice resulted in the resident's tests for blood chemistry reaching a panic level with the need to transfer the resident to an acute care center for treatment. (Resident B) Finding includes: The closed clinical record for Resident B was reviewed on 01/10/11 at 1:30 P.M. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A blood chemistry laboratory test, completed on 05/18/10, indicated the resident's BUN (blood urea nitrogen) level was elevated at 32 mg/dl. The normal range for a BUN was 7 - 18 mg/dl. The resident's creatinine level was very slightly elevated at 1.4 mg/dl. The normal range for a blood creatinine level was .6 - 1.3 mg/dl. The resident's sodium, potassium, chloride, and carbon [MEDICATION NAME] levels were all within the normal range. A nursing progress note, dated 06/30/10, untimed, indicated the following: "Res b/p (blood pressure 120/59, p (pulse) 104 r (respirations) 18 t (temperature) 99.0 after Tylenol - res a/o (alert and oriented) lethargic - hard to arouse- res skin warm et dry - mm (mucous membranes) dry - diaphoretic on back - resp free et (and) easy with no sob (shortness of breath) - mouth breathing res abd (abdomen) nontender with + boso (bowel sounds) - res have decreased dietary intake fluids encouraged - oral care given - (physician's name) notified n.o. (new order) received for ua (urinalysis), cbc (complete blood count), chem 6 (blood chemistry test) - may straight cath (daughter's name) called et informed of n.o." Further nursing notes indicated the urinalysis was collected at 2:00 P.M. on 06/30/10. The physician called an order for [REDACTED]. The resident continued to be lethargic the evening of 06/30/10. On 07/01/10 at 8:45 A.M., the laboratory called to report a "panic" blood chemistry level with a BUN of 108. The physician was notified, and the resident was sent to an acute care facility. The resident was noted to have trouble breathing just prior to being transported to the hospital. The hospital admission history and physical assessment, dated 07/01/10, indicated the resident presented to the emergency room with dry tongue, white blood cells in her urine, and a BUN of 118 mg/dl and a creatinine level of 3 mg/dl. The resident was diagnosed with [REDACTED]. The nutritional assessment, signed and dated by the dietitian on 12/29/10, indicated the resident's daily fluid intake requirement was 1400 ml. The intake and output records for Resident B, from 06/01/10 - 06/30/10 indicated the resident's meal fluid intake was below the 1400 ml requirement. The care conference notes, dated 05/13/10 indicated although her appetite was decreased, there were no dietary or hydration concerns. The 06/23/10 care conference note indicated the resident had gained weight from 05/10 - 06/10, and there were no dietary or hydration concerns noted. The quarterly MDS (minimum data set) assessment for Resident B, completed on 06/07/10, indicated the resident was moderately cognitively impaired, required extensive staff assistance for eating and toileting needs, was incontinent of both her bowels and bladder, and had a recent weight loss. The current health care plans for Resident B, dated as current through 08/10, indicated the only plan addressing any hydration needs was a plan to prevent urinary tract infections by providing the fluid as on the menu and 4 ounces of fluid every meal. A plan to address eating needs indicated the resident required staff assistance for eating. The specific fluid intake amounts for Resident B from 06/01/10 - 06/19/10 indicated the resident's daily fluid intake averaged 750 cc (cubic centimeters) per day. However, from 06/23/10, a week prior to her transfer to the acute care facility on 06/30/10 indicated the following total cc (cubic centimeters) of fluid per day: 06/23/10 - 460, 06/24/10 - 480, 06/25/10 - 497, 06/26/10 - 426, 06/27/10 - 686, 06/28/10 - 240, 06/29/10 - 385, and 06/30/10 - 180. There was no nursing progress note, prior to 06/30/10, informing the physician and/or the dietician of the resident's decrease in fluid intake. There was also no plan to address the resident's chronic less than required intake of fluids from 06/01/10 - 06/30/10. Interview with the DON (Director of Nursing) on 01/13/11 at 1:45 P.M., indicated the resident received an additional 360 cc's of fluid daily with the medication pass supplement which had been ordered for Resident B in May 2010 due to weight loss. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"house supplement" three times a day for all 30 days in June 2011. The DON indicated even though the supplement was given at meal time, the 120 cc's of fluid was not included in the fluid intake totals for the day recorded by the nursing staff after each meal. However, there was no specific way to document how much of the supplement had been consumed. The DON indicated if the nurse's initials were not circled and "refused" or some percentage charted on the back of the MAR, then the resident consumed all 120 cc's of the supplement. However, even the additional 360 cc's of fluid still did not bring the resident's total fluid intake even close to her required 1400 ml of fluid per day. Interview with the Director of Nursing, on 01/13/10 at 3:45 P.M. indicated the facility did not have a "Hydration Program." She indicated she relied on staff communication between licensed nurses and direct care aides to notice a decreased fluid intake, assess the resident, and get any needed interventions. She indicated she had inserviced the staff on the dementia unit, where Resident B had resided, in September 2010, regarding the need to ensure adequate fluid intakes for the residents. She indicated the inservice was in response to a concern regarding another resident's hydration. This federal tag relates to Complaint IN 925. 3.1-46(b)