Every finding on record at Owen Valley Rehabilitation and Healthcare Center

Based on interview and record review, the facility failed to ensure a new PASARR (Preadmission Screening and Resident Review) Level 1 was completed when a new mental health diagnosis and new psychoactive medications were added for 1 of 3 residents reviewed for PASARR. (Resident 8)Findings include: On 2/20/26 at 9:55 a.m., Resident 8's clinical record was reviewed. Diagnoses included, but were not limited to, bipolar disorder (a chronic mental health condition characterized by intense mood shifts between extreme highs and lows), hoarding disorder (a mental health condition characterized by persistent, extreme difficulty discarding possessions), obsessive-compulsive disorder (a chronic mental health condition characterized by uncontrollable, recurring thoughts (obsessions) and repetitive behaviors (compulsions) performed to reduce anxiety), and post-traumatic stress disorder (a mental health condition triggered by experiencing or witnessing terrifying, life-threatening events, such as abuse, accidents, or combat).A PASARR Level I, dated 2/8/22, indicated the resident had no mental health disorders and no mental health medications. The Level I screen indicated there was no evidence of any PASARR condition or disability. If changes occurred or new information refuted these findings, a new screen must be submitted. The MAR (Medication Administration Record) indicated the following orders:Quetiapine (antipsychotic medication) 25 milligrams (mg), 1 tablet twice daily for schizoaffective disorder, initiated 8/27/22 and discontinued 4/9/23.Quetiapine 25 mg, 1 tablet twice daily for bipolar disorder, initiated 4/9/23 and discontinued 11/16/23.Quetiapine 25 mg, 2 tablets twice daily for bipolar disorder, initiated 11/16/23 and discontinued 5/3/24.Effexor (antidepressant medication) XR (extended release) 37.5 mg, 1 capsule daily for hoarding disorder, initiated 4/15/24 and discontinued 5/22/24.Quetiapine 25 mg, 2 tablets daily for bipolar disorder, initiated 5/3/24 and discontinued 12/4/25.Effexor XR 37.5 mg, 1 capsule daily for obsessive-compulsive disorder, initiated 5/22/24 with no end date.Quetiapine 25 mg, 1 tablet daily for bipolar disorder, initiated 12/4/25 with no end date. A review of Resident 8's care plan indicated the resident has/is at risk for: impaired psychosocial well-being, sensory deficits, communication deficits, cognitive deficits related to: Behaviors, Bipolar disorder, Hoarding items in room, Insomnia/sleep disorder, Refuses or resistant to care showers and labs, Verbally/Physically [sic] aggression towards others. Resident has episodes of becoming hyper-focused on past injuries to ankle and ribs, refusing therapy services. The care plan was revised on 8/26/25.During an interview with the Social Services Director (SSD) on 2/23/26 at 10:00 a.m., she indicated a new significant mental health disorder or new psychotropic medication would trigger a new PASARR Level 1 review. The SSD indicated there was not a new PASARR Level 1 on file for Resident 8. The SSD indicated they would review new diagnoses and new psychotropic medications monthly at the pharmacy review meetings.On 2/23/26 at 3:00 p.m., the Director of Nursing (DON) provided a copy of admission Criteria, dated March 2019, she indicated this was a current policy used by the facility. The policy indicated .10. All new admissions and readmissions are screened for mental disorders (MD).per the Medicaid PASARR process.On 2/23/26 at 3:43 p.m., the Administrator provided the policy labeled Resident Assessment-Coordination with PASARR Program, dated 5/10/25, he indicated this was an active policy used by the facility. The policy indicated the following .i. Negative Level I Screen - permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later.6. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority.9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a Level II resident review. Examples include: a. A resident who exhibits behavioral psychiatric or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis).3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

Based on observation, interview, and record review, the facility failed to ensure a resident with significant weight loss was weighed as ordered by the physician for 1 of 2 residents reviewed for nutrition. (Resident 51)Findings include:On 2/18/26 at 10:10 a.m., Resident 51's clinical record was reviewed. The diagnoses included, but were not limited to, vascular dementia and osteoporosis. The resident was not on a physician prescribed weight loss program.On 1/5/26, the resident weighed 138.6 pounds. On 2/5/26, the resident weighed 124.6 pounds, which was a 10.1 percent weight loss in 30 days.A care plan, revised on 2/17/26, indicated the resident was at risk for malnutrition. The interventions included, but were not limited to, Obtain weight as indicted report to RD [Registered Dietician], physician .A physician's order with a start date of 2/11/26 and an end date of 3/11/26 indicated, Weekly weights x [times] 4 weeks for 4 weeks.The clinical record lacked weights for the resident after 2/5/26During an interview on 2/23/26 at 2:20 p.m., the Dementia Care Director indicated she was unaware the resident had triggered for weight loss, and there was no record of the resident being weighed after 2/5/26.During an interview on 2/23/26 at 3:05 p.m., the Director of Nursing indicated the 2/11/26 physician's order for weighing the resident was entered into the clinical record in a manner that prevented staff from seeing it as a task to be completed, and staff would not have known to weigh the resident as ordered. 3.1-46(a)(1)

Based on observation, interview, and record review, the facility failed to ensure, a resident's medical record was complete and accurately documented (Resident 40).During an interview on 2/23/26 at 11:55 a.m., LPN 1 indicated Resident 40's fentanyl patch (a strong opioid medicine prescribed by doctors for severe pain) was out of stock. When she went to do a lunch medication administration, the medication administration record (MAR) indicated another nurse had placed a new patch on the resident's left chest. During an observation at that time, a patch was observed on the resident's right side of his chest, signed by LPN 3, and dated for 2/20/26. The nurse further indicated no patches were administered from the emergency drug kit (EDK) because the pharmacy needed a new prescription from the prescriber. On 2/23/26 at 12:01 p.m., the resident's clinical record was reviewed. The diagnoses included, but were not limited to Parkinson's disease, catatonic disorder (a condition that changes how a person's brain controls their body, affecting how they move, talk, and behave), and pain. A 12/10/25 physician's order, indicated the resident was prescribed a 25 microgram (mcg) fentanyl patch to be applied to the skin every 72 hours for pain at 6:00 a.m., and the old patch was to be removed at 5:59 a.m. A progress note, dated 2/23/26 at 1:44 p.m., indicated the resident's fentanyl patch was due to be changed on LPN 1's shift. She called the pharmacy to request a refill and obtain an authorization code for the EDK. The pharmacy technician told her a new prescription was needed and they were unable to provide an authorization code. She contacted the prescriber for a new prescription. A review of the resident's MAR indicated the following:- On 2/20/26 at 5:01 a.m., LPN 3 removed and applied a new fentanyl patch. - On 2/23/26 at 5:34 a.m., LPN 2 applied a new fentanyl patch. The resident's record lacked documentation the 2/20/26 patch was removed. During an interview on 2/23/26 at 4:04 p.m., the Director of Nursing (DON) indicated LPN 2 had erroneously charted she gave the resident a new patch, when she should have charted she removed the 2/20/26 patch. The facility had not applied a new patch because they had to get a new prescription from the doctor. On 2/23/26 at 4:20 p.m., the DON provided the facility policy Charting and Documentation, revised 7/2017, and indicated it was the policy currently being used. A review of the policy indicated, . 7. Documentation of . treatments will include care-specific details, including: a. The date and time the prodecure/treatment was provided . 3.1-50(a)(1)3.1-50(a)(2)

Based on interview and record review, the facility failed to ensure the admission Minimum Data Set (MDS) assessment was completed within 14 calendar days from the admitted for 4 of 4 residents reviewed for Resident Assessment. (Resident 132, Resident 133, Resident 282, Resident 75) Findings include: 1. On 12/9/24 at 11:56 a.m., Resident 132's clinical record was reviewed. The diagnosis included, but was not limited to, urinary tract infection. The resident was admitted to the facility on [DATE]. The admission MDS assessment for Resident 132 indicated it was still in progress. The completion date should have been on 12/2/24, which was 14 calendar days from the admitted . 2. On 12/9/24 at 12:00 p.m., Resident 133's clinical record was reviewed. The diagnosis included, but was not limited to, clostridium difficile. The resident admitted to the facility on [DATE]. The admission MDS assessment for Resident 133 indicated it was still in progress. The completion date should have been on 12/1/24, which was 14 calendar days from the admitted . 50647 3. On 12/5/24 at 2:00 p.m., Resident 282's clinical record was reviewed. The diagnoses included, but were not limited to, major depressive disorder, post-traumatic stress disorder, and schizoaffective disorder (a chronic mental illness). Resident 282 was admitted on [DATE]. Resident 282's admission MDS assessment, dated 11/21/24, indicated it was still in progress, at the time of record review this indicated it was 28 days past due. During an interview on 12/9/24 at 11:00 a.m., the MDS Coordinator indicated an admission MDS assessment needed to be completed and signed by the 14th calendar day after admission. She indicated the admission assessment for Resident 282 was still in progress and that it was overdue. 4. On 12/5/24 at 11:06 a.m., Resident 75's clinical record was reviewed. The diagnoses included, but were not limited to, encephalopathy (a general term for a brain disorder), urinary tract infection and escherichia coli (type of bacteria). Resident 75 was admitted on [DATE]. Resident 75's admission MDS assessment, dated 10/14/24, indicated the RN verified and signed the admission assessment on 11/2/24, which was 20 days after admission. During an interview with the MDS Coordinator on 12/9/24 at 11:00 a.m., she indicated the admission assessment for Resident 75 was completed late. During an interview with the MDS Coordinator on 12/9/24 at 11:05 a.m., she indicated the facility did not have a policy for MDS assessments, she indicated they used The Centers for Medicare & Medicaid Services (CMS) Resident Assessment Instrument (RAI) tool. A review of the RAI User's Manual (v.1.19.1, effective 10/1/24) on 12/9/24 at 12:30 p.m., indicated .For all non-Admission OBRA [Omnibus Budget Reconciliation Act] and PPS [Prospective Payment System] assessments, the MDS Completion Date must be no later than 14 days after the Assessment Reference Date. For the Admission assessment, the MDS Completion Date must be no later than 13 days after the Entry Date . 3.1-31(d)(1)

Based on interview and record review, the facility failed to ensure residents were invited to participate in the care planning conference for 1 of 1 resident reviewed for care planning. (Resident 67) Findings include: On 12/4/24 at 2:15 p.m., Resident 67 indicated she had not been invited to her care plan conferences. On 12/5/24 at 10:23 a.m., Resident 67's clinical record was reviewed. The diagnoses included, but were not limited to, atrial fibrillation and major depressive disorder. The quarterly Minimum Data Set (MDS) assessment, dated 10/24/24 indicated Resident 67 had moderate cognitive impairment. The clinical record lacked documentation of Resident 67 having been invited to participate in the care plan conference after the quarterly MDS assessment, dated 10/24/24. On 12/9/24 at 10:46 a.m., the Social Service Designee (SSD) indicated they would invite the resident and/or resident's responsible party to care plan conferences after the comprehensive or quarterly MDS assessment. Resident 67's quarterly MDS assessment was completed in October 2024. The clinical record lacked documentation of an invitation or the care plan conference after the quarterly MDS assessment in October 2024. On 12/9/24 at 12:50 p.m., the Director of Nursing (DON) provided a copy of the facility policy, Baseline Care Plan, dated 10/20/23, and indicated it was the policy currently being used. A review of the the policy lacked documentation of resident and/or resident's representative invitation to care plan meeting after MDS assessments. 3.1-35(d)(2)(B)

Based on interview and record review, the facility failed to electronically submit to the Centers for Medicare and Medicaid (CMS) complete and accurate Registered Nurse (RN) hours based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for quarter 4 of fiscal year 2023 (7/1/23-9/30/23). Findings include: On 2/2/24 at 2:01 p.m., the facility's Payroll Based Journal (PBJ) Staffing Data Report was reviewed. The report indicated the facility had no RN hours for 7/8/23, 7/9/23, 7/16/23, 9/23/23, 9/24/23, and 9/30/23. On 2/2/24 at 2:03 p.m., the staffing sheets and time cards for the above dates were reviewed and indicated the facility did have RN hours for those dates. During an interview at that time with the Director of Nursing (DON), she indicated the Administrator who was working at the facility during CMS quarter 4 of fiscal year 2023, did not put the PBJ hours in correctly for the RN hours. During an interview on 2/2/24 at 2:13 p.m., the DON indicated the facility did not have a policy related to correctly entering the PBJ hours. .

Based on observation, interview, and record review, the facility failed to ensure a sanitary and comfortable environment for 3 of 4 units observed. A urine odor was observed and air vents were not clean. (200 unit, 300 unit, 400 unit) Findings include: 1. On the following dates and times, the full length of the 200 unit hallway was observed to have a strong odor of urine: - On 1/29/24 at 11:20 a.m. and 2:40 p.m. - On 1/30/24 at 10:40 a.m., 12:05 p.m., and 3:00 p.m. - On 2/2/24 at 9:45 a.m., 11:10 a.m., and 1:25 p.m. 2. On the following dates and times, the 400 unit hallways and common area were observed to have a strong odor of urine: - On 1/29/24 at 10:20 a.m., 1:30 p.m., and 3:10 p.m. - On 1/30/24 at 10:45 a.m., 1:10 p.m., and 3:20 p.m. - On 2/2/24 at 10:05 a.m., 11:30 a.m., and 1:35 p.m. 3. On the following dates and times, the 3 ceiling air vent covers on the 200 unit were observed to have a dark fuzzy substance on them: - On 1/29/24 at 11:21 a.m. and 2:41 p.m. - On 1/30/24 at 10:41 a.m., 12:06 p.m., and 3:01 p.m. - On 2/2/24 at 9:46 a.m., 11:11 a.m., and 1:26 p.m. 4. On the following dates and times, the 3 ceiling air vent covers on the 100 unit were observed to have a dark fuzzy substance on them: - On 1/29/24 at 11:24 a.m. and 2:44 p.m. - On 1/30/24 at 10:44 a.m., 12:09 p.m., and 3:04 p.m. - On 2/2/24 at 9:49 a.m., 11:14 a.m., and 1:29 p.m. During an interview on 2/2/24 at 1:45 p.m., the Maintenance Director indicated the 200 unit and 400 unit emitted an odor of urine, likely from the carpeting, and was in need of extensive cleaning to eliminate the odors. The ceiling air vent covers on the 200 unit and 100 unit had a dark fuzzy substance on them and were in need of cleaning. On 2/2/24 at 2:30 p.m., the Director of Nursing provided the facility's Homelike Environment policy, effective date 12/1/23 and indicated this was the policy currently utilized by the facility. A review of the policy indicated, .the residents are provided with a safe, clean, comfortable, and homelike environment .pleasant, neutral scents . 3.1-19(f)

Based on record review and interview, the facility failed to notify the residents family of an accident for 1 of 3 residents reviewed for accidents. (Resident B) Findings include: On 6/29/23 at 12:00 p.m., Resident B's clinical record was reviewed. The Quarterly MDS (Minimum Data Set) assessment, dated 4/10/23, indicated Resident B had severe cognitive impairment. The progress notes included, but were not limited to: - On 6/25/23 at 2:21 p.m., Resident B was witnessed in the dining room standing, attempting to ambulate away from his wheelchair. Resident B tripped over his foot pedals and landed on his right side. Resident B was assessed and placed back in his wheelchair. Resident B requested to go back to bed. Physician was notified and mobile x-rays were ordered. The clinical record lacked family notification of the new orders for x-ray's following Resident B's fall until 6/26/23 at 8:30 a.m. During an interview on 6/29/23 at 2:30 p.m., the ADON (Assistant Director of Nursing) and ADM (Administrator) indicated Resident B resided at a group home and his aunt was his emergency contact. This Federal tag relates to Complaint IN00411250. 3.1-5(a)(1)

Based on interview and record review, the facility failed to ensure an x-ray was completed in a timely manner for 1 of 3 residents reviewed for accidents. (Resident B) Finding includes: On 6/29/23 at 12:20 p.m., Resident B's clinical record was reviewed. The Quarterly MDS (Minimum Data Set) assessment, dated 4/10/23, indicated Resident B had severe cognitive impairment. The Progress Notes included, but were not limited to: - On 6/25/23 at 2:21 p.m., Resident B was witnessed in the dining room standing, attempting to ambulate away from his wheelchair. Resident B tripped over his foot pedals and landed on his right side. Resident B was assessed and placed back in his wheelchair. Resident B requested to go back to bed. Physician was notified and mobile x-rays were ordered. - On 6/26/23 at 8:30 a.m., called mobile x-ray company for estimated time of arrival and could not get the x-ray companies dispatch to answer. Resident B continued to rest in bed, with complaint of mild pain to right leg. - On 6/27/23, at 9:30 a.m., called the mobile x-ray company for the estimated time of arrive and was informed the order was re-scheduled for today (6/27/23) secondary to x-ray technician unable to complete within business hours yesterday. Facility expressed to x-ray company the importance of getting the x-ray completed due to Resident B's increased pain and notable bruising and upgraded to stat (immediately). - On 6/27/23 at 10:57 a.m., the x-ray company called to inform the facility the x-ray would be completed either late afternoon or evening, and there was a slight possibility that it would not be done today. - On 6/27/23 at 11:21 a.m., the physician was notified of the status of the x-ray order. A new order was received to send resident to the ER for evaluation. On 6/29/23 at 2:30 p.m., the ADON indicated the x-ray was not completed and the physician notified the x-ray was not completed until 6/27/23. This Federal tag relates to Complaint IN00411250. 3.1-49(g)

Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain good grooming and personal hygiene for 4 of 6 residents reviewed for activities of daily living. (Resident 39, Resident 178, Resident 24, Resident 56) Findings include: 1. On 3/6/23 at 10:50 a.m., Resident 39 was observed in bed in her room with whiskers approximately 1/2 inch long on her chin. On 3/8/23 at 2:40 p.m., Resident 39 was observed in bed in her room with whiskers approximately 1/2 inch long on her chin. On 3/9/23 at 10:30 a.m., Resident 39 was observed in the activity area with whiskers approximately 1/2 inch long on her chin. During an interview on 3/8/23 at 2:25 p.m., the resident indicated she would rather have not had whiskers on her chin. On 3/9/23 at 10:45 a.m., Resident 39's clinical record was reviewed. The diagnoses included, but were not limited to, dementia, muscle weakness, and hypothyroidism. The Quarterly MDS (Minimum Data Set) assessment, dated 1/17/23 indicated the resident required extensive physical assistance of 1 person for personal hygiene. 2. On 3/6/23 at 11:00 a.m., Resident 178 was observed in bed in his room with whiskers approximately 1/2 inch long under his nose and on his chin and jaw. On 3/8/23 at 12:41 p.m., Resident 178 was observed in bed in his room with whiskers approximately 1/2 inch long under his nose and on his chin and jaw. On 3/9/23 at 9:50 a.m., Resident 178 was observed in bed in his room with whiskers approximately 1/2 inch long under his nose and on his chin and jaw. During an interview on 3/8/23 at 12:45 p.m., Resident 178 indicated he usually did not have whiskers on his face and would like to have been shaven. He was unable to shave himself due to his weakness and required assistance. On 3/8/23 at 1:00 p.m., Resident 178's clinical record was reviewed. The diagnoses included but were not limited to, osteomyelitis and heart failure. A care plan, initiated 3/2/23, indicated the resident required the physical assistance of 1 person for personal hygiene. 3. On 3/6/23 at 2:35 p.m., Resident 24 was observed in his bed with whiskers approximately 1/4 inch long under his nose and on his chin and jaw. On 3/8/23 at 11:05 a.m., Resident 24 was observed in his bed with whiskers approximately 1/4 inch long under his nose and on his chin and jaw. On 3/9/23 at 10:10 a.m., Resident 24 was observed in his bed with whiskers approximately 1/4 inch long under his nose and on his chin and jaw. During an interview on 3/9/23 at 10:15 a.m., Resident 24 indicated he usually did not have whiskers on his face and would like to have been shaven. Staff did not often offer to shave him. On 3/8/23 at 1:10 p.m., Resident 24's clinical record was reviewed. The diagnoses included, but were not limited to, Parkinson's disease and venous insufficiency. The Annual MDS assessment, dated 11/27/22, indicated the resident required limited assistance of 1 person for personal hygiene. 34848 4. On 3/6/23 at 10:36 a.m., Resident 56 was observed with facial whiskers and brown substance beneath his nails On 3/7/23 at 11:36 a.m., Resident 56 was observed with facial whiskers and brown substance beneath his nails. During an interview at that time, his wife indicated she wished the staff would do better about shaving his facial hair. On 3/8/23 at 11:05 a.m., Resident 56 was observed with facial whiskers and brown substance beneath his nails. On 3/9/23 at 10:22 a.m., Resident 56 was observed with brown substance beneath his nails and his whiskers were unevenly shaved. On 3/9/23 at 11:00 a.m., Resident 56's clinical record was reviewed. The diagnoses included, but were not limited to, hemiplegia (paralysis) and hemiparesis (weakness) on his dominant side and aphasia (a disorder that affects a person's ability to communicate) following cerebral infarction (stroke). The Quarterly MDS assessment, dated 11/19/22, indicated the resident was totally dependent on staff with personal hygiene, and had one-sided impairment in his upper and lower extremities. An 8/4/22 ADL (activities of daily living) care plan, indicated the resident had impairment in functional status in regard to transfers, bed mobility, toileting, and eating. The care plan did not include interventions which addressed his personal hygiene. During an interview on 3/9/23 at 10:55 a.m., the Director of Clinical Services indicated the residents needed to be shaved and whiskers needed to be removed. During an interview on 3/9/23 at 2:22 p.m., CNA (Certified Nursing Assistant) 1 indicated she tried to shave the residents every day and it's an understanding that the men should be offered a shaved every day. On 3/9/23 at 2:55 p.m., the Director of Clinical Services provided the facility policy, Grooming, revised on 1/25/18, and indicated it was the policy currently used. A review of the policy indicated, .observe condition of resident nails, hair, and facial hair .shave .clean debris from around and under finger and toe nails . 3.1-38(a)(3)(D) 3.1-38(a)(3)(E)

Based on interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident with falls for 1 of 3 residents reviewed for accidents. (Resident 60) Finding includes: Resident 60's clinical record was reviewed on 3/9/23 at 10:00 a.m. The diagnosis included, but was not limited to, Alzheimer's disease. The Quarterly Minimum Data Set (MDS) assessment, dated 11/20/22, indicated the resident had not fallen since admission or prior assessment either with injury or with no injury. The prior assessment was dated 8/26/22. A review of the Fall-Initial Occurrence Note, indicated the resident had a fall with injury on 10/9/22 and had a fall with no injury on 10/30/22. During an interview on 3/9/23 at 11:48 a.m., the Director of Clinical Services indicated the Quarterly MDS assessment, dated 11/20/22, was incorrect and they missed the falls on 10/9/22 and 10/30/22. On 3/9/23 at 3:39 p.m., the Director of Clinical Services indicated the facility did not have a policy related to MDS. They used the RAI (Resident Assessment Instrument) manual. A review of the Resident Assessment Instrument (RAI) Version 3.0 Manual, Section J1900 indicated, . Determine the number of falls that occurred since admission/entry or reentry or prior assessment [OBRA or Scheduled PPS] and code the level of fall-related injury for each . 3.1-31(d)

Based on interview and record review, the facility failed to ensure an activities of daily care (ADL) care plan was developed for 2 of 6 residents reviewed for ADL's. (Resident 60, Resident 16) Findings include: 1. Resident 60's clinical record was reviewed on 3/9/23 at 10:00 a.m. The diagnosis included, but was not limited to, Alzheimer's disease. The Quarterly Minimum Data Set (MDS) assessment, dated 11/20/22, indicated the resident was extensive assistance of 1 for activities of daily living (ADL's). A review of the care plans lacked documentation of a current care plan for ADL's. 2. Resident 16's clinical record was reviewed on 3/9/23 at 2:55 p.m. The diagnosis included, but was not limited to, Alzheimer's disease. The Significant Change MDS assessment dated , 1/6/23, indicated the resident was dependent of 2 person's for ADL's. A review of the care plans lacked documentation of a current care plan for ADL's. During an interview on 3/9/23 at 4:15 p.m., the Assistant Director of Nursing (ADON) indicated the facility was still working to get all care plans updated for Resident 60 and Resident 16 since the facility was purchased by another company in 2022. 3.1-35(a)

Based on observation, interview, and record review, the facility failed to document in the clinical record a skin tear (a wound that happens when the layers of skin separate or peel back) for a resident with a skin tear for 1 of 3 residents reviewed for skin conditions. (Resident 12) Findings include: During an observation on 3/6/23 at 10:05 a.m., Resident 12 was observed to have a Band-Aid and a purple bruise on her right forearm. During an interview on 3/7/23 at 1:45 p.m., Resident 12 indicated about a week ago, she was being transferred with a mechanical lift and the sling caused the bruise and the skin tear on her right arm. During an observation on 3/8/23 at 10:10 a.m., Certified Nursing Assistant (CNA) 2 and CNA 3 were observed to transfer Resident 12 with mechanical lift. At that time, Resident 12 was observed to have a white dressing on her right forearm. During an observation on 3/9/23 at 11:03 a.m., the Assistant Director of Nursing (ADON) removed the white dressing on Resident 12's right forearm. She indicated there was a skin tear on her right forearm. At that time, Resident 12 indicated she had gotten a skin tear during a transfer with mechanical lift. On 3/9/23 at 10:45 a.m., Resident 12's clinical record was reviewed. The diagnoses included, but were not limited to, cerebral palsy (impaired muscle coordination) and diabetes mellitus. Resident 12's Progress notes dated 3/1/23 through 3/8/23 lacked documentation of a skin tear to right forearm. Resident 12's Non-Pressure assessment dated [DATE] at 7:14 p.m., lacked documentation of Resident 12's skin tear. During an interview on 3/8/23 at 10:19 a.m., CNA 2 indicated Resident 12 skin was fragile. She had a skin tear on her right forearm. During an interview on 3/9/23 at 11:37 a.m., the ADON indicated Resident 12 had a skin tear on her right forearm. When a resident received a skin tear, the nurse would document the skin tear in the clinical record, call physician and family. Resident 12's skin tear on her right forearm was not documented in her clinical record. On 3/9/23 at 12:45 p.m., the Director of Clinical Services provided the facility policy, Pressure Injury and Skin Condition Assessment, dated 2/19/21 and indicated this was the policy currently being used by the facility. A review of the policy indicated .3. A wound assessment will be initiated and documented in the resident chart when pressure and/or other ulcers are identified by licensed nurse . 3.1-37(a)

Based on observation, interview, and record review the facility failed to ensure staff assessed and addressed the needs of residents with significant weight loss for 2 of 5 residents reviewed for nutrition. (Resident 66, Resident 33) Findings include: 1. On 3/8/23 at 12:18 p.m., Resident 66 was observed eating lunch in the main dining room. He was slowly eating bites and staff were observed to encourage him to eat. On 3/6/23 at 2:41 p.m., Resident 66's clinical record was reviewed. The diagnoses included, but were not limited to, dysphagia (difficulty swallowing) following cerebral infarction (stroke), one-sided hemiplegia (paralysis) and hemiparesis (weakness), vitamin deficiency, and gastro-esophageal reflux disease (GERD). The Quarterly Minimum Data Set (MDS) assessment, dated 11/27/22, indicated the resident required supervision (oversight, encouragement, or cueing) with eating. Review of the resident's monthly weight report the following: - In September 2022, the resident weighed 145 pounds (lbs.) - In October 2022, the resident weighed 146.4 lbs. - In November 2022, the resident weighed 145 lbs. - In December 2022, the resident weighed 126 lbs. - In January 2023, the resident weighed 127.2 lbs. - In February 2023, the resident weighed 124.4 lbs. - In March 2023, the resident weighed 124.2 lbs. This was a significant weight loss of 14.34% over 6 months. A 2/2/23 physician's progress note indicated the resident had experienced weight loss, . unacceptable decline . and staff were to . continue aggressive - fortified supplements [to] determine highest level of food consistency appropriate . for the resident. She continued, . look into carnation inst. [instant] breakfast [a powdered instant drink that is manufactured with protein, vitamins, and minerals], etc. A 2/2/23 nutritional note, indicated the resident had significant weight loss of 14.2%. The Registered Dietician indicated the resident should receive Ensure (a nutritional shake) once a day versus twice a day to prevent excessive intake. A 2/27/23 nutritional assessment, indicated the resident experienced significant weight loss of 14% over 180 days. The Registered Dietician indicated staff should continue the current plan of care and the resident did not need any new nutritional interventions, despite the clinical record which assessed a continued weight loss. A 2/27/23 care plan indicated the resident was at nutritional risk related to a greater than 14% weight loss over 180 days. During an interview on 3/10/23 at 3:39 p.m., the Director of Clinical Services indicated further interventions should have been implemented for the resident. 38312 2. During an observation on 3/8/23 on 12:16 p.m., Resident 33 was observed to be feeding herself fried chicken and cheese potatoes. On 3/8/23 at 11:43 a.m., Resident 33's clinical record was reviewed. The diagnoses included, but were not limited to, hemiparesis (paralysis on one side of the body), mood disorder, anemia, and diabetes mellitus. Resident 33's weights indicated the following: - On 9/9/22 at 5:03 p.m., her weight was 193.5 pounds. - On 10/17/22 at 1:48 p.m., her weight was 186.5 pounds. - On 11/25/22 at 2:28 p.m., her weight was 181.9 pounds. - On 12/5/22 at 4:51 p.m., her weight was 184.3 pounds. - On 1/2/23 at 5:02 p.m., her weight was 172.8 pounds. - On 2/3/23 at 7:18 p.m., her weight was 168.2 pounds. - On 3/6/23 at 8:07 a.m., her weight was 169.8 pounds. This was a significant 12.25 percent weight loss over six months. A care plan, dated 2/10/23, indicated Resident 33 was at nutritional risk related to weight loss. The intervention was registered dietician evaluation as needed. A progress note, dated 2/10/23 at 4:28 p.m., indicated Resident 33 had significant weight loss. The RD recommended an updated blood sugar and A1C (blood test which measures the average blood sugar levels over the past 3 months). The clinical record lacked documentation of a physician notification of the RD recommendations of updated blood sugar and A1C. During an interview on 3/8/23 12:59 p.m., the Assistant Director of Nursing (ADON) indicated the clinical record lacked documentation of the physician being notified of the RD recommendation dated 2/10/23. On 3/9/23 at 2:00 p.m., the Director of Clinical Services provided the facility policy, Nutritional Monitoring, undated, and indicated this was the policy currently being used by the facility. A review of the policy indicated .6. Assess factors affecting appropriate nutritional intake and take corrective action . 3.1-46(a)(1)

Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice. There was not an order for the oxygen and the equipment was not dated. (Resident 178) Finding includes: On 3/6/23 at 11:00 a.m., Resident 178 was observed in bed in his room receiving 2 liters of oxygen via a nasal cannula from an oxygen concentrator machine (a machine that takes in air from the room to filter out nitrogen in order to provide higher amounts of oxygen for oxygen therapy). The oxygen humidifier bottle, oxygen tubing, and nasal cannula were not labeled with a time or date. On 3/8/23 at 12:41 p.m., Resident 178 was observed in bed in his room receiving 2 liters of oxygen via a nasal cannula from an oxygen concentrator machine. The oxygen humidifier bottle, oxygen tubing, and nasal cannula were not labeled with a time or date. On 3/9/23 at 9:50 a.m., Resident 178 was observed in bed in his room receiving 2 liters of oxygen via a nasal cannula from an oxygen concentrator machine. The oxygen humidifier bottle, oxygen tubing, and nasal cannula were not labeled with a time or date. During an interview on 3/9/23 at 9:55 a.m., the resident indicated he constantly needed the oxygen delivery from the machine and nasal cannula. On 3/8/23 at 1:00 p.m., Resident 178's clinical record was reviewed. The diagnoses included, but were not limited to, osteomyelitis and heart failure. The clinical record lacked a physician order for oxygen therapy for the resident. During an interview on 3/9/23 at 10:55 a.m., the Director of Clinical Services indicated there was no physician order for the oxygen, and the oxygen humidifier bottle, oxygen tubing, and nasal cannula were not labeled with a date or time. On 3/9/23 at 2:55 p.m., the Director of Clinical Services provided the facility's Oxygen Therapy policy, undated, and indicated it was the policy currently used by the facility. A review of the policy indicated, .verify MD [medical doctor] order for oxygen .oxygen tubing, nasal cannula .are changed every 7 days .change humidifier jar every 7 days . 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to ensure the facility was free from urine odors for 5 of 5 days during the survey. (200 Unit Hallway). Findings include: During an observation on 3/1/22 at 11:45 A.M. and 3:10 P.M., the 200 Unit Hallway was observed to have a strong urine odor. During an observation on 3/2/22 at 10:30 A.M., 12:15 P.M., 2:40 P.M., and 3:20 P.M., the 200 Unit Hallway was observed to have a strong urine odor. During an observation on 3/3/22 at 10:15 A.M., 12:10 P.M., and 2:55 P.M., the 200 Unit Hallway was observed to have a strong urine odor. During an observation on 3/4/22 at 10:05 A.M., 12:30 P.M., and 3:10 P.M., the 200 Unit Hallway was observed to have a strong urine odor. During an observation on 3/7/22 at 10:00 A.M., 11:40 A.M., 2:40 P.M., and 3:20 P.M., the 200 Unit Hallway was observed to have a strong urine odor. During an interview on 3/7/22 at 3:30 P.M., the Director of Plan Operations indicated there was a strong odor of urine along the 200 unit hallway. On 3/7/22 at 3:01 P.M., the facility Administrator provided the Resident Rights, amended date November, 2016, and indicated these were the Resident Rights currently used by the facility. A review of the Resident Rights indicated, .the resident has a right to a .clean, comfortable, and homelike environment . 3.1-19(f)

Based on observation, interview, and record review, the facility failed to ensure hot water temperatures remained at a safe and comfortable level for 11 out of 24 rooms assessed for safe water temperatures. Hot water was greater than 120 degrees Fahrenheit. (Room 204, Room 110, Room 114, Room 210, Room 206, Room 203, Room 208, Room 414, Room 410, Room 411, Room 407) Findings include: 1. During an observation on 3/2/2022 at 12:20 p.m., Room 204's hot water was observed to be hot to the touch. 2. During an observation on 3/3/2022 at 9:42 a.m. through 10:20 a.m., the following was observed: -Room 110 had a hot water temperature of 121 degrees Fahrenheit. -Room 114 had a hot water temperature of 124 degrees Fahrenheit. -Room 204 had a hot water temperature of 124.3 degrees Fahrenheit. -Room 210 had a hot water temperature of 121.3 degrees Fahrenheit. -Room 206 had a hot water temperature of 122.2 degrees Fahrenheit. -Room 203 had a hot water temperature of 125.1 degrees Fahrenheit. -Room 208 had a hot water temperature of 121.3 degrees Fahrenheit. The resident residing in Room 208 had moderate cognitive impairment. -Room 414 had a hot water temperature of 121.9 degrees Fahrenheit. The resident residing in Room 414 had severe cognitive impairment. -Room 410 had a hot water temperature of 122.2 degrees Fahrenheit. The resident residing in Room 410 had severe cognitive impairment. -Room 411 had a hot water temperature of 122 degrees Fahrenheit. The resident residing in Room 411 had severe cognitive impairment. -Room 407 had a hot water temperature of 122.1 degrees Fahrenheit. The resident residing in Room 407 had severe cognitive impairment. 3. During an observation on 3/3/2022 at 10:35 a.m. through 11:07 a.m., with the Director of Plant Operations (DOP) present, using the facility thermometer, the following was observed: -Room 110 had a hot water temperature of 123.4 degrees Fahrenheit. -Room 114 had a hot water temperature of 121.3 degrees Fahrenheit. -Room 107 had a hot water temperature of 122.2 degrees Fahrenheit. -Room 204 had a hot water temperature of 121.5 degrees Fahrenheit. -Room 210 had a hot water temperature of 120.4 degrees Fahrenheit. -Room 206 had a hot water temperature of 121.1 degrees Fahrenheit. -Room 203 had a hot water temperature of 120.0 degrees Fahrenheit. -Room 208 had a hot water temperature of 121.3 degrees Fahrenheit. -Room 414 had a hot water temperature of 124.9 degrees Fahrenheit. -Room 410 had a hot water temperature of 122.2 degrees Fahrenheit. -Room 411 had a hot water temperature of 123.3 degrees Fahrenheit. -Room 407 had a hot water temperature of 122.2 degrees Fahrenheit. During an interview on 3/3/2022 at 11:10 a.m., the DOP indicated he liked the water temperatures to be between 115-118 degrees Fahrenheit. The current water temperatures were too hot. On 3/3/2022 at 11:32 a.m., the Administrator provided the facility's policy, Water Temperature Testing Life Safety with a revised date of 8/20/2018, and indicated this was the policy currently being used by the facility. A review of the policy indicated, . Required Water Temperatures: . Patient room temperatures are specified by state requirements . Indiana 100-120 degrees Fahrenheit . 3.1-45(a)(1)

Based on observation, interview, and record review, the facility failed to provide food that was served at an appetizing temperature for 2 of 3 residents reviewed for food quality choices. (Resident 2, Resident 18) Findings include: During an interview on 3/2/22 at 2:37 p.m., Resident 2 indicated the meals were served cold. During an interview on 3/3/22 at 10:02 a.m., Resident 18 indicated the meals were served cold. On 3/4/22 at 12:14 p.m., a test tray was obtained. The menu included a fish sandwich with cheese on a bun and french fries. The fish sandwich was observed to be warm with unmelted cheese on top and the french fries were warm. The food tasted cold. At that time, the Administrator indicated the food on the test tray was not hot. During an interview on 3/4/22 at 2:19 p.m., Resident 2 indicated her lunch was served cold. During an interview on 3/4/22 at 2:35 p.m., Resident 18 indicated her lunch was served cold. On 3/7/22 at 3:00 p.m., the Dining Service Chef Circle Notes were reviewed and indicated the following: -On 12/20/21 at 1:30 p.m., the opportunities for growth were the food temperatures were low on the hall. -On 1/3/22 at 1:30 p.m., the opportunities for growth were the food temperatures were low on the hall. -On 1/17/22 at 1:30 p.m., they discussed more about the food temperatures on the hall. On 3/7/22 at 3:01 p.m., the Administrator provided the facility policy, Resident Rights Amended [DATE], dated 1/1/17, and indicated it was the policy currently being used by the facility. A review of the policy indicated, The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice . 3.1-3(u)(3)

Based on observation, interview, and record review, the facility failed to ensure a care plan intervention was implemented for 1 of 3 residents reviewed for accidents. (Resident 74) Findings include: On 3/6/22 at 11:10 A.M., Resident 74's clinical record was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, with a problem start date of 2/6/20, indicated the resident was at risk for falling as related to medications and impaired balance. An approach/intervention, dated 1/19/22, indicated non skid strips (strips of an abrasive nature adhered to the floor to increase traction and reduce the risk of slipping) were to be applied to the resident's bathroom floor. On 3/6/22 at 2:10 P.M., the resident's bathroom floor was observed to be free of non skid strips. During an interview on 3/7/22 11:00 A.M., the Director of Health Services indicated the non skid strips had not been added to the resident's bathroom floor as indicated in the care plan. 3.1-35(g)(2)

Based on observation, interview, and record review, the facility failed to ensure a fall intervention was in place for a resident which resulted in a fall and sustained [MEDICAL CONDITION] that required medical intervention for wound closure for 1 of 4 residents reviewed for accidents (Resident C) Findings include: On 1/19/21 at 11:50 a.m., Resident C was observed to be sitting in his wheelchair in his room. Resident C's bed was observed to have bilateral mobility bars at the head of his bed. On 1/19/21 at 2:32 p.m., Resident C's clinical record was reviewed. The [DIAGNOSES REDACTED]. Resident First Meeting Minutes, dated 10/22/20 at 2:45 p.m., indicated bed rails were still appropriate and least restrictive. The quarterly Minimum Data Set (MDS) assessment, dated 11/19/20, indicated Resident C was cognitively intact, required extensive assistance of two or more staff with bed mobility, was totally dependent on two or more staff with transfers, and had bilateral upper and lower extremity impairment. A care plan, initiated on 1/11/16 and current through target date 3/2/21, for Resident C indicated: PROBLEM: .FALLS: I am at risk for falls due to impaired functional mobility because of [DIAGNOSES REDACTED] (a progressive inherited condition which leads to muscle weakness and disability), cerebellar ataxia and tremors, medications .GOAL: I want to remain free from falling and fall related injuries . The fall care plan lacked the mobility bars (bars at the head of bed to assist with mobility) as an intervention. A care plan, initiated on 8/15/17 and current through target date 3/2/21, for Resident C indicated: PROBLEM: .ADL's (activities of daily living): Resident has impairment in functional status in regards to transfers, bed mobility, toileting, and eating related to [DIAGNOSES REDACTED] .GOAL: Resident will maintain or improve in functional status in regards to bed mobility, transfers, eating, and toileting .APPROACH: mobility bars as ordered by the physician . Physician orders, dated 12/2/20 through 12/31/20, for Resident C indicated, .Bed rail assessed as enabler for safe transfers or increased mobility . (start date 3/3/19). Resident C's nurse's progress notes indicated the following: -12/15/20 at 2:41 a.m., Resident C was found face down on the floor under the air conditioner unit. The nurse noticed a small amount of blood from the Foley catheter (sterile tube inserted into the bladder to drain urine) from the trauma of pulling on the catheter during the fall. -12/15/20 at 4:45 a.m., Resident C was found by the Certified Resident Care Assistant (CRCA) on the floor under the air conditioner unit with a laceration on his head. -12/18/20 at 12:02 p.m., Resident C had sustained 2 falls. He was observed on the floor next to his bed. He had a 7 cm x 2 cm x 8 cm laceration on his forehead. The medical doctor (MD) came to the facility to stitch the laceration on his forehead. Resident C previously had bed rails, and the new bed did not. When Resident C returns, will ensure his bed rails are in place. The root cause was Resident C fell out of bed bed. Resident C's physician progress notes [REDACTED].acute event: fell 2 times from bed overnight .unclear why fell - went to his right off the bed (previously had rails on bed for positioning) .gash on forehead left upper just into hair line flap measuring 7 x 2 x 8 cm (centimeter) still attached .wound cleansed with saline (wound cleanser) and [MEDICATION NAME] (would cleanser) .[MEDICATION NAME] 2% (local anesthetic) administered for good anesthesia flap reattached with 5 three 0 running sutures inferiorly (below) and with 5 five sutures superiorly (above) .acute wound addressed etiol (cause) of fall (lack of side rails for positioning) . Interview, on 1/20/21 at 9:19 a.m., CRCA 1 indicated she worked night shift on 12/14/20, on the COVID unit. Resident C fell out of bed twice. After the second fall, Resident C received a laceration on his head. The resident did not have bilateral mobility bars at the head of his bed. Interview, on 1/20/21 at 10:33 a.m., Registered Nurse (RN) 1 indicated she worked the COVID-19 unit on night shift on 12/14/20. Resident C fell out of bed twice. With the second fall, Resident C hit his head on the air conditioner unit, which caused a [MEDICAL CONDITION]. She could not recall if Resident C had mobility bars on his bed. Interview, on 1/20/21 at 11:48 a.m., Qualified Medication Aide (QMA) 1 indicated prior to Resident C moving to the COVID unit, his fall interventions were bilateral mobility bars at the head of the bed. His fall interventions would be the same while he was on the COVID unit. On 1/20/21 at 1:50 p.m., the Executive Director (ED) provided the facility's policy, Fall Management Program Guidelines, dated 5/22/18, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .2. Should the resident experience a fall the attending nurse shall completed the Fall Event This includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode . This Federal tag relates to Complaint IN 624. 3.1-45(a)(2)

Based on interview and record review, the facility failed ensure identification of and implement treatment and services for assessed decreased protein levels and for gradual weight loss which resulted in sever weight loss for 1 of 4 residents reviewed for nutrition (Resident 30). Findings include: On 11/15/19 at 1:30 P.M., Resident 30's clinical record was reviewed. [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment, dated 5/2/19, and the most current quarterly Minimum Data Set assessment, dated 9/5/19, indicated the resident was cognitively impaired and required the extensive assistance of 1 person to eat and drink. Current Physician orders, active through (MONTH) 2019, indicated on 9/10/19 the resident was ordered a regular puree diet with thin liquids, on 4/25/19 it was ordered for the resident to have special meals, and on 5/8/19 it was ordered to offer the resident a snack at bedtime. CMP (comprehensive metabolic panel) lab results, dated 4/29/19, indicated the resident' protein level was 5.0 g/dL (grams per deciliter), below the normal range of 6.0 - 8.3 g/dL. The resident's [MEDICATION NAME] level was 2.1 g/dL, below the normal range of 3.5 - 5.5 g/dL. The resident's red blood cell level was 3.76 M/cmm (cells per microliter), below the normal range of 3.9 - 5.4 M/cmm. The resident's hemoglobin level was 11.1 g/dL, below the normal range of 12.0 - 16.0 g/dL. No further CMP labs were ordered and no additional results were located in the resident's clinical record. The resident's current care plan, with a start date of 5/1/19 and current through (MONTH) 2019, indicated: PROBLEM: NUTRITION: Resident has potential for alteration in nutritional status related to diagnoses, medications, fluid balance, diet, intake, physical activity and metabolic demands. Anticipate wt (weight) variance r/t (related to) dx (diagnosis) MRDD (Mental [MEDICAL CONDITION] and Developmental Disabilities), routine meal intake. GOAL: Maintain weight at a healthy range for the Resident without any unwarranted significant weight changes, tolerate physician ordered diet, have personal food and dining preferences met; promote and/or maintain skin integrity, and be without any s/s (signs or symptoms) of any unfavorable nutrition outcome. APPROACH: offer snack at bedtime. APPROACH: Assist with meals as needed. APPROACH: Obtain weight as ordered/needed. APPROACH: Offer alternate food and beverage items as needed. APPROACH: Provide diet/supplements/medications as ordered. The care plan lacked updated interventions which addressed assessed decreased protein levels and assessed continued weight loss. A review of the Nutritional Status Assessment, dated 5/2/19, indicated, .resident is at risk for decreased intakes related to receiving a mechanically altered diet . and .staff will weigh resident as ordered and notify MD (Medical Doctor) and dietician of any significant change . The resident's weights were recorded as follows: -5/1/19 145.4 lbs (pounds) -5/2/19 143.2 lbs -5/9/19 142.8 lbs -5/16/19 144.6 lbs -5/23/19 139.2 lbs -5/30/19 142 lbs -6/6/19 141.6 lbs -6/13/19 141 lbs -6/27/19 137.2 lbs -7/4/19 136.4 lbs -7/11/19 135 lbs -7/18/19 134.2 lbs -7/25/19 134 lbs -8/1/19 133.6 lbs -8/8/19 134.6 lbs -8/15/19 130.6 lbs -8/22/19 131.6 lbs -8/29/19 129.6 lbs -9/5/19 130.8 lbs -9/12/19 131.4 lbs -9/19/19 132 lbs -9/26/19 128.4 lbs -10/1/19 130 lbs -10/10/19 128.6 lbs -10/17/19 130 lbs -10/24/19 128.8 lbs -10/31/19 122.8 lbs -11/7/19 126.6 lbs -11/14/19 127 lbs On 5/16/19 the resident weighed 144.6 pounds. On 11/14/19 the resident weighed 127 pounds. This indicated the resident experienced severe weight loss of 12.17% in a 6 month time period. The clinical record lacked documentation to indicate the Registered Dietician and/or Physician were notified of assessed weight loss. The clinical record lacked documentation of Dietician or Physician response to the assessed weight loss. A Quarterly Nutrition Note, dated 6/4/2019 at 10:01 [NAME]M., indicated the resident had an intake of 93% of meals and 70% of snacks, contained no new recommendations, and indicated, .slight dip in weight . Between 6/24/19 and 9/10/19 , the clinical record lacked documentation of nutrition assessments. A Quarterly Nutrition Note, dated, 9/10/2019 at 3:07 P.M., indicated the resident had a 14.6 pound weight loss in the past 5 months, with the resident having an intake of 82% meals and 60% snacks, and no new recommendations. A Resident Dining and Nutrition Preference document, dated 5/14/19, indicated the resident's favorite foods were sweets. During an interview, on 11/15/19 at 4:20 P.M., the Dietary Manager indicated the resident was served the dessert, which was on the menu at each meal, in puree form. During an interview, on 11/18/19 at 2:50 P.M., the Director of Health Services indicated when a resident lost weight the physician and registered dietician were notified and would made recommendations for nutritional supplements if deemed necessary to maintain acceptable nutritional parameters. There were no nutritional supplements ordered for the resident and there were no other interventions added to the care plan to prevent further weight loss. 3.1-46(a)(1)

A. Based on interview and record review, the facility failed to ensure the residents' environment remained free of non-consensual sexual interactions between residents on a secured unit (Legacy Lane), which resulted in two cognitively impaired residents being involved in two sexual interactions (8/28/2014 and 9/2/2014) with each other. (Resident #C and Resident #D) The Immediate Jeopardy began on 8/28/2014 at 10:10 p.m., when Resident #D was observed with his hand up Resident #C's shirt and was grabbing her breast. The Executive Director, Director of Health Services, Assistant Director of Health Services and the Clinical Support Nurse were notified of the Immediate Jeopardy on 9/24/2014 at 1:30 p.m. B. Based on interviews and record reviews the facility failed to provide supervision to prevent elopement on the secured dementia unit for 1 of 1 residents reviewed for elopement. (Resident #94) Findings include: A. The facility form titled Social Services or Physician New or Worsening Behavior Notification, dated 8/28/2014 at 10:10 p.m., for Resident #D indicated, "Res (Resident) had another Res (not identified) on his lap c (with) his hand up her shirt grabbing her breast...." Current interventions tried: redirection, ingaging (sic) in activities...Social Service or Physician order/response to communication: Will look at his meds (medication) in the AM (morning) for evaluation agree w/(with) interventions attempted...." A facility form titled Mental Health Wellness Circumstance, assessment and Inter-dated 8/28/2014 at 10:10 p.m., for Resident #D indicated, "Type of incident: Social/Sexual inhibition...[DIAGNOSES REDACTED]." Social Service Progress Note dated 9/2/2014, "Res (Resident #C) was found in a male residents (Resident #D) room with her pants off. She and the man were not making contact at the time. Male res had been in bed, where he sleeps nude. This res (Resident #C) was unable to state what happened & was unable to answer "yes" "no" questions. Res continues to interact as usual. Staff did remove her from his room. (See nursing documentation) Also, added intervention for this res to utilize onsies outfits so she can't remove her own clothing/other residents would be unable to remove them either...." A facility form titled Clinically at Risk Individual Monitoring Sheet dated 9/4/2014, for Resident #D indicated, "Reason for discussion: Behavior/altercation 8/28/2014 and 9/2/2014... 8/28/2014 res (Resident #D) had another res (not identified) on his lap c (with) his hand up her shirt grabbing her breast. res (sic) were redirected c (with) success. 9/2/2014 increased Prozac (antidepressant medication) to 40 mg QD (daily) et (and) psych consult. 9/2/2014, another res (Resident #C) came into his rm (room) et (and) res were found in bed. 0 (No) injuries et (and) resident were conseal (consensual/sic). Recommended clinical intervention: see above. Recommended physician order: see above...." Resident #C was dressed and removed from Resident #D's room. Resident #C was examined by LPN (Licensed Practical Nurse) #4. Resident #C's Nurses notes dated 9/2/2014, and signed by LPN #4 indicated, "... 8:15 a.m., Nurse exam res (resident). res. was resistant when removing pants. Noted discharge of yellow/thick const. (consistency) on pull up res also noted to be slightly red. 8:30 a.m., res. 1:1 (one on one care) c CRCA (Clinical Resource Certified Assistant/CNA) 8:40 a.m., Speciman (sic) collected from res. brief.... 10:45 a.m., Dr. (name) here stated no longer needs 1:1 et to place res. into one piece clothing. ...10:00 p.m.-6:00 a.m., signed by RN #3 indicated, Staff monitored resident closely this shift. Toileted per staff. No redness noted to periarea. No active drainage noted. No c/o's (complaints of) voiced. No S/S (signs or symptoms) of pain noted...." Resident #D's Nurses notes dated 9/2/2014, and signed by LPN #4 indicated, "...7:45 a.m., Housekeeping reported to CRCA that res. was sitting on side of bed naked c (with) nothing on from waist down. 7:50 a.m. CRCA note same observation from above. CRCA's noted res. acted strangely et (and) surprise when they walked in room. CRCA's removes res (Resident #C) from res. room. 8:00 a.m. Nurse notified of incident nurse reported situation to E.D. 8:15 a.m., res lying in bed sleeping.... 10:45 a.m., Dr. (name) here to see stated increase Prozac to 40 mg daily to decrease libido. Review of Resident #C and Resident #D's Nurses Notes and the Skilled Nursing Assessment and Data Collection forms dated from 8/28/2014-9/23/2014, lacked documentation which indicated the residents were closely monitored. On 9/22/14 at 2:04 p.m., interview with Medical Records/LPN (Licensed Practical Nurse) indicated, if sexual interaction were not consensual it is abuse. I would separate them, notify the nurse on duty, Executive Director, Director of Health Services, and physician. With Resident #C and Resident #D we had a little situation where her pants were off and he was fully undressed and she wandered into his room. I don't think anything happened. They're both confused and the Medical Director said she didn't think anything happened. The families were notified. On 9/22/14 at 2:16 p.m., interview with the DHS (Director of Health Services) indicated, "We consider it abuse if it was emotional distress and not consensual. If it is consensual and both parties consent we don't consider abuse. "We had an incident like that on Legacy Lane when a female went into a male room and he sleeps naked. She was found standing in the middle of his room. She had her bottoms off. We did a full assessment on her. There was no vaginal bleeding. This happened 4-6 weeks ago maybe. We did not report. It didn't appear to be any sexual assault." On 9/22/14 at 3:27 p.m., an interview with the Executive Director (ED) indicated, "We have a training program and corporate compliance hotline. We do abuse inservices once a year. We would have to determine if the parties were willing or not. Do an investigation, contact physician, and family. When asked if this would be a reportable to the state. It depends on if it were consensual. I just can't assume something happened." If two residents were not cognitively intact and found in a compromising situation is that a reportable? "It depends on the investigation. We would have to investigate." On 9/23/2014 at 3:15 p.m., an interview with LPN #4 indicated a specimen was obtained from Resident #C, but the physician did not order any test to be done on the specimen and it was disposed of. On 9/23/2014 at 10:44 a.m., an interview with the Medical Director/ personal physician (same person) for Resident #C indicated, being called about Resident #C having been found in room of a male resident. This nurse said she took some vaginal secretions. I had no intention of doing a rape kit. I didn't feel it was clinically indicated, so the specimen collected was disposed of. I think she entered a room and got into the bed and he probably woke up and saw her in his bed. I didn't examine the lady. I felt like it was inappropriate behavior on the residents part. She wanders around all the time. I understood she was sitting on the bed with her pants down and he was lying in the bed. On 9/23/2014 at 3:25 p.m., an interview with Housekeeper #1 indicated the Housekeeper found Resident #C in Resident #D's bed, both residents were awake. Resident #C was sideways on the bed and Resident #D was laying long ways on the bed. The Housekeeper informed the nurse and the CRCA of the event. He then indicated he filled out an incident report. On 9/23/2014 at 3:45 p.m., an interview with the DHS (Director of Health Services) indicated there was no incident report filled out by any staff concerning the event on 9/2/2014, in regard to Resident #C and Resident #D. The only reports related to this event were in the residents charts filled out by nursing. On 9/24/2014 at 2:00 p.m., an interview with Executive Director indicated, the female resident involved in the event on 8/28/2014 and 9/2/2014, was Resident #C. Review on 9/ 4 at 12:00 p.m., of the facility's training for staff indicated, "Module 4: Being with a Person with Dementia, Actions & Reactions: Why?: Goal. The goal of this lesson is to: Understand reasons that might cause a person with dementia to act, or react, in a certain way....Reasons: Health conditions, medications, communication, environment, the task, unmet needs, resident's life story, you...." A psychiatric evaluation titled Diagnostic & Mental Status Examination Report dated 9/10/2014, indicated, "Diagnostic Evaluation Results: ...Overall cognitive functioning appeared moderately severely impaired.... Diagnoses: [REDACTED]. Recommendations: 1....Sexual behavior appears to have been instigated by female resident...." Resident #C and Resident #D had no nurses notes in the clinical record for the sexual interaction, which occurred on 8/28/2014. Resident #C had no Clinically at Risk Individual Monitoring Sheet, Mental Health Wellness Circumstance form, Social Services or Physician New or Worsening Behavior Notification, nor a Social Services progress note in the clinical record for the sexual interaction which occurred on 8/28/2014. Resident #C's clinical record was reviewed on 9/22/2014 at 2:24 p.m. [DIAGNOSES REDACTED]. A physicians progress note dated 4/17/2014, indicated "...within a few minutes she is promptly up and we have trouble with her going into other peoples rooms lying down and taking a nap in other peoples beds, neither of which is acceptable or appropriate for the facility or for her...." The quarterly MDS (Minimum Data Set) assessment, completed on 6/11/2014, assessed Resident #C's BIMS (Brief Interview for Mental Status) score as 00, out of a score of 0-15. This score indicated the resident could not complete the interview. The delirium assessment as always having inattention and disorganized thinking. The behavior assessment, assessed Resident #C has having other behavior symptoms such as... public sexual acts, disrobing in public...for 1-3 days. Wandering...for 1-3 days. The careplan for Resident #C dated 9/23/2014 till present, indicated "I (Resident #C) have a DPOA (durable power of attorney) in place...I (Resident #C) reside on Legacy Lane, a secured venue, for my safety. I have a DX (diagnosis) of Alzheimer's Disease....Moods and Behaviors...At times I will sit on the lap of a staff member with no warning and attempt to sit on laps of my peers. I enjoy being close to others, enjoying the intimate closeness. I will at times get in beds with others as well. I will often times become somewhat intrusive of others personal space. Please redirect me....On 9/2/2014 I was found in another residents room with no pants on...Please ensure that I am wearing one piece outfits to prevent me from removing thme (sic) without staff assit (sic). Please encourage me to stay in common areas with peers. discourage me from wandering into others rooms...." A Psychotherapy/Behavior Therapy Note dated 9/10/2014, for Resident #C indicated: "Recommendations: Patient c (with) no signs of negative sequelae (any abnormal bodily condition or disease related to or arising from a pre-existing disease) from incident. Patient has hx (history) of sitting in laps of staff or residents indiscriminately. Patient is incapable cognitively of planning & implementing multi-stage goal directed behavior. hospitalization is clinically contraindicated as it would not enhance her current safety level & likely would drastically increase dementia related confusion, anxiety, & agitation & accelerate cognitive decline." On 9/18/2014 at 12:07 p.m., an interview with LPN (Licensed Practical Nurse) #4 indicated Resident #C is mostly non-verbal, rarely communicates verbally. Observations of Resident #C on 9/18/2014, 9/19/2014, 9/22/2014, 9/23/2014, and 9/24/2014. Multiple attempts on these days to communicate with Resident #C, no verbal communication observed. On 9/20/2014 an interview with Resident #C's spouse/DPOA indicated the Resident is mostly non-verbal. Occasionally she will say a few words, and seems to recognize the spouse and accept hugs and kisses from the spouse. Resident #D's clinical record was reviewed on 9/23/2014 at 11:00 a.m. [DIAGNOSES REDACTED]. The 14 day MDS (Minimum Data Set) assessment, completed on 9/9/2014, indicated Resident #D's BIMS (Brief Interview for Mental Status) score was a 4 out of a score of 0-15. A score of 4 indicated Resident #D's cognitive ability was severely impaired. The residents behavior was identified has having delusions, physical behavior symptoms directed toward others...other behavioral symptoms such as...public sexual acts... for 1-3 days. A physicians progress not dated 8/27/2014, indicated, "Patient Profile: The patient is an [AGE] year old male transferred from (name) (geriatric psychiatric hospital) to OVHC (Owen Valley Health Campus). Present Medical Illness: History is obtained almost completely from the chart as the patient is very pleasantly confused and he has a history of being quite difficult and obnoxious. In fact the chart reveals....Other patients were "scared" of the patient...." The careplan for Resident #D dated 9/23/2014 to present, indicated "I (Resident #D) have a power of attorney (POA) in place...I currently reside on legacy Lane, a secured venue, for my safety. Related to my dx (diagnosis) of Dementia with behaviors. ...On 8/28/2014 I had a behavioral expression of touching a female resident's breasts. Please encourage me to participate in group activities for diversion....I received a new order on 8/29/2014 for Prozac to reduce my libido. On 9/2/2014, my doctor increase my Prozac to decrease my sexual libido. I have a dx of dementia with behaviors. I also will wander at times....I sleep nude or only underwear per my normal routine. On 9/20/2014 I was exit seeking and made way into shower room...." Resident #D had a physicians order dated 8/29/2014, at 1:30 p.m., Prozac 20 mg 1 tablet by mouth daily - decrease libido. According to The Lippincott's Nursing Drug Guide, copyright 2014, Prozac is an antidepressant and Interventions included, "...Monitor patient for response to therapy for up to 4 wk (week) before increasing dose...." No labeled or unlabeled use was listed to decrease libido. A physicians order dated 9/2/2014 at 10:45 a.m., increase Prozac to 40 mg 1 tablet by mouth daily to decrease libido. A physicians order dated 9/2/2014 at 10:45 a.m., the order indicated, "May obtain psych (psychiatric) eval (evaluation) from Dr. (name)." A psychiatric evaluation titled Diagnostic & Mental Status Examination Report dated 9/10/2014, indicated, "Diagnostic Evaluation Results: ...Overall cognitive functioning appeared moderately severely impaired.... Diagnoses: [REDACTED]. Recommendations: 1....Sexual behavior appears to have been instigated by female resident...." On 9/24/2014 at 2:13 p.m., the Executive Director provided the itinerary for 9/2/2014. The itinerary indicated she was notified of the events on 9/2/2014 at approximately 7:45 a.m. "...Resident (#C) was lying in Resident (#D's) bed naked, and had been seen 15 minutes previously clothed. Resident (#D) had no pants on and was sitting on the side of the bed, he reportedly was startled when the staff member entered the room.... I asked the staff to start a timeline to document where Resident (#C) had been last, fifteen minute checks were started....The facts were that Resident (#C) was in his bed in his room and he was sitting on the side of the bed. Resident (#C) was not fighting or showing any signs of doing anything she did not want to do. She is capable to physically showing when she does not want to do something. Both have dementia. Resident (#D) was relatively new and staff did not know him well yet. If they had engaged sexual intercourse, neither were showing any emotional or psychological signs of trauma. Both families were made aware of incident. No allegations of abuse and/or rape were made.... Resident (#D) room is fairly close to Resident (#C's). The week prior Resident (#C) had sat on Resident (#D's) lap. Resident (#C) may have fondness towards this particular patient. This incident did not fall into a reportable category (sic) listed on Abuse/Neglect Procedural Guidelines. Consultation with Nursing consultant and Legacy consultation with Memory Care consultant did not indicate this was a reportable incident." Review of the continuation of Nurses notes for Resident #C indicated, a nurses note dated: 8/22/2014 at 3:45 p.m. 8/23/2014 at 11:00 a.m. 8/24/2014 for 6:00 a.m. - 2:00 p.m., one entry 8/24/2014 for 2:00 p.m.- 10:00 p.m., one entry 8/25/2014 at 9:30 a.m. Review of the continuation of Nurses notes for Resident #D indicated, a nurses note dated: 8/26/2014 at 1:45 p.m., "Res (Resident) arrived at facility. 8/26/2014 10:00 p.m. - 6:00 p.m., one entry 9/9/2014 at 2:00 p.m. 9/11/14 at 1:30 p.m. 9/23/2014 at 9:45 a.m. Review of the Skilled Nursing Assessment and Data Collection for Resident #D dated 9/2/2014, indicated a nurses note on: 9/2/2014 at 5:00 p.m. 9/2/2014 for 10:00 p.m.-6:00 a.m., one entry. The timeline dated 9/2/2014, provided by the facility for Resident #C and Resident #D written on a nurses note indicated, an entry every fifteen minutes from 6:00 a.m.-10:45 a.m., for both residents. Review of the continuation of the timeline for Resident #C indicated, a note on: 9/2/2014 at 9:00 p.m. 9/2/2014 for 10:00 p.m. - 6:00 a.m. one entry 9/2/2014 for 6:00 a.m. - 2:00 p.m. one entry 9/6/2014 at 12:00 p.m. 9/6/2014 for 2:00 p.m. - 10:00 p.m., one entry 9/7/2014 for 6:00 a.m. - 2:00 p.m., one entry 9/21/2014 at 10:00 a.m. Review of the continuation of the timeline for Resident #D indicated a note on: 9/2/2014 for 10:00 p.m.- 6:00 a.m.,, one entry 9/3/2014 for 6:00 a.m. -2:00 p.m. one entry 9/4/2014 at 6:00 a.m. No other documentation in the clinical record indicating 15 minute checks nor close observation of Resident #C or Resident #D. The itinerary provided by the Executive Director for 9/2/2014, indicated Resident #C and Resident #D's rooms were fairly close, no attempt made to move Resident #C nor Resident #D's room. An observation on 9/23/2014 at 2:00 p.m., of the distance between Resident #C's and Resident D's rooms, it was determined when standing in front of Resident C's room facing out into the hallway Resident D's room was across the hall and two rooms up from Resident C's. Resident D's room was the last room on the left next to the exit door from the unit. On 9/26/2014 at 11:48 a.m., the Director of Health Services (DHS) provided the CLINICALLY AT RISK (CAR) PROGRAM GUIDELINES, dated 6/2014, and indicated the policy was the one currently being used by the facility. The policy indicated: "Program Overview...Every effort will be made to identify those residents who are clinically at risk and provide proactive interventions to manage their medical needs and minimize/eliminate further decline when possible...Criteria for residents who will be followed by CAR team:..Resident with behavior issues that impact their care or the care of others. Resident is to be discussed in Car unit behavior concern is manageable....Procedure: 1. The CAR team will meet weekly to discuss those resident that meet the criteria of the Clinically at Risk program.....Scribe- complete documentation on the Individual Resident Monitoring Sheet....5. The CAR team will review current interventions for effectiveness and potential changes and make recommendations based on individual resident's needs. 6. For those interventions that do not require a physician's orders [REDACTED]. dietary/nursing/clinical measures, the responsible clinician will take the appropriate action for implementation. 10. The Individual Monitoring Sheet will be filed in the resident's medical record under the assessment tab and become a permanent part of the medical record." The facility provided documentation dated 9/24/2014, indicating Resident #C was provided one on one care and fifteen minutes checks beginning at 2:00 p.m., and remains current. A physicians order dated for 9/24/2014 at 3:15 p.m., indicated Resident #D was transferred to a psychiatric hospital for evaluation and treatment. An interview with the ADON on 9/28/2014 at 2:00 p.m., indicated Resident #C's room had been moved to the other end of the hall, and a plan was in place to separate the female residents rooms from the male residents room. At that time, an observation of Resident #C's room indicated, the resident had been moved to the other end of the hall. The immediate jeopardy that began on 8/28/2014, was removed on 9/26/2014, when the facility transferred Resident #D to a psychiatric hospital for treatment and evaluation, and Resident #C was provided one on one care and documentation of 15 minutes checks were provided, The Plan of Correction, dated 9/26/14, indicated, " ...All residents on Legacy Unit were assessed by Social Services ...to determine if any other residents were at risk for sexually acting out or were involved with the above residents in question ... Any identified residents will have their care plan updated and interventions put in place ...The Mental Health Wellness Circumstance Form will be completed and behavior closely monitored for 72 hours for follow up ...Each resident on a Mental Health Wellness/Behavior Management Program shall have behaviors monitored each shift ... Any new or exacerbation of an existing behaviors should indicate Social Services referral ... The Interdisciplinary Team will initiate investigation and follow up...Nursing, Dietary, Housekeeping, and Department Leaders were educated by the Director of Health Services, Assistant Director of Health Services ...on Abuse and Behavior Observations, with emphasis on Supervision of cognitively impaired resident behaviors. Education was conducted on 9/24 and 9/25/14 ... Any staff not receiving education by 9/25/14 will not be allowed to work until education is completed. Systemically, all changes in condition, including behavioral changes will be monitored for 72 hours and longer if indicated ...Any behavior changes and/or sexual acting out will be addressed on the resident care plans/profiles by the MDS Nurse and Social Services at the time of the meeting. Clinically at risk residents which include behavior are reviewed weekly at CAR meetings ...DHS and/or ADHS will round daily on the unit to monitor behavior for residents identified on program. This will occur daily for 3 months, 3 times weekly for one month and weekly thereafter until substantial compliance achieved ..., " but the noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for minimal harm/discomfort that is not immediate jeopardy, because all employees had not been inserviced. B. On 9/18/14 at 10:15 a.m., an interview was conducted with the Administrator. The Administrator indicated Resident #94 had eloped from the secured Legacy unit on 9/14/2014 at "noon" after a dietary delivery had been made to the unit. The Resident (#94) proceeded through the locked Legacy unit doors, through the wander guard protected front doors of the facility, proceeding to the sidewalk and was seen by the nursing staff through the windows of the Legacy unit. The Legacy unit staff, proceeded to redirect Resident #94 back onto the Legacy unit. An investigation was conducted. On 9/19/14 at 9:30 a.m., an observation was conducted of the secured Legacy unit. Resident #94 was located in her room, sitting in a chair with her legs crossed. A Wanderguard security bracelet was on her right wrist. The Legacy Lane (LL) unit had 3 (entrances), all to be secured by automatic locking fire doors. On 9/19/14 at 9:50 to 9:57 a.m. a record review was conducted of Resident #94's Clinical Medical Record (CMR.) The following were noted: [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment noted a BIMS (Brief Interview for Mental Status) being 4 out of 15. This indicated the Resident had a cognition deficit. A current Profile History Report (care plan/ service plan) indicated: "...General Information: 8/15/2014- Present: ...I currently reside on Legacy lane, a secured venue, for my safety due to my dx (diagnosis) of Dementia and exit seeking verbalizations...Elopement Risk: ... Keep an eye on my whereabouts through out your shift... I do not want to be able to wander freely and not exit the unit attended... ADL's (Activities of Daily Living) 8/15/2014- Present...Provide me with supervision... at meals... Cognition: 8/15/2014- Present: I have...poor safety awareness...." The Treatment Administration Record (TAR) indicated, "... Wanderguard on at all times...Dementia w/(with) exit seeking behaviors...." On 9/19/14 at 9:58 a.m., an interview was conducted with Resident #94 indicating no ability to comprehend and converse in a logical manner. "...if those people don't quit coming around here, I'm gonna have to go on down to the lake and get some fishing done... there's isn't enough milk up here to catch more fish ..." Resident #94 was unable to offer communication about the elopement. On 9/19/14 at 10:00 a.m., an interview was conducted with Unit Manager of the Legacy Unit in regard to the elopement of Resident #94 on 9/14/14 at noon. The Unit Manager indicated Resident #94 was an elopement risk, wore an security alarm bracelet "Wanderguard" and was demented in ability to think clearly. "...it happened at the noon meal time, (Resident #94's name) was at the end of the hallway by the locked doors, and eloped after a dietary person made a delivery to the unit. (Resident #94's name) was seen on the sidewalk outside the Legacy dining room windows. A staff immediately went to to them and brought them back..." The Unit Manager indicated the supervision of Resident #94 on 9/14/2104, was not the expectation of the facility. On 9/19/14 at 10:00 a.m., a record review was conducted of the Policy and Procedure titled, "Procedure Guidelines. Elopement Risk Procedure... Elopement Overview. Elopement occur when a resident leaves a premise or a safe are without authorization... and/or any necessary supervision to do so...." This Federal tag relates to Complaint IN 849. 3.1-4(a)(2)

Based on record review and interview, the facility failed to consider observable behaviors as symptoms as potential severe adverse reactions to a medication for 1 resident in 3 reviewed for [MEDICAL CONDITION] drug use and untreated behaviors which resulted in restlessness, scratching, injurious behavior, multiple abrasions, rug burns, and skin wounds. (Resident C) Findings: A review of Resident C ' s clinical record was conducted on 4/08/11 at 4:00 pm. The record indicated the resident had the following diagnoses, but not limited to: Anxiety, Dementia with behavioral disturbances, [MEDICAL CONDITION], and hypertension. He admitted to the facility, from an inpatient psychiatric hospital, on 4/01/11 at 4:30 pm. A review of the hospital discharge medication sheet, dated 4/01/11 at 1:44 pm, indicated the resident was to receive the following medications, but not all inclusive: [MEDICATION NAME] (anti-psychotic) 10 mg. (milligram) po (oral) q hs (each bedtime), [MEDICATION NAME] (anti-anxiety) 0.5 mg po [MEDICATION NAME] (anti-[MEDICAL CONDITION]) 800 mg. q6h prn...Ambien ([MEDICAL CONDITION]) 10 mg. qhs prn..." The current Physician discharge orders, for Resident C, were dated as current 4/01/11 at 1:44 pm and faxed at 2:19 pm. The orders indicated the resident had admitted to the hospital on 3/18/11 with a [DIAGNOSES REDACTED]. The following discharge orders indicated "...the following psych meds should be continued...please see MAR (medication administration record) for other medications..." The noted 2 meds were "1. [MEDICATION NAME] 0.5 mg. (milligram) PO (by mouth )daily, 2. Zyrexa [MEDICATION NAME] 10 mg PO daily @ HS (bedtime)..." The MAR indicated [MEDICATION NAME] 0.5 mg po q4h prn to be [MEDICATION NAME] 0.5 mg po QD routine to be continued..." The Discharge Summary, indicated the resident had admitted to the hospital on [DATE], to the Intensive Care Unit related to "syncopal attacks at home", began displaying spells of agitation and observed to be very anxious, restless, agitated, confused, and poor judgement, so was transferred to the Psychiatric floor of the hospital. Resident C was started on [MEDICATION NAME] 2.5 mg. BID (twice daily), dose was gradually increased to 5 mg at bedtime. The patient was given [MEDICATION NAME] 0.5 mg BID for severe anxiety and his [MEDICATION NAME] was increased to 10 mg on 3/28/11 and the medications were documented, in the summary, to be continued at the nursing facility. On 4/11/11 the " Website 'Drugs.com' was reviewed for the side effects of [MEDICATION NAME] (anti-psychotic medication). ' "The '[MEDICATION NAME] Side Effects' indicated " ...Seek medical attention right away if any of these SEVERE side effects occur when using [MEDICATION NAME] Orally Disintegrating Tablets...Severe allergic reactions (rash,; hives, itching;...trouble sitting still...trouble walking or standing ...Dermatologic side effects...frequently include ecchymosis (bruising)...pruitus (itch; a tingling or faintly burning skin sensation that prompts a person to rub or scratch) " ...skin ulcer ...Hypersensitivity...generalized pruritic skin eruption...reported case patient presented with severe, generalized pruritic skin eruption 60 days after ingestion of [MEDICATION NAME] ([MEDICATION NAME]) ... " "The Nursing Spectrum Drug Handbook-2010" indicated [MEDICATION NAME]'Adverse Reactions'[MEDICAL CONDITION] " C.N.A. #2 was interviewed on 4/12/11 at 2:22 pm. She indicated " ...work on weekend on Saturday 4/02...he was handful. Couldn't keep in bed...kept taking clothes off ...impossible to keep him in bed on mats...Tried to give the best care we could ...family there and agreed for him to be on floor...family requested he had med to calm him some...didn't sleep still. He'd have his clothes off in 5 minutes after they were put on him...would wiggle on mat...did get [MEDICAL CONDITION] being on carpet...he done (sic) it to himself... " An interview, on 4/12/11 at 3:25 pm, with C.N.A. #1, indicated she had worked from 6am to 6 pm on 4/01/11, the day of Resident C's admission. They indicated " ...impossible to get him to sit still...had a serious case of the wiggles...he would snake, slither' sometimes on mat, sometimes on rug. Always scratching and picking on skin... " C.N.A. #3, interviewed at 3:06 pm on 4/12/11, indicated they had worked nights on Saturday (4/2) and Sunday (4/3)...was on the floor with doctor's order. Kept stripping...would slide on the carpet (without ) clothes on...Sunday night...found a onesie with a sweater...borrowed it and put it on...it was on still slid around on floor but his skin was covered...also...took off elbow and knee pads...had [MEDICAL CONDITION] legs, arm, area, chest and forehead-thinks they were rug burns...didn't crawl...whole body would slide across carpet...had put 1 mat on floor...he...folded it and pushed it out of the way ...over the weekend ... " Nurse #2, interviewed on 4/12/11 at 2:44 pm, indicated " ...he couldn't walk...kept trying to get up his alarms kept going off at 3:00 am...controlled fall...helped him to the floor...ended getting rug burn from crawling around on floor...wanted to stay... area on knee was red from fall...happened on ...floor within 10 minutes...wanted to get him up and not let him crawl look what happened...did 1:1...rest of shift...did incident report on skin... " An Incident Report, dated 4/02/11 at 02:45 am, was provided by the facility on 4/12/11. The report indicated " ...witnessed...res (resident)...up walking around bed attempting to turn off alarm...writer assist res to floor...res declined to get up off floor ...received abrasion to L (left) knee and L outer leg...assisted fall...self inflicted injury-witnessed... " A review of 2 documents, dated 4/2/11, titled " Other Skin Impairment Assessment " indicated the resident had abrasions which were not present upon admission to the facility. The left outer knee had a length of 7.5 cm by a width of 4.0 cm and was noted to be tender. The left outer lower leg had an abrasion with a length of 10.0 cm by 3.5 cm width and also noted to be tender. There were 2 additional skin assessments, dated 4/2/11, which indicated 2 abrasions to the knees, which were observed on admission. The left knee had a length of 4.0 cm by 4.0 cm and the right knee had length of 5.2 cm by 3.0 cm. width. A physician ' s progress note, dated 4/2/11, indicated " ...Exam at this time reveals a large male resident resting on the floor...skin...is remarkable in that he has some superficial abrasions or bruises on...forehead, scattered on...arms and both ...legs ...would appear to be, one would guess, from his behavior of getting up and down from...chair, up and down from...bed, and scooting around on the floor...think we should consider either [MEDICATION NAME] or at this point increasing his [MEDICATION NAME] to at least 5 mg. in the morning and continue the 10 mg. at night... " A " Change in Condition Form ", dated 4/3/11 at 11:50 am, indicated " ...Family at bedside...stated res was receiving [MEDICATION NAME] Q4h routine at (hospital name)...state res seems to be worse since med was decreased...requesting change...1. [MEDICATION NAME] q4h routine Alzheimer's with behaviors... " The nursing notes, dated 4/04/11 at 3:00 pm, indicated the wife and niece visited the facility. " Wife notified...resident remains restless...non-redirect able, crawling on floor, removing clothes...rolling up mat on floor...informed of safety concerns because resident...repeatedly removing clothes...scooting across carpet causing abrasions throughout-currently has abrasions on chest, stomach, back, buttocks, in addition to abrasions he came with...also scratching at ...picking ...abrasions ...scabs ...niece researched [MEDICATION NAME] and those are side effects ...wife requests we stop [MEDICATION NAME] ...informed ...staff ...place 2 mattress(sic), three mats ...numerous blankets on floor to keep resident from causing further injury to self ... " The nurse indicated that the resident would roll up the mats, stack them and then roll on the floor. The notes on 4/4/11 at 6 pm, indicated " res has multiple rash areas et res noted to be picking at skin, tearing in several places ... " The nursing notes, dated 4/5/11 at 10:30 am, indicated the accepting hospital had contacted the facility and stated " ...concerned about the extent of the abrasions ...reported to (name) that resident had been stripping off clothes ...rolling on carpet ...we had repeatedly put back on his clothing ...reported that resident had voiced ...he was itching ...doing a lot of scratching/picking at areas ... " At 11:30 am, " ...wife called ...requested how resident was previous night ...informed her that per report resident had been restless, demanding to be on floor, stripping off clothing..." The wife indicated the "son was going to (hospital name) ...had reported severe pain ...were sedating him ...having a wound specialist look at him..." The notes, on 4/5/11 at 11:55 am, indicated " ...did report to (name) families (sic) concern about possible reaction to [MEDICATION NAME] ...that resident had been restless throughout night ...repeatedly stripping off clothes ...scratching himself ... " An interview with Nurse #4 on 4/12/11 at 1:34 pm, indicated " ...first time ...taking care of him ...was working 6:00 am to 6:00 pm on 4/4- Monday ...pretty frequently had someone in room ...C.N.As took turns ...he was scratching and picking rashy (sic) areas ...asked 'Do you hurt?...he said 'I itched' (sic) and he pointed to the rashy area ...rash was dots on chest, forehead ...above buttocks... " The Unit Manager was interviewed on 4/12/11 at 1:55 pm. She indicated her name was " ...not on staffing sheet...was here Sunday (4/3) and Monday (4/4)...put himself on carpet while disrobed...crawled, scoot(sic) around, lay on back and push across floor with his feet, knees bent on back, lay and pull himself across carpet on all fours ...had carpet burn on knees, you could tell it was carpet burns, lateral side of (L) leg, elbows and forehead, rib cage, both buttocks, both thighs, and back...were(sic) rash when you rubbed hand across rash areas, it had texture of orange peel on the rash areas...could tell the difference between the rug burn areas and rash areas...he kept picking at forehead...scratch front chest...ribs...She asked 'Does it hurt?'...he replied 'Bad'...was very adamant..." The Unit Manager indicated the staff probably had used [MEDICATION NAME] cream on the resident, as the facility had a standing order for the cream until the physician could be reached for a different treatment. The Clinical Nurse (DCS) was interviewed on 4/12/11 at 3:55 pm. She indicated the facility did not have any standing orders for hydro-cortisone cream (for itching and/or inflammation) or [MEDICATION NAME] cream, so the creams would not have been used on the resident. There were no physician's orders located or provided which would have indicated the resident's itching had been addressed. There were no orders or treatments located in the clinical record, or provided for an oral and/or topical medication to address the resident's itching. An phone interview was conducted, on 4/21/11 at 10:30 am, to reconfirm Resident C's [MEDICAL CONDITION] medication regime with his readmission to the hospital. His medications had been changed to "[MEDICATION NAME] 100 mg. Q HS, [MEDICATION NAME] 50 mg BID at 8 am and 1 pm, [MEDICATION NAME] 500 mg. BID, [MEDICATION NAME] 250 mg at 1:00 pm, Klonopin 0.5 mg TID (3 times daily) and Benedryl Q 4H, prn (for itching) He was no longer taking [MEDICATION NAME]. A review of the hospital nursing notes indicated: " addendum: 4/05/11 at 10:01 pm, Pt describes pain as "throbbing but not too bad". 4/6/11 at 2:14 am, "No agitation or aggression noted. Pt confused but cooperative with all care...easily redirected to allow assistance with all transfers...in bed at this time with bed alarm set, brakes locked, bed in low position, non skid footwear on...only attempted to get out of bed on own 1 time..." 4/6/11 at 9:00 am, "all wounds still red and weepy...cleansed...ointment applied per orders..." 4/6/11 at 4:25 pm, "Pt has shown no S/S (signs and symptoms) of agitation nor aggression today is restless when out of bed. However, cooperative with staff..." 4/7/11 at 2:10 am, "No agitation or aggression noted. Pt confused but cooperative with all care..." 4/7/11 at 11:19 am, "Pt stated...has poison ivy and...it itches...benedryl ordered..." 4/7/11 at 3:28 pm, " Pt has shown no S/S of agitation nor aggression today. He is calm and cooperative..." 4/08/11 at 3:00 am, "Pt has been cooperative with care and took his pm meds crushed w/o (without) difficulty...start of shift...sitting in w/c with chair alarm set...transporting self via w/c (without) difficulty..." This federal tag is related to complaint number IN 970 3.1-48(a)(3) 3.1-48(a)(5) 3.1-48(a)(6)

Based on observation, interview, and record review, the facility failed to protect a resident from self injurious behaviors and seek an acute care facility to prevent further injury to his skin for 1 resident in 3 reviewed for provision of care, in that the resident was placed on his floor where he constantly moved about by scooting, crawling, rubbing, and snake-like movements over the carpet, often with bare skin from disrobing and voiced complaints of itching. This constant moving resulted in skin concerns including abrasions, rug burns, rashes, and other skin damage which required treatment by the wound team at the hospital. (Resident C) Findings include: A review of Resident C ' s clinical record was conducted on 4/08/11 at 4:00 pm. He admitted to the facility, from an inpatient psychiatric hospital, on 4/01/11 at 4:30 pm. The record indicated the resident had the following diagnoses, but not limited to: Anxiety, Dementia with behavioral disturbances, [MEDICAL CONDITION], and hypertension. The notes, written by ADHS (Assistant Director of Health Services), were reviewed. On 4/1/11 at 4 pm, the notes indicated speaking with the (name) of hospital unit related to Resident C's history. It was noted the nurse from the hospital indicated "...he had behavioral issues...was restlessness not aggression...Dr. (name) wanted (resident)...to...rehab so can get stronger so he can pace...no behaviors since 3/23/11..." On 4/1/11 at 5 pm, the notes indicated, "...asked...if...(name) would accept resident back if...were unable to meet his needs..." The notes, dated 4/1/11 at 6 pm, indicated "...resident restless, constantly moving around in bed scratching at forehead and bilateral lower legs stating 'did you bite me" wife redirecting resident that no one bit him, but...keeps on picking..." C.N.A. #2 was interviewed on 4/12/11 at 2:22 pm. She indicated "...work on weekend on Saturday 4/02 ...he was handful. Couldn't keep in bed...kept taking clothes off ...impossible to keep him in bed on mats...Tried to give the best care we could ...family there and agreed for him to be on floor...family requested he had med to calm him some...didn't sleep still. He'd have his clothes off in 5 minutes after they were put on him...would wiggle on mat...did get [MEDICAL CONDITION] being on carpet...he done (sic) it to himself..." An interview, on 4/12/11 at 3:25 pm with C.N.A. #1, indicated she had worked from 6 am to 6 pm on 4/01/11, the day of Resident C's admission. They indicated " ...impossible to get him to sit still...had a serious case of the wiggles...he would snake, slither, sometimes on mat, sometimes on rug. Always scratching and picking on skin... " C.N.A. #3, interviewed, on 4/12/11 at 3:06 pm, indicated she had worked nights on Saturday (4/2) and Sunday (4/3). " ...he was on the floor with doctor's order. Kept stripping ...would slide on the carpet (without ) clothes on...Sunday night ...found a 'onesie' with a sweater...borrowed it and put it on...it was on still slid around on floor but his skin was covered...also...took off elbow and knee pads...had [MEDICAL CONDITION] legs, arm, area, chest and forehead-thinks they were rug burns...didn't crawl ...whole body would slide across carpet...had put 1 mat on floor...he...folded it and pushed it out of the way...over the weekend... " Nurse #2, interviewed on 4/12/11 at 2:44 pm, indicated " ...he couldn't walk ...kept trying to get up his alarms kept going off at 3:00 am...controlled fall...helped him to the floor...ended getting rug burn from crawling around on floor...wanted to stay... area on knee was red from fall...happened on...floor within 10 minutes...wanted to get him up and not let him crawl look what happened...did 1:1...rest of shift...did incident report on skin... " An Incident Report, dated 4/02/11 at 02:45 am, was provided by the facility on 4/12/11. The report indicated " ...witnessed...res (resident)...up walking around bed attempting to turn off alarm...writer assist res to floor...res declined to get up off floor ...received abrasion to L (left) knee and L outer leg...assisted fall...self inflicted injury-witnessed... " The nursing notes, dated 4/04/11 at 3:00 pm, indicated " Wife notified...resident remains restless...non-redirectable, crawling on floor, removing clothes...rolling up mat on floor...informed of safety concerns because resident...repeatedly removing clothes...scooting across carpet causing abrasions throughout-currently has abrasions on chest, stomach, back, buttocks, in addition to abrasions he came with...also scratching at...picking...abrasions...scabs...staff...place 2 mattress(sic), three mats ...numerous blankets on floor to keep resident from causing further injury to self... " "...resident would roll up the mats, stack them and then roll on the floor...notes on 4/4/11 at 6 pm...res has multiple rash areas et res noted to be picking at skin, tearing in several places... " The nursing notes, dated 4/5/11 at 10:30 am, indicated the accepting hospital had contacted the facility and stated " ...concerned about the extent of the abrasions ...reported to (name) that resident had been stripping off clothes...rolling on carpet ...we had repeatedly put back on his clothing...reported that resident had voiced...he was itching...doing a lot of scratching/picking at areas..." At 11:30 am, after resident transferred to psychiatric hospital, " ...wife called...son going to (hospital name)... reported severe pain...were sedating him...having a wound specialist look at him..." An interview with Nurse #2, on 4/12/11 at 1:34 pm, indicated "...6:00 am to 6:00 pm on 4/4/11- Monday...he was scratching and picking rashy (sic) areas...asked 'Do you hurt?...he said 'I itched' and he pointed to the rashy area...rash was dots on chest, forehead...above buttocks... " The Unit Manager was interviewed on 4/12/11-1:5 5pm. She indicated " ...was here Sunday (4/3) and Monday (4/4)...put himself on carpet while disrobed...crawled, scoot around, lay on back and push across floor with his feet, knees bent on back, lay and pull himself across carpet on all fours...had carpet burn on knees, you could tell it was carpet burns, lateral side of (L) leg, elbows and forehead, rib cage, both buttocks, both thighs, and back...were(sic) rash when you rubbed hand across rash areas, it had texture of orange peel on the rash areas...could tell the difference between the rug burn areas and rash areas... " There were no orders or treatments located in the clinical record, or provided for an oral and/or topical medication to address the resident's itching. There was no documentation located or provided related to any conversation, with a Physician, which indicated the increased size and number of skin injuries the resident had acquired during all the contact of movement across the carpet, many times with bare skin. An observation of Resident #C was conducted, on 4/8/11 at 2:30 pm, at the hospital. The resident was sitting in his wheelchair,wearing a pair of nylon shorts, smiling, and watching a couple of patients in the small dining room. A staff member was also present. She was in the process of removing the resident's dressings from his bilateral legs. There were large, very red, meaty wounds on the bilateral legs, the worst visible on the left leg, knee area, and calf (medial, lateral, and frontal area ) The skin was sloughing off (layering down) and was light yellowish in color. The staff member indicated the wounds would be given air at that time. The resident was asked what had happened and he replied "I think I was in a car wreck". She indicated he was receiving wound care. She indicated she had taken care of the resident prior to his discharge to the Extended Care Facility and he was no trouble at all to care for, "in fact he is real funny sometimes..." The resident was readmitted to the hospital on [DATE]. Documentation from the hospital, dated 4/5/11 at 9:55 am, (received on 4/8/11 at 2:00 pm) indicated "...Upon arrival...was noted...patient had extensive abrasions with new scabbing. Abrasions surrounded by redness, were warm...slightly swollen...sensitive to touch...called facility...DON and Administrator both identified that...patient put himself on...floor...they could not restrain him to prevent injury..." The hospital provided a list of the resident's abrasions, scabs, bruises, and all areas located on the patient/resident's body, with measurements, that were new and/or larger since 4/01/11. There were 27 abrasions ranging from 1 cm to 20 cm. They include the following, but not all inclusive: 1. L lateral (outside portion) knee (20 cm length and 5 cm width), L lateral knee (20 cm length and 8 cm width), L lateral knee/leg (17 cm length and 8 cm width), L medial knee (10 cm diameter), L medial knee (7 cm diameter). 2. R lateral hip (10 cm diameter) abrasion and L lateral hip (11 cm diameter) abrasion. 3. R lateral calf below knee cap (4 cm diameter), R medial knee cap (6 cm diameter), on R knee cap (5 cm diameter), R lateral knee cap (6 cm diameter), R medial below knee cap (3 cm diameter) The nursing facility "Nursing Admission Assessment", dated 4/02/11 at 00:15 am, indicated a front and back body map. The front side of body map had noted: an abrasion on forehead, a scratch on left upper chest, scab and abrasion on bilateral knees, scattered scratches on frontal bilateral calf area, and a scratch on the outer portion of the right foot. The back side of body map had bilateral red elbows with scratches and a scab, and a red left heel. The facility "Skin Impairment Assessment", dated 4/02/11, indicated the following abrasions occurred, but were not present on admission. "L outer knee (7.5 cm length and 4.0 cm width) and tender, L outer lower leg (10.0 cm length and 3.5 cm width) and tender. ( admitted scattered scratches anterior L leg, abrasion L knee-4.0 cm length with 4.0 cm width)." The second skin assessment document, dated 4/4/11, indicated the following skin issues occurred, but were not present upon admission. "R hip bruise (3.0 cm length and 3.0 cm width) and bilateral hip rash (general length) itching and red..." This federal tag is related to complaint number IN 970. 3.1-37(a)