Every finding on record at Plainfield Health Care Center

Based on interview and record review, the facility staff failed to honor a resident's multiple requests to be transferred to an acute care hospital emergency department after an extended occurrence of pain, for 1 of 3 residents reviewed for resident rights. (Resident B)Findings include:During an interview on 8/13/26 at 11:17 a.m., Resident B indicated, on 7/25/26, he had severe pain and could not get comfortable. The only way he could get comfortable was to be on his knees. He asked LPN 3 to get another dose of his pain medication to control his pain. She contacted the nurse practitioner (NP), and he was given another as needed dose of his pain medication. The pain continued. He requested to go to the emergency room to get checked out. LPN 3 contacted the on call NP. LPN 3 returned and told him she had indicated he had just returned from a lengthy hospital stay and should not be going back to the emergency room (ER). Resident B told the nurse again that he wanted to go to the ER. The nurse told him she could not send him to the ER without the NP's order. He asked her what if he called and was told he cannot go. Resident B indicated his severe pain persisted, and by late evening on 7/25/26, he called 911. The facility staff got mad at him. When emergency medical services arrived he was taken to the ER for evaluation, and was told he had some sort of throat issue.The clinical record review for Resident B was completed on 8/13/26 at 10:39 a.m. Diagnoses included cervical radiculopathy (inflamed or squeezed nerves causing sharp neck pain, tingling, numbness, or weak muscles that travel down into the shoulder, arm, or hand), lumbar radiculopathy (inflamed or squeezed nerves causing sharp pain, tingling, numbness, or weak muscles that travel down the buttock and legs), cerebral palsy (abnormal development or damage to the developing brain, affecting muscle control, balance, and posture), and anxiety disorder.A text message record, dated 7/25/26 at 1:56 a.m., between LPN 3 and the on call NP, was provided by the Director of Nursing (DON) on 8/14/26 at 11:02 a.m. The text thread indicated the following:LPN 3: Res [Resident] is complaining of 10/10 constant pain from his left armpit to toes. Dilaudid [medication to treat pain] 2mg [milligram] q [every] 8 hrs [hours]. Can he have an additional tablet x 1 now for what he describes as excruciating pain.LPN 3: He [is] currently sitting on the floor. Due to soft surfaces causing the pain [to] worsen.On call NP: Ok to give Dilaudid 2mg PO [by mouth] x 1LPN 3: Rs [resident] is demanding to go to the hospital.On call NP: He just got back from the hospitalLPN 3: Exactly, I heard him laughing on the phone with friends. When he seen me, he started screaming.LPN 3: Is it ok to send him out?On call NP: DocumentLPN 3: I will document and explain I did not receive an order to send him to the hospital.On call NP: NotedA nursing progress note, dated 7/25/26 at 5:14 a.m., entered by LPN 3, indicated Resident complained of 10/10 pain from his armpit to his toes. Prn [as needed] pain meds were previous {previously} given. Md [Medical Doctor] notified and also gave authorization to give an additional pain pill x 1. Despite pain management efforts. Res [resident] could be heard screaming down hallway. Then, a few minutes later he can be heard laughing on the phone with friends. States that he gets an unexplainable jolt through his body. Res was seen shifting his body multiple times. Res went from a sitting position, to standing, to kneeling at nurse's station. He states that if he sits on a soft surface. He has immediate discomfort. Np [on call] aware and states to continue to document events. Writer did not receive authorization to send res back to hospital. Resident aware.A nursing progress note, dated 7/25/26 at 11:16 p.m., entered by RN 4, indicated Res [resident] call [called] 911. He has been taken to {provider name} hospital as per his request. No distress, awake and alert.A nursing progress note, dated 7/26/26 at 2:19 a.m., entered by LPN 3 indicated, Res [resident] returned to facility at baseline [normal condition]. No new orders received.A Resident Concern Form submitted to the Social Services Director (SSD), dated 7/26/26, provided by the DON on 8/14/26 at 11:53 a.m., included the following: On 7/24/26 I [Resident B] was having really bad left side pain (10/10). [LPN 3] was the nurse that night I requested to go get checked out .when [LPN3] called [DON], [DON] said that the NP on call would {SIC} the final call and the NP on call said No I couldn't go to get checked out due to me getting out of the hospital a few days after and I said laid there for over 24 more hours before I had called 911 myself. I want it noted that I as a patient that lives here and has multiple health issue was refused care and told I wasn't allowed to go and get checked out by the NP on call. The form's Investigation/Follow Up indicated Resident was spoken with to understand concern. Resolution indicated, Resident informed of nursing protocol. Resident also informed of his rights. He stated he understood. The form was signed by the SSD on 7/27/26.During a telephone interview on 8/14/26 at 1:50 p.m., LPN 3 indicated, per facility protocol, she had asked the on call NP if she could send him out to the ER. She told Resident B, upon reading the on call NP's responses, that his transfer to the ER had not been authorized by the provider. She had not told the resident he could not call 911 himself.During a telephone interview on 8/14/26 at 1:59 p.m., RN 4 indicated the emergency medical services showed up at the facility late evening. He was unaware that Resident B had called them. His shift started at 3:00 p.m. on 7/25/26 and he had not had the occasion to interact with the resident that day and had not received any reports of Resident B having any concerns. During an interview on 8/14/26 at 9:54 a.m., the DON indicated she was at the facility the evening he had been kneeling at the nurses' station. Around 1:00 a.m. on 7/25/26, she observed Resident B sitting at a table in the dining room. He would get out of the wheelchair and get on his knees. She asked him if he was okay. She asked him if he wanted to go to the hospital and he replied no. She had told nursing staff prior to leaving the facility that if he requested to go to the hospital, to send him. Residents have the right to go to the ER anytime they felt necessary. She would be surprised if the staff had not honored that request.A current facility policy, revised 8/2020, titled, Resident Rights, provided by the DON on 8/14/26 at 11:02 a.m., included the following: Purpose To promote and protect the rights of all residents in the facility. Policy All residents have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.The Facility will ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the Facility.This citation relates to Intake 3120980.410 IAC (Indiana Administrative Code) 16.2-3.1-3(a)(1)

Based on record review and interview, the facility failed to protect a resident's psycho-social well-being by not addressing trauma related triggers for a resident with post-traumatic stress disorder (PTSD, a mental health condition triggered by experiencing or witnessing a terrifying or life-threatening event) for 1 of 1 resident reviewed for PTSD (Resident B). Findings include:On 6/23/26 at 11:08 a.m., during an interview with Resident B, he indicated he was sexually touched inappropriately as a child and did not like his genitalia to be touched by anybody. He indicated he was told he could take his showers independently when he was admitted to the facility. He indicated a CNA came to get him for a shower and insisted on washing him even after he told her not to touch him. The CNA used two washcloths; she took one washcloth and washed his legs, feet, genitals, and then faced his head and face. She kept washing him even after the resident asked her to stop several times. Washing his genitals triggered him. He indicated he wanted to shower every other day, but he wanted to do it by himself because he did not like being touched by others. He indicated other triggers for his PTSD were fire alarms, smoke, verbal, and physical violence. Another incident occurred when a nurse came into his room and shoved his medication in his mouth between 5:45 a.m. and 6:00 a.m. The nurse didn't turn his light on and did not tell him what she was doing. This provoked a response in him which included throwing water pitchers and law enforcement being called on him. On 6/23/26 at 12:01 p.m., a record review was completed for Resident B. He had the following diagnoses which included, but were not limited to, cerebral palsy (a group of neurological disorders that affect a person's ability to move, maintain balance, and posture), PTSD, attention-deficit-hyperactivity disorder (ADHD, a common neurodevelopmental disorder), anxiety, and autistic disorder (a neurological and developmental condition that affects how a person communicates, interacts, learns, and behaves). On 2/25/26 his Brief Interview for Mental Status (BIMS) assessment indicated he was cognitively intact with a score of 15 out of 15. Resident B had a care plan, dated 5/23/26, that indicated he had a history of trauma related to sexual abuse. The goal dated 5/23/26 indicated to create an emotionally and physically safe environment. Approaches indicated to help residents deal with anxiety producing experiences and to provide him with Play-Doh or another preferable activity when expressing anxiety or agitation. Resident B had a trauma informed assessment completed on 5/22/26. It indicated abuse, violence, or sexual assault had been an event for him in his life that had caused problems for him. In the description, it indicated resident was abused as a child but he did not want to go into details. Resident B had a trauma informed assessment completed on 2/12/26. It indicated abuse, violence, or sexual assault had been an event for him in his life that had caused problems for him. Again, in the description, it indicated he was abused as a child, but he did not want to go into details. Resident B's record lacked documentation of the resident's PTSD and/or trauma triggers. The record lacked documentation of ways to ensure his environment was emotionally or physically safe for him related to his PTSD and trauma. A policy titled, Care Planning, was provided by the Executive Director (ED) on 6/25/26 at 8:55 a.m. It indicated, .A comprehensive person-centered care plan will be developed for each resident. The care plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychological needs. A policy titled, Social Service Assessment and Documentation was provided by the ED on 6/25/26 at 8:57 a.m. It indicated, .The facility will use a multi-pronged approach to identifying a resident's history of trauma as well as his or her cultural preferences. This includes asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event.The facility will identify triggers which may re-traumatize residents with a history of trauma. A trigger is a psychological stimulus that prompts recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening. This citation relates to Intakes 3027633 and 3050779.

Based on observation, record review, and interview, the facility failed to ensure vital sign equipment was cleaned, hand hygiene was completed between residents, and enhanced barrier precautions (EBP) (infection control practices designed to prevent the spread of multidrug-resistant organisms in nursing homes) during a medication pass observation (Residents S, T, and U). Findings include:During a continuous observation of a medication pass with Licensed Practical Nurse (LPN) 6, on 6/24/26, from 5:06 a.m. to 5:55 a.m., the following was observed. -LPN 6 prepared medications for Resident S and took the medications and vital signs machine to the resident's room. LPN 6 used the pulse oximeter (device that clips on the finger to check the oxygen level) to check Resident S's oxygen level. LPN 6 gave the resident his medications. She then adjusted his blankets, left the room to obtain new oxygen tubing, and returned to apply the resident's oxygen. LPN 6 adjusted Resident S's blankets, left the room to obtain another blanket, and placed it on the resident. LPN 6 removed the vital signs machine from the resident's room and placed it back in the hallway. LPN 6 did not clean the vital signs machine before, or after, she used it. -LPN 6 proceeded to Resident T's room after the resident's feeding tube pump (set up to administer artificial nutrition) alarmed. LPN 6 did not complete hand hygiene after completing Resident S's care and proceeding to Resident T. LPN 6 obtained a new container of feeding and replaced Resident T's feeding bag and tubing connected to the gastrostomy tube (g-tube) (tube inserted into the stomach for artificial nutrition and medications). LPN 6 flushed the g-tube before hanging the new system. LPN 6 wore gloves but did not wear a gown while caring for the resident's g-tube. -LPN 6 returned to the medication cart, prepared, and administered medication to Resident U. -LPN 6 returned to the medication cart and prepared medication for Resident T. LPN 6 returned to Resident T's room and administered a liquid medication through the resident's g-tube. LPN 6 flushed the g-tube before and after the medication administration. LPN 6 wore gloves for the procedure but did not wear a gown. Resident T's record was reviewed on 6/24/26 at 6:43 a.m. A physician's order, dated 4/23/26, indicated enhanced barrier precautions (EBP) (infection control practices designed to prevent the spread of multidrug-resistant organisms in nursing homes) related to g-tube. The order indicated the staff should have worn a clean gown and gloves while performing high contact care activities, including caring for the feeding tube. A care plan, initiated on 5/19/26, indicated the resident required EBP related to the g-tube. Interventions included, but were not limited to, staff members wore clean gowns and gloves while performing high contact resident care activities, including caring for the feeding tube. During an interview, on 6/24/26 at 6:29 a.m., the Director of Nursing (DON) indicated the staff should have completed hand hygiene before, and after, entering a room or completing a medication pass. During an interview, on 6/24/26 at 9:43 a.m., the DON indicated EBP should have been used when the staff provided care for the resident's g-tube. EBP included wearing a gown and gloves. During an interview, on 6/24/26 at 9:55 a.m., the DON indicated vital sign equipment should have been cleaned between each resident, after each use. On 6/25/26 at 8:55 a.m., the Executive Director (ED) provided a document titled, Hand Hygiene, last revised in June 2020, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: The Facility considers hand hygiene the primary means to prevent the spread of infections. Procedure.V. Facility Staff and volunteers must perform hand hygiene procedures in the following circumstances including but not limited to.B. Alcohol-based hand hygiene products can and should be used to decontaminate hands: i. Immediately upon entering a resident occupied area.regardless of glove use; ii. Immediately upon exiting a resident occupied area.regardless of glove use.iii. Before moving from one resident to another in a multiple-bed room or procedure area regardless of glove use. On 6/25/26 at 8:55 a.m., the ED provided a document titled, Standard and Enhanced Precautions, dated 4/1/24, and indicated it was the policy currently being used by the facility. The policy indicated .Purpose: To ensure the use of appropriate personal protective equipment to improve infection control as required in the care of residents.Procedure.IV. Standard Precautions.E. Resident-Care Equipment: I. Resident care equipment soiled with blood, body fluids, secretions, and excretions are handled in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of other microorganisms to other residents and environments.V. Enhanced Barrier Precautions.B. For residents whom EBP are indicated, EBP should be used when performing the following high-contact resident care activities.vii. Device care or use.feeding tube. 410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)

Based on record review and interview, the facility failed to develop and maintain a comprehensive, facility-specific assessment that accurately identified and documented the staffing resources necessary to care for its resident population, including the specific number and ratio of staff required to meet resident needs. This deficient practice had the potential to affect 103 of 103 residents residing in the facility. Findings include:On 5/18/26 at 12:10 p.m., the Administrator provided a copy of the Facility Assessment. The assessment was reviewed and indicated the following statistics: an average resident population consisting of 185 admissions/stays, including 106 ongoing stays (57.3%), and 134 long-stay residents (72.4%). The Facility Assessment indicated the facility had a resident population with significant care needs, which included, but was not limited to: 99 residents (53.5%) requiring assistance with activities of daily living (ADLs) 89 residents (48.1%) requiring maximal assistance or assistance from two or more staff members for ADL care 125 residents (67.6%) with psychiatric/mood diagnoses 102 residents (55.1%) with neurological conditions 166 residents (89.7%) requiring anticoagulation monitoring Residents residing on a designated Memory Care Unit requiring specialized dementia care and supervision Section II: Staffing, Training, Services, & Personnel, revealed the facility included generalized narrative statements indicating, The facility's overall staffing plan is based on resident acuity and an 'hours per patient day' (PPD) basis.The facility designates individual staff assignments. The assessment failed to specify the actual staffing resources required to meet resident needs, including the number and ratio of direct care staff, licensed nurses, management personnel, or ancillary staff needed for the facility's identified census and acuity. The Sufficiency Analysis Categories demonstrated the facility documented only the term Evaluated under the categories of Overall Staffing, Staff Training/Competencies/Skill Sets, and Services for multiple resident care domains, which included, but was not limited to: cognitive impairment/dementia, wandering and elopement and behavioral health needs. The Facility Assessment failed to provide measurable, facility-specific staffing determinations to care for its population in areas which included, but were not limited to: minimum number of nursing staff required per shift, required ratio of certified nursing assistants (CNAs) to residents, required ratio of licensed nurses to residents, staffing needs specific to the Memory Care Unit, staffing adjustments based on resident acuity, admissions, discharges, or behavioral health needs; and documentation demonstrating how staffing sufficiency was analyzed and determined. During an interview on 5/21/26 at 11:08 a.m., the Administrator indicated she had a brief opportunity to review the Facility Assessment when she was hired, but that the document had been created, updated, and revised by corporate staff off-cite from the facility. In her review, the Administrator indicated the assessment was not sufficiently detailed or specific to accurately identify the building's staffing needs, and the document failed to clearly specify the number and staffing ratios necessary to meet resident care demands based on census and acuity. On 5/21/26 at 1:37 p.m., the Administrator indicated there was no policy to address the Facility Assessment document procedures/requirements, but she located and provided a copy of the CMS guidelines, revised 5/10/24. The guidelines specified, .The facility assessment must address or include the following. The care required by the resident population, using evidence-based, data-driven methods that consider the types of diseases, conditions, physical and behavioral health needs, cognitive disabilities, overall acuity, and other pertinent facts that are present within that population, consistent with and informed by individual resident assessments as required underS 483.20;. The facility's resources, including but not limited to the following. Services provided, such as physical therapy, pharmacy, behavioral health, and specific rehabilitation therapies. All personnel, including managers, nursing and other direct care staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care. The facility must use this facility assessment to. Consider specific staffing needs for each resident unit in the facility and adjust as necessary based on changes to its resident population. Consider specific staffing needs for each shift, such as day, evening, night, and adjust as necessary based on any changes to its resident population.

Based on observation, interview, and record review, the facility failed to ensure kitchen staff were knowledgeable of the dishwasher rinse temperature required for sanitization during 1 of 1 dishwasher observation. This deficient practice had the potential to affect 101 residents who received meals from the kitchen. Findings include:During an observation, on 5/17/26 at 10:14 a.m., [NAME] 9 started the dishwasher and observed the wash cycle reached 150 degrees Fahrenheit (F), and the rinse cycle reached 171 degrees F. At the same time, [NAME] 9 indicated the dishwasher was a high temperature sanitization, the temperatures were the normal temperatures the dishwasher reached for the wash and rinse cycles, and it was sufficient to sanitize the dishes. [NAME] 9 indicated she washed pots and pans after the meal was completed, the dishwasher had been used several times before it was checked and should have been warmed up. During an interview, on 5/17/26 at 11:26 a.m., the Dietary Manager indicated the dishwasher needed to reach 160 degrees F on the wash cycle and 180 degrees F on the rinse cycle in order to sanitize the dishes. During an interview, on 5/20/26 at 9:45 a.m., the Registered Dietitian (RD) indicated the dishwasher's rinse cycle had to reach at least 180 degrees F to sanitize the dishes. They discovered there was an issue with the temperature gauges on the dishwasher. The cook should have been aware of the required dishwasher temperatures for sanitization and had previously received training. On 5/18/26 at 9:49 a.m., the Executive Director (ED) provided a document titled, .Certified Conveyor Dishmachine., dated 2019, and indicated it was the policy currently being used by the facility. The policy indicated, .Operating temperatures-wash (min).high-temp 160 F Sanitizing Rinse (min).high-temp 180 F. 410 IAC (Indiana Administrative Code) 16.2-3.1-20(h)

Based on record review and interview, the facility failed to ensure resident specific dementia care plans were developed and utilized prior to psychotropic medications being initiated or increased for 4 of 5 residents reviewed for dementia (Residents 19, 76, 7, and 11). Findings include: 1. Resident 19's record was reviewed on 5/19/26 at 9:47 a.m. Census information indicated the resident was admitted to the facility on [DATE]. Diagnoses on the resident's profile included, but were not limited to, unspecified dementia (a decline in mental abilities severe enough to interfere with daily life) with mood disturbance. An admission Minimum Data Set (MDS) assessment, dated 5/1/26, indicated the resident had a moderate cognitive impairment. The resident's comprehensive care plan lacked documentation of a dementia care plan, including potential behaviors and behavioral interventions. A Medication Administration Record (MAR), dated April 2026, was reviewed. The MAR included a physician's order, dated 4/29/26, to monitor any targeted behavior each shift, document the number of episodes, interventions used, and the outcome of interventions. The MAR indicated the resident had zero behaviors during the month. A care plan, initiated on 4/29/26, indicated the resident had an activities of daily living (ADL) self-care performance deficit related to dementia. The care plan included interventions regarding the resident's ADL status and level of assistance needed but lacked documentation of dementia related behaviors or behavior interventions. A MAR, dated May 2026, indicated the resident had zero behaviors during the month. A physician's order, dated 5/5/26, indicated Rexulti (atypical antipsychotic medication) 0.5 milligrams (mg) by mouth once daily for agitation/anxiety. Progress notes, dated 4/29/26 to 5/5/26, lacked documentation of behaviors or interventions provided to manage behaviors. A Nurse Practitioner (NP) progress note, dated 5/5/26, indicated the visit was medically necessary for ongoing skilled management of dementia with agitation and behavioral disturbance related to behavioral outbursts. The resident exhibited increased agitation including yelling at staff and the provider related to the facility's rules. The NP indicated to continue behavioral management strategies and initiate a trial of Rexulti. The note lacked documentation of specific behaviors that occurred, interventions attempted prior to the initiation of Rexulti, and what the aforementioned behavioral management strategies consisted of. A physician's order, dated 5/6/26, indicated the resident's trazodone (atypical antipsychotic) was increased from 150 mg to 200 mg by mouth daily at bedtime for insomnia (a common sleep disorder that makes it difficult to fall asleep, stay asleep, or get restful sleep). Progress notes, dated 4/29/26 to 5/6/26, lacked documentation the resident exhibited insomnia or interventions attempted. An activities care plan, initiated on 5/7/26, indicated the resident's favorite activities were bingo, painting, and watching television. A physician's order, dated 5/16/26, indicated haloperidol (antipsychotic medication) 5 mg by mouth stat (immediately) for anxiety and agitation. A progress note, dated 5/16/26, indicated, At approximately 1815 [6:15 p.m.], resident verbalized to this writer that if he could not leave the facility, he would kill himself. Resident appeared highly anxious and restless, with noted diaphoresis [excessive, abnormal sweating] and rapid breathing. He was persistent in his request to go home. Resident's family was notified immediately. Family arrived approximately 1845 [6:45 p.m.] and provided emotional support, which resulted in some de-escalation of resident's distress. Interdisciplinary team.was notified promptly and provided instructions to maintain constant supervision of the resident until family arrival. Following the departure of the resident's daughter, IDT [interdisciplinary team] directed initiation of 1:1 monitoring for safety. On-call provider was contacted and issued an order for haloperidol 5 mg by mouth.stat, which was carried out as ordered. The note lacked documentation of further assessment of the suicidal ideation such as a plan in place, interventions attempted other than calling the resident's family, or why the haloperidol was administered despite the resident's family visit resulting in some de-escalation of the situation. An NP progress note, dated 5/18/26, indicated since the last evaluation the resident expressed suicidal ideation and stated if he could not leave the facility, he would kill himself. The resident appeared highly anxious and was persistent in his request to go home. The resident's family was notified and provided emotional support, and this resulted in some deescalation of his distress. A care plan, initiated on 5/18/26, indicated the resident expressed suicidal ideation due to wanting to leave the facility. Interventions indicated staff would encourage the resident's friends and family to visit, staff would encourage the resident to attend activities to help occupy the mind, medications administered as ordered, staff would listen to the resident's concerns, psychiatric consult referral, and staff would monitor for effectiveness and side effects of medication. During an interview, on 5/19/26 at 11:11 a.m., Certified Nurse Aide (CNA) 16 indicated Resident 19 exhibited behaviors at times including agitation, yelling out, and anxiety. CNA 16 indicated she knew what interventions to use with residents who had dementia and exhibited behaviors based on her getting to know them. CNA 16 indicated she thought there might have been a binder at the nurse's station with behavior interventions, but she was unable to locate anything. Behaviors interventions might have been included on the CNA plan of care sheet in the computer, but when she accessed it she indicated there were no behavior interventions, only interventions for falls. If a resident exhibited a behavior they were able to document it on a new alert and notify the nurse for them to document. 2. Resident 76's record was reviewed on 5/20/26 at 12:47 p.m. Diagnoses on the resident's profile included, but were not limited to, moderate vascular dementia (reduced or blocked blood flow to the brain, leading to cognitive decline and memory problems) with agitation. A quarterly Minimum Data Set (MDS) assessment, dated 3/9/26, indicated the resident had a severe cognitive impairment. A physician's order, dated 12/6/25, indicated the resident received antianxiety medication and should be monitored for behaviors including agitation, anxiety, nervousness, compulsiveness, physical aggression, combativeness, excitation/irritability, verbal aggression, panic, and any other behaviors every shift. A physician's order, dated 12/6/25, indicated the resident received antipsychotic medication and should be monitored for behaviors including hallucinations, physical aggression, verbal aggression, paranoia, delusions, repetitive verbalizations that affect function, and any other behaviors every shift. A physician's order, dated 12/7/25 and discontinued 1/23/26, indicated sertraline (antidepressant) 25 milligrams (mg) by mouth at bedtime for depression. A physician's order, dated 12/8/25, indicated the resident exhibited anxious and depressive behavior which should be monitored every shift. A Medication Administration Record (MAR), dated December 2025, indicated the resident had zero behaviors during the month. Progress notes, dated December 2025, lacked documentation the resident exhibited behaviors. A physician's order, dated 1/23/26, indicated sertraline 50 mg by mouth at bedtime for depression for 7 days. A physician's order, dated 1/23/26, indicated sertraline 75 mg by mouth daily for depression, to be initiated on 2/1/26. A MAR, dated January 2026, indicated the resident had zero behaviors during the month. Progress notes, dated January 2026, lacked documentation the resident exhibited behaviors. A MAR, dated February 2026, indicated the resident had zero behaviors during the month. A MAR, dated March 2026, indicated the resident had zero behaviors during the month. Progress notes, dated March 2026, lacked documentation the resident exhibited behaviors. A physician's order, dated 3/30/26, indicated Depakote (anticonvulsant that can be used as a mood stabilizer) delayed release tablet, give 125 mg by mouth in the afternoon for dementia with behavioral disturbance. The resident's current care plans indicated the resident had bowel and bladder incontinence, activities of daily living (ADL) self-care performance deficit, and was at nutritional risk due to dementia. A care plan, developed on 5/11/26, indicated the resident had the potential to demonstrate physical behaviors related to dementia. The resident had become aggressive and physically hit another resident. Interventions were generalized and indicated analyze key times, places, circumstances, triggers, and what de-escalates behavior and document, assess and address for contributing sensory deficits, assess and anticipate the resident's needs, evaluate for side effects of medications, and psychiatric consult as indicated. The resident's care plans lacked documentation of a resident-specific dementia care plan, including resident-specific interventions to utilize prior to the initiation or increase of psychotropic medications. During an interview, on 5/20/26 at 2:39 p.m., the [NAME] President (VP) of Clinical indicated dementia related interventions should have been included in the resident's care plans, and there was not any other location for staff to find interventions. During an interview, on 5/20/26 at 2:50 p.m., the VP of Clinical indicated she reviewed the resident's record and was unable to find a resident-specific dementia care plan. 3. Resident 7's record was reviewed on 5/21/26 at 10:44 a.m. Diagnoses on the resident's profile included, but were not limited to, Alzheimer's disease (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior) unspecified. A quarterly Minimum Data Set (MDS) assessment, dated 3/13/26, indicated the resident had a severe cognitive impairment. A physician's order, dated 9/25/25, indicated the resident received antianxiety medication and should be monitored for behaviors including agitation, anxiety, nervousness, compulsiveness, physical aggression, combativeness, excitation/irritability, verbal aggression, panic, and any other behaviors every shift. A physician's order, dated 9/25/25, indicated the resident received antipsychotic medication and should be monitored for behaviors including hallucinations, physical aggression, verbal aggression, paranoia, delusions, repetitive verbalizations that affect function, and any other behaviors every shift. A physician's order, dated 9/25/25, indicated the resident required monitoring for anxiety and depression every shift. A physician's order, dated 1/17/26, indicated the resident should be monitored for any targeted behavior. A care plan, last revised on 1/29/26, indicated the resident was resistive to care related to dementia, refused labs, had a history of putting feces in the trash can, took off clothes in public, refused showers, removed décor off tables, at times did not sleep through the night, thought bugs were invading her body and blood was running down her fingers. Interventions were generalized and indicated allow the resident to make decisions about the treatment regime to provide a sense of control, educate resident, family, and caregivers of the possible outcomes of not complying with treatment or care, encourage as much participation and interaction by the resident as possible during care and activities, give a clear explanation of all care activities prior to and as they occur, and provide the resident with opportunities for choice during care provision. The care plan lacked documentation of resident-specific interventions. A physician's order, dated 2/24/26 and discontinued 4/30/26, indicated lorazepam (antianxiety medication) 0.5 milligrams (mg) by mouth twice daily for anxiety. A physician's order, dated 4/29/26, indicated lorazepam 0.5 mg by mouth three times daily for delusional disorders. A Medication Administration Record (MAR), dated April 2026, indicated the resident exhibited three occurrences of agitation, anxiety, verbal aggression and repetitive verbalizations that affect function, on 4/1/26, evening shift, which improved with being distracted or soothed and redirection. The resident exhibited one occurrence of agitation on 4/30/26, day shift. The MAR lacked documentation of interventions attempted or their efficacy for the agitation documented on 4/30/26. A progress note, dated 4/28/26, indicated the resident had a behavior of moving chairs in the dining area and grabbing chairs when other residents were about to sit. The resident argued with staff and residents and stated, These are my chairs. The resident was redirected with snacks and drinks which was effective. The note lacked documentation of why the lorazepam would have been increased if the interventions were effective. During an interview, on 5/21/26 at 2:40 p.m., the Registered Nurse (RN) Consultant indicated she was not able to find any additional documentation of non-pharmacological interventions attempted prior to the increase of the lorazepam. During an interview, on 5/19/26 at 11:50 a.m., the [NAME] President (VP) of Clinical indicated when a resident exhibited behaviors, two or three non-pharmacological interventions should have been attempted prior to medication changes. Behaviors, interventions attempted, and the efficacy of the interventions should have been documented on the MAR. Resident 19's care plan was reviewed, and she was unable to find a dementia care plan. 4. On 5/21/26 at 1:48 p.m. Resident 11's medical record was reviewed. She was a long-term care resident whose diagnoses included but were not limited to Parkinsons (a progressive neurological disorder that affects movement and the nervous system) disease and dementia (a decline in mental abilities severe enough to interfere with daily life). A progress note, dated 1/4/26, indicated Resident 11 was in the dining room when she put herself on the floor and refused to get back into her wheelchair, was throwing utensils and refused to take oral medications. The note indicated the on-call Nurse Practitioner (NP) was notified and a one-time dose of Intramuscular (IM) Haldol (an antipsychotic medication) was given. Resident 11 had active orders for behavior monitoring. The orders indicated the nurse should count the number of times the resident exhibited a target behavior related to anxiety and depression, and that number should be charted every shift along with any intervention put in place and outcome after that intervention. The order did not specify what behaviors they were targeting. Resident 11's January 2026 Electronic Medication Administration Record (eMAR) indicated she did not have any target behaviors on 1/4/26. A progress note, dated 1/15/26, indicated Resident 11 had increased anxiety and delusions related to looking for lost pets, being verbally loud, attempting to stand unassisted and refusing to take oral medications. The note indicated the on-call NP was notified and a one-time dose of IM Haldol was given. Resident 11's January 2026 eMAR indicated she did not have any target behaviors on 1/15/26. A progress note, dated 2/28/26, indicated Resident 11 had increased agitation and aggression related to attempting to throw her drink on staff members, refusing snacks, spitting oral medications out and being difficult to redirect. The note indicated the on-call NP was notified and a one-time dose of IM Haldol was given. Resident 11's February 2026 eMAR indicated she did not have any target behaviors on 2/28/26. A progress note, dated 3/29/26 indicated Resident 11 had behaviors related to biting, spitting and yelling at staff and her son, refusing to take oral medications and yelling and screaming. The note indicated the on-call NP was notified and a one-time dose of IM Haldol was given. Resident 11's March 2026 eMAR indicated she did not have any target behaviors on 3/29/26. Resident 11 had a pharmacy review done on 4/21/26 the recommendation for that review was to clarify the indication of use for Quetiapine (an antipsychotic medication contraindicated in those with dementia related psychosis) as it was indicated Resident 11 was on Quetiapine for dementia with mood disturbances. The NP indicated they would change the indication for use to psychosis due to known physiological condition. Resident 11 had an active order for Quetiapine related to f06.2 (a clinical medical code used for Psychotic disorder with delusions due to a known physiological condition). Resident 11's current medical diagnoses list was reviewed and lacked evidence that Resident 11 was diagnosed with psychotic disorder with delusions due to a known physiological condition. Resident 11's care plans were reviewed and lacked an individualized, person-centered care plan related to Resident 11's dementia care. On 5/20/26 at 10:53 a.m. a copy of a current facility policy titled, Psychotropic Drug Management dated 01/2025 was provided. That policy indicated, .Purpose. III. To ensure the resident receives only those medications, in doses and for the duration clinically indicated to treat the resident's assessed condition(s). IV. To ensure non-pharmacological interventions are considered and used when indicated, instead of, or in addition to, medication. IV. Psychotherapeutic drugs.will never be used for the convenience of staff. V. The facility will utilize individualized, non-pharmacological approaches to care (e.g., purposeful and meaningful activities). Meaningful activities are those that address the resident's customary routines, interests, preferences, and choices to enhance the resident's wellbeing. a. Centers for Medicare and Medicaid Services (CMS) has identified the following as inappropriate reasons to use antipsychotics:.VIII. Uncooperativeness (e.g. refusal/difficulty receiving care). G. The attending medical practitioner may order an emergency dose of a psychotherapeutic medication if the resident is in danger of harm to self or others. X. Nursing Responsibility A. Consider other factors that may be causing expressions or indications of distress before initiating a psychotropic medication, such as an underlying medical condition (e.g., urinary tract infection, dehydration, delirium), environmental (lighting, noise) or psychosocial stressors. 410 IAC (Indiana Administrative Code) 16.2-3.1-37

Based on record review and interview, the facility failed to submit a new level one Pre-admission Screening and Resident Review (PASRR) (a federally mandated process to prevent inappropriate placements of individuals with Serious Mental Illness [SMI] or Intellectual/Developmental Disabilities [I/DD] into Medicaid-certified nursing facilities) when new SMI were added for a resident for 1 of 7 residents reviewed for PASRR compliance (Resident 12). Findings include:On 5/19/26 at 10:22 a.m. Resident 12's medical record was reviewed. On 3/16/26 new diagnoses of dementia and major depressive disorder were added to Resident 12's diagnoses list.The record lacked evidence of a new level one PASRR assessment being done when these new SMI diagnoses were added.On 5/21/26 at 2:03 p.m. the Executive Director (ED) indicated they did not do a new level one PASRR assessment for Resident 12 when the new diagnoses were added on 3/16/26. She indicated they had initiated a new level one at that time.On 5/21/26 at 9:53 a.m. a copy of a current facility policy titled Pre-admission Screening and Resident Review (PASRR), dated 6/2020 was provided. That policy indicated, .V. A negative Level 1 screen permits admission to proceed and ends the PASARR process, unless a possible serious mental disorder or intellectual disability arises later.410 IAC (Indiana Administrative Code) 16.2-3.1-16(d)

Based on record review and interview the facility failed to ensure pharmacy recommendations were appropriately reviewed and addressed timely by a medical professional for 2 of 5 Residents (Resident 11 and 81) reviewed for unnecessary medications.Findings include:A pharmacy recommendation dated 10/28/25 indicated Resident 11 had an order for Aspirindaily, Carbidopa/Levodopa (a medication used to treat Parkinson's disease.) extended release three times a day and Nitrofurantoin (an oral antibiotic used primarily to treat and prevent uncomplicated bacterial urinary tract infections). The pharmacist recommended to discontinue the Aspirin due to risk of bleeding, discontinue Nitrofurantoin due to liver toxicity and lowering the frequency of Carbidopa/Levodopa from three times a day to two times a day. The Nurse Practitioner (NP) indicated they would discontinue Aspirin, keep Carbidopa/Levodopa according to neurology orders and keep Nitrofurantoin with no rational for keeping that medication. The recommendation was signed 10/30/25.A pharmacy recommendation dated 11/16/25 indicated Resident 11 had an order for Nitrofurantoin. The pharmacist recommended discontinue that order due to liver toxicity. The NP indicated they would discontinue Nitrofurantoin and the recommendation was signed on 11/20/25.Resident 11 had a discontinued order for Nitrofurantoin with a discontinued date of 11/23/25.A pharmacy recommendation dated 12/16/25 indicated Resident 11 had an order for Aspirin daily, Carbidopa/Levodopa extended release three times a day. The pharmacist recommended discontinue the Aspirin due to risk of bleeding and lowering the frequency of carbidopa/levodopa from three times a day to two times a day. The recommendation lacked a response or signature for those recommendations.Resident 11 had a discontinued order for Aspirin with a discontinue date of 1/6/26.A pharmacy recommendation dated 1/25/26 indicated Resident 11 had an order for Hydroxyzine (a prescription antihistamine used to treat anxiety) every 6 hours as needed. The pharmacist recommended adding a stop date after 14 days or discontinuing the medication. The recommendation lacked a response or signature for those recommendations.A pharmacy recommendation dated 2/20/26 indicated Resident 11 had an order for Lorazepam (a prescription medication used to treat anxiety) every 8 hours as needed. The pharmacist recommended adding a stop date after 14 days or discontinuing the medication. The recommendation lacked a response or signature for those recommendations.A pharmacy recommendation dated 3/20/26 indicated Resident 11 had an order for Hydroxyzine every 6 hours as needed. The pharmacist recommended adding a stop date after 14 days or discontinuing the medication. The NP indicated they would discontinue Hydroxyzine and the recommendation was signed on 3/30/26.Resident 11 had a discontinued order for Hydroxyzine with a discontinue date of 3/30/26. A pharmacy recommendation dated 3/20/26 indicated Resident 81 had an order for Aspirin daily,Omeprazole (a stomach acid reducer) daily, Famotidine (a stomach acid reducer) 20mg daily and Duloxetine (an antidepressant) 90mg daily. The pharmacist recommended discontinue Aspirin and Omeprazole due to Clopidegrel (an antiplatelet blood thinner) use, adjust the Famotidine dose from 20mg daily to 20mg every other day due to poor kidney function and reduce the Duloxetine dose from 90mg daily to 60mg daily. The NP indicated they would reduce the Duloxetine dose to 60mg daily, but did not address the recommendations for Aspirin, Omeprazole or Famotidine. The recommendation was signed on 3/30/26.A pharmacy recommendation dated 4/21/26 indicated Resident 81 had an order for Aspirin daily, Omeprazole daily and Famotidine 20mg daily. The pharmacist recommended discontinue Aspirin and Omeprazole due to Clopidegrel use and adjust the Famotidine dose from 20mg daily to 20mg every other day due to poor kidney function. The recommendation lacked a response or signature for those recommendations.Resident 81 had an active order for Aspirin daily, Omeprazole daily and Famotidine 20mg daily.On 5/20/26 at 10:53 a.m. a copy of a current facility policy titled Psychotropic Drug Management dated 01/2025 was provided. That policy indicated, .H. The Attending physician will respond to any irregularities reported by the pharmacist as described in section VI (D) by reviewing the irregularities and documenting in the resident's medical record that the irregularity has been reviewed, and what, if any, action has been taken to address it. If no action has been taken, the attending physician must document his/her rationale. ii. Documentation by the Attending Physician must occur within 30 days of issuance of the pharmacist's report, unless the irregularity is an emergent issue requiring immediate action.According to the Centers for Medicare and Medicaid Services (CMS) State Operations Manual (SOM) skilled nursing facilities are required to have a physician review any pharmacy recommendations and respond in writing whether they accept or reject the recommendation. If a recommendation is rejected the physician must document a clinical rational for why the recommendation was rejected.410 IAC (Indiana Administrative Code) 16.2-3.1-25(h)

Based on record review, observation, and interview, the facility failed to provide nephrostomy (a procedure where a thin, flexible tube is inserted through the skin of your lower back directly into the kidney to drain urine) monitoring and care for a resident with tubes for 1 of 1 resident reviewed for nephrostomy tubes (Resident 8).Findings include: On 5/19/26 a record review was completed for Resident 8. She had the following diagnoses which included but were not limited to tachycardia (fast heart beat), anemia (a common blood condition where your body lacks enough healthy red blood cells or hemoglobin to carry oxygen to its tissues), and chronic kidney disease (a condition in which your kidneys are damaged or have a problem with their structure that prevents them from filtering blood the way they should).Resident 8 had a care plan indicating she had nephrostomy tubes dated 5/14/24. She was not observed wearing an abdominal binder as care planned. A treatment order, dated 8/22/25, indicated Resident 8 had nephrostomy tubes for her left and right kidneys and the dressings should be changed on shower days on Monday and Thursday.Her record lacked orders to observe the sites for signs and symptoms of infection, placement, care of the insertion sites, enhanced barrier precautions, and to monitor for any output post flushing with 10ml (milliliter) of saline. An Admit/Remit note, dated 5/13/26 at 6:25 p.m., indicated Resident 8 returned from the hospital.Resident 8's progress notes lacked documentation of the nephrostomy tubes. On 5/21/26 at 11:25 a.m., Registered Nurse (RN) 8 was observed demonstrating care of the nephrostomy tubes. She was able to unclamp the left tube but unable to unclamp the right tube. The tubes had dressings covering the insertion sites, but they were undated. On 5/21/26 at 11:30 a.m., Resident 8 indicated the staff were not caring for her tubes since she had been back from the hospital on 5/13/26.On 5/21/26 at 11:34 a.m., during an interview with the Medical Assistant (MA) from the nephrologist office. She indicated the dressings should be completed to the insertion sites and the tubes could be flushed if they were clamped. On 5/21/26 at 1:00 p.m., the Director of Nursing indicated they were changing the dressings two times per week and flushing the tubes daily.A policy titled, Nephrostomy Tube, Care of was provided by the Executive Director (ED) on 5/26/26 at 9:48 a.m. It indicated, .verify there is a physician order for this procedure, review the resident's care plan to assess for any special needs of the resident.410 IAC (Indiana Administrative Code) 16.2-3.1-41(a)(1)410 IAC (Indiana Administrative Code) 16.2-3.1-41(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a resident's risk for pressure ulcers (localized damage to the skin and underlying soft tissue from prolonged pressure) was addressed for a resident who developed pressure ulcers and failed to ensure the resident's low air loss mattress (specialized mattress) was set appropriately for 1 of 4 residents reviewed for pressure ulcers (Resident 9). Findings include:During an observation, on 5/17/26 at 10:53 a.m., Resident 9 was lying in bed on a low air loss mattress. The control unit was hanging on the resident's foot board. A dial on the control board was turned all the way to the right on firm. The dial included weights between the softest and firmest settings. During an observation, on 5/20/26 at 10:47 a.m., the Wound Nurse completed Resident 9's treatment. The resident was lying in bed on a low air loss mattress. The dial on the low air loss mattress control unit was turned all the way to the right on firm. At the same time, the Wound Nurse indicated low air loss mattress settings were based on the resident's weight. The dial included weights so they would know where to set it. The Wound Nurse indicated the resident weighed about 170 pounds, and he would adjust the mattress accordingly. The physician's orders for the low air loss mattresses were ordered at to comfort instead of including their specific weight. The Wound Nurse indicated the staff had probably provided care, turning the mattress to firm, and forgot to turn it back. During an observation, on 5/21/26 at 9:26 a.m., Resident 9 was lying in bed. The low air loss mattress was set to 190 pounds. Resident 9's record was reviewed on 5/19/26 at 2:18 p.m. Census information indicated the resident was admitted to the facility on [DATE]. Diagnoses on the resident's profile included, but were not limited to, dementia (a decline in mental ability severe enough to interfere with daily life) in other diseases classified elsewhere. A patient risk profile indicated the resident's Braden score (assessment to determine the resident's risk for pressure ulcer development), dated 1/21/26, indicated a very limited risk. A baseline care plan, dated 1/21/26, lacked documentation the resident was at risk for skin breakdown. A care plan, initiated on 1/21/26, and in place prior to the resident's pressure ulcer development, indicated the resident was at risk for pressure ulcers related to dementia and the need for assistance with activities of daily living. Interventions indicated administer medications as ordered and monitor and document side effects and effectiveness, avoid positioning the [resident name] on her, do not massage over bony prominences, use mild cleansers for perineal care, and ensure heels were floated with the use of two pillows. The care plan lacked documentation of resident specific interventions. A patient risk profile indicated the resident's Braden score, dated 1/27/26, indicated a very limited risk. An admission Minimum Data Set (MDS) assessment, dated 1/27/26, indicated the resident had a severe cognitive impairment and was not at risk of pressure ulcer development. A patient risk profile indicated the resident's Braden score, dated 2/3/26, indicated a very limited risk. A patient risk profile indicated the resident's Braden score, dated 2/12/26, indicated a very limited risk. A significant change MDS assessment, dated 3/20/26, indicated the resident had a significant cognitive impairment, was at risk of pressure ulcer development, and had two stage three pressure ulcers (a serious skin injury characterized by full-thickness tissue loss exposing subcutaneous fat) which were not present upon admission. A wound summary indicated the resident developed a stage three pressure ulcer to the coccyx (tailbone), on 3/18/26, and the area healed on 4/15/26. The resident developed a stage 3 pressure ulcer to the left hip, on 3/17/26, which measured 4 centimeters (cm) in length, 4 cm in width, and 0.01 cm in depth, with slough (dead, non-viable tissue) covering the wound bed. The area to the left hip remained a stage 3, and was measured, on 5/14/26, at 2 cm in length, 2 cm in width, and 1.4 cm in depth. The wound bed remained covered in slough. A patient risk profile indicated the resident's Braden score, dated 4/20/26, indicated a very limited risk, despite the resident having developed two stage three pressure ulcers. A physician's order, dated 4/22/26, indicated low air loss mattress with bolsters to comfort settings and check every shift. A weight, dated 5/19/26, indicated the resident weighed 162.4 pounds. During an interview, on 5/21/26 at 9:27 a.m., Certified Nurse Aide (CNA) 14 indicated she did not know how to set the low air loss mattresses. The CNAs did not change the settings or know how to adjust them. She had not received any training on low air loss mattresses or how to adjust them. During an interview, on 5/21/26 at 9:29 a.m., Licensed Practical Nurse (LPN) 15 indicated the staff did not adjust low air loss mattress. The low air loss mattresses were set by the Wound Nurse and left how they were set. She had not received any training on how to adjust the low air loss mattresses. If there was an issue with one she would have tried to troubleshoot and let the Wound Nurse know. On 5/21/26 at 10:38 a.m., the Executive Director provided an undated document titled, Operations, and indicated it was the policy currently being used by the facility. The policy indicated, .2. Pressure Adjustment Knob: The pressure adjustment knob controls the air pressure in the mattress. Turning the knob clockwise will increase the pressure; counter-clockwise decreases the pressure. Higher pressures will support heavier residents. The pressure should be adjusted according to individual comfort preferences. On 5/21/26 at 12:51 p.m., the ED provided a document titled, Pressure Injury Prevention, last revised in January 2026, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: To identify residents at risk for skin breakdown, implement measures to prevent and/or manage pressure injury and minimize complications and promote optimal skin health. Policy: The facility will assess, monitor, and implement evidence-based interventions to prevent pressure injuries. Residents at risk will receive individualized care plans addressing key risk factors such as moisture control, pressure redistribution, positioning, mobility, and nutrition. 410 IAC (Indiana Administrative Code) 16.2-3.1-40(a)(1)

Based on record review and interview, the facility failed to code the Minimum Data Set (MDS) accurately for 2 of 8 residents reviewed for MDS accuracy (Resident 2 and 81).Findings include:1. On 5/20/26 at 2:04 p.m., a record review was completed for Resident 2. She had the following diagnoses which included but were not limited to diabetes, hypertension (high blood pressure), atrial fibrillation (irregular heartbeat), and hyperlipidemia (high cholesterol).A significant change Minimum Data Set (MDS) assessment, dated 11/13/25, section A1500 Preadmission Screening and Resident Review indicated the resident did not have a level II.The Notice of PASRR Level II Outcome, dated 6/30/22, indicated Resident 2 received a PASRR level II with the determination of Long Term Approval without Specialized Services.2. On 5/20/26 at 11:25 a.m., a record review was completed for Resident 81. She had the following diagnoses which included but were not limited to acute kidney failure, hypertension, anemia, diabetes, insomnia, and anxiety.The quarterly MDS, dated [DATE], section N Medications indicated Resident 81 was taking an anticoagulant.The Medication Administration Record (MAR) for February 2026 was reviewed and lacked documentation of Resident 81 receiving an anticoagulant.The physician orders for February 2026 lacked an order for an anticoagulant.On 5/21/26 at 1:10 p.m., the Regional MDS Nurse indicated the items were not coded correctly and informed the MDS coordinators of the errors.A policy titled, RAI (Resident Assessment Instrument) was provided by the Executive Director (ED) on 5/21/26 at 9:53 a.m. It indicated, .The facility will make error corrections in and resubmit to IQIES (Internet Quality Improvement and Evaluation System).

Based on interview and record review, the facility failed to ensure a resident's representative was notified of new medication orders for 1 of 6 residents reviewed for unnecessary medications (Resident 19), and the facility failed to ensure informed consent was obtained prior to the initiation or increase of psychotropic medications for 3 of 6 residents reviewed for unnecessary medications (Residents 19, 76, and 7). Findings include:1. During an interview, on 5/17/26 at 11:55 a.m., Resident 19's representative indicated they were not notified of medication changes. She found out later when the resident mentioned he thought his medications had been changed. Resident 19's representative indicated the facility had not notified her when the resident was started on Rexulti (antipsychotic medication) or when the trazodone (antidepressant) was increased. No informed consent was obtained for the psychotropic medications including discussion of black box warnings (warns of potential serious risks associated with a medication), benefits, risks, or other potential treatments. Resident 19's record was reviewed on 5/19/26 at 9:47 a.m. Census information indicated the resident was admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) assessment, dated 5/1/26, indicated the resident had a moderate cognitive impairment. A physician's order, dated 5/5/26, indicated Rexulti 0.5 milligrams (mg) by mouth once daily for agitation/anxiety. The record lacked documentation an informed consent was obtained from the resident's responsible party for this medication. An order change progress note, dated 5/5/26, indicated a black box warning was identified for the Rexulti. The note included an area to document the responsible party's notification of the black box warning, but the area was left blank. A physician's order, dated 4/29/26 and discontinued on 5/6/26, indicated trazodone 150 mg by mouth daily at bedtime for insomnia. A physician's order, dated 5/6/26, indicated trazodone 200 mg by mouth daily at bedtime for insomnia. The record lacked documentation an informed consent was obtained from the resident's responsible party for the medication increase. An order change progress note, dated 5/6/26, indicated a black box warning was identified for the trazodone. The note included an area to document the responsible party's notification of the black box warning, but the area was left blank. The resident's record lacked documentation the resident's representative was notified of the new order for Rexulti or increase of trazodone.A physician's order, dated 5/16/26, indicated haloperidol (antipsychotic medication) 5 mg by mouth stat (immediately) for anxiety and agitation. The record lacked documentation an informed consent was obtained from the resident's responsible party for this medication. An order change progress note, dated 5/16/26, indicated a black box warning was identified for the haloperidol. The note included an area to document the responsible party's notification of the black box warning, but the area was left blank. During an interview, on 5/19/26 at 12:27 p.m., the [NAME] President (VP) of Clinical indicated she was unable to find documentation an informed consent had been obtained from the resident's representative for the initiation of the Rexulti and haloperidol and the increase of trazodone. The resident's representative was not notified of the new medication orders, and she should have been. 2. Resident 76's record was reviewed on 5/20/26 at 12:47 p.m. Diagnoses on the resident's profile included, but were not limited to, moderate vascular dementia (reduced or blocked blood flow to the brain, leading to cognitive decline and memory problems) with agitation. A quarterly Minimum Data Set (MDS) assessment, dated 3/9/26, indicated the resident had a severe cognitive impairment. A physician's order, dated 12/7/25 and discontinued 1/23/26, indicated sertraline (antidepressant) 25 milligrams (mg) by mouth at bedtime for depression. A physician's order, dated 1/23/26, indicated sertraline 50 mg by mouth at bedtime for depression for 7 days. A physician's order, dated 1/23/26, indicated sertraline 75 mg by mouth daily for depression, to be initiated on 2/1/26. The record lacked documentation an informed consent was obtained from the resident's representative for the sertraline increase. An order change progress note, dated 1/23/26, indicated a black box warning was identified for the sertraline. The note included an area to document the responsible party's notification of the black box warning, but the area was left blank. A physician's order, dated 3/30/26, indicated Depakote (anticonvulsant that can be used as a mood stabilizer) delayed release tablet, give 125 mg by mouth in the afternoon for dementia with behavioral disturbance. The record lacked documentation an informed consent was obtained from the resident's representative for the Depakote. An order change progress note, dated 3/31/26, indicated a black box warning was identified for the Depakote. The note included an area to document the responsible party's notification of the black box warning, but the area was left blank. During an interview, on 5/20/26 at 2:50 p.m., the [NAME] President (VP) of Clinical indicated she reviewed the resident's record and was unable to find documentation informed consent was obtained when the resident's psychotropic medications were changed. 3. Resident 7's record was reviewed on 5/21/26 at 10:44 a.m. Diagnoses on the resident's profile included, but were not limited to, Alzheimer's disease (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior) unspecified. A quarterly Minimum Data Set (MDS) assessment, dated 3/13/26, indicated the resident had a severe cognitive impairment. A physician's order, dated 2/24/26 and discontinued 4/30/26, indicated lorazepam (antianxiety medication) 0.5 milligrams (mg) by mouth twice daily for anxiety. A physician's order, dated 4/29/26, indicated lorazepam 0.5 mg by mouth three times daily for delusional disorders. The record lacked documentation informed consent was obtained from the resident's responsible party for the medication increase. An order change progress note, dated 4/29/26, indicated a black box warning was identified for the lorazepam. The note included an area to document the responsible party's notification of the black box warning, but the area was left blank. During an interview, on 5/19/26 at 12:27 p.m., the [NAME] President (VP) of Clinical indicated informed consent should have been obtained for new orders or increases of psychotropic medications. During an interview, on 5/21/26 at 2:40 p.m., the Nurse Consultant indicated she was not able to find documentation informed consent was obtained from the resident's representative for the lorazepam increase. On 5/19/26 at 1:50 p.m., the Executive Director (ED) provided a document titled, Informed Consent, dated 2/26/25, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: To ensure that the Facility respects the resident's right to make an informed consent decision prior to deciding to undergo certain medical therapies and procedures. Policy: I. The Attending Physician will determine when material circumstances have changed so that an informed consent is required from the resident before providing treatment. The Attending Physician will then obtain an informed consent from the resident or authorized representative before allowing the resident to make a decision to undergo a therapy or procedure that requires an informed consent. The use of an informed consent will be done for but not limited to the use of: A. Psychotherapeutic Drugs. I. Obtaining Informed Consent A. The Attending Physician (or attending licensed healthcare professional who orders the therapy) must obtain informed consent before initiating a treatment or procedure that requires informed consent. i. An informed consent is required but not limited to, the administration of psychotherapeutic drugs. ii. The resident or representative must sign an informed consent form.iii. Upon procuring the informed consent, the Attending Physician must document itin the resident's medical record. iv. When obtaining consent for use of psychotherapeutic drugs, the resident will: a. Receive an informed consent form.stating the risks and benefits for the use of these medications. b. When admitted with orders for psychotherapeutic drugs, licensed staff will verify with the resident that the risks and benefits have been explained to them prior to consent or use. c. Have risks and benefits for use explained to them. d. Receive a new consent if medications change or dosage is increased. On 5/19/26 at 1:50 p.m., the Executive Director (ED) provided a document titled, Resident Rights, dated August 2020, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure: I. State and federal laws guarantee certain basic rights to all residents of the Facility. These rights include, but are not limited to, a resident's right to.D. Be fully informed and participate in his/her treatment including being fully informed in a language that he or she can understand of his/her total health status including his/her medical condition.R. Treat the decisions of a resident representative as the decisions of the resident to the extent required by the court or delegated by the resident, in accordance with applicable law. 410 IAC (Indiana Administrative Code) 16.2-3.1-3(n)(2) 410 IAC (Indiana Administrative Code) 16.2-3.1-5(a)(2)

Based on record review and interview, the facility failed to identify and provide wound care services by ensuring wound assessments and treatments were provided to prevent worsening wounds for 1 of 3 residents reviewed for wound care (Resident B).Findings include:On 3/11/26 at 3:00 p.m., during a phone interview, Resident B indicated she received good care, but the facility did not change her wound dressings for 10 days after admission. She indicated the staff looked at her leg wounds but did not change the dressings. On 3/10/26 at 10:30 a.m., the medical record of Resident B was reviewed. The resident was admitted to the facility from a local hospital on 1/8/26. admission diagnoses included, but were not limited to, kidney failure (occurs when kidneys lose the ability to adequately filter waste products, excess fluid, and toxins from the blood), edema (swelling), and hypotension (low blood pressure). Review of the hospital discharge instructions, dated [DATE], included a diagnosis of deep tissue injury (a serious form of pressure injury where soft tissue beneath the skin is damaged by intense or prolonged pressure which appears as intact skin with purple/maroon discoloration or a blood-filled blister) to bilateral lower extremities (BLE). An admission nursing skin assessment note, dated 1/8/26, indicated bruises to buttock, edema to BLE, weeping areas to BLE, bruising behind knees, redness under breasts and groin. On 1/9/26 the facility Nurse Practitioner (NP) visit note indicated no wounds. On 1/12/26 a Physician Assistant (PA) visit note indicated no wounds. Review of the medical record indicated documentation of skin assessment on 1/12/26 indicated an open area right lower leg front and front left lower leg. The assessment lacked documentation of additional wound assessment including description or measurements of wounds. On 1/13/26 a NP visit note indicated dressings present but did not observe wounds. A care plan, dated 1/14/26, indicated the resident had potential for pressure ulcer development related to immobility. The goal indicated, pressure ulcer will show signs of healing and remain free from infection by/through review date. The record lacked documentation of a care plan for non-pressure wounds or interventions to treat and prevent non-pressure wounds. On 1/15/26 a Physician Assistant (PA) visit note indicated they did not observe wounds. An admission Minimum Data Set Assessment, dated 1/15/26, indicated the resident was alert and oriented and had no cognitive deficits. She required assistance for daily care needs. From 1/16/26 to 1/22/26 daily skilled nurse's notes indicated No change in skin integrity. On 1/18/26 and 1/19/26, skin assessments were not completed in the daily skilled note. The medical record lacked documentation of skin assessment completion on 1/19/26. On 1/20/26 an NP visit note indicated, Her leg pain has improved. She says her bandages on anterior bilateral LE have not been changed since the hospital. The wound on her left leg has some drainage. Not warm to the touch and no spreading erythema. Wounds to be cleaned and bandages changed. The medical record lacked documentation of physician orders for wound care from admission on [DATE] until 1/21/26. A Physician order, dated 1/21/26, indicated to cleanse area to the left inner leg with normal saline, apply hydrogel (high water content wound dressing) to area and cover with foam dressing every day shift for wound care and as needed for soilage. Order was discontinued on 1/23/26. A Physician Order, dated 1/21/26, indicated cleanse right anterior leg with normal saline, apply xerofoam (sterile, non-adherent, petrolatum soaked gauze dressing containing an antimicrobial) to site, and cover with a foam dressing every day shift for wound care and as needed (PRN) for soilage wound care. Order was discontinued on 1/23/26. On 1/23/26 an NP visit note indicated a diagnosis of cellulitis (a potentially serious bacterial infection affecting the deep layers of the skin and underlying tissue). The record lacked documentation of interventions of treatment or antibiotic. A Physician order, dated 1/23/26, indicated cleanse right anterior leg with normal saline, apply xerofoam to site, and cover with a foam dressing every evening shift for wound care and as needed for soilage wound care. Order was discontinued on 1/29/26. A Physician order, dated 1/23/26, indicated cleanse area to the left inner leg with normal saline, apply hydrogel to area, and cover with a foam dressing every evening shift for wound care and as needed for soilage. Order was discontinued on 1/29/26. Review of the Treatment Administration Record (TAR) a weekly skin assessment was signed as being completed on 1/12/26, 1/19/26, and 1/26/26. On 1/26/26 and 1/27/26 skilled nursing notes indicated no changes in skin integrity. Dressing changes per treatment orders. Preventive skin cream/ointment. Review of the medical record indicated documentation of skin assessment on 1/26/26 indicated an open area to right lower leg front and front left lower leg. The assessment lacked documentation of additional wound assessment including description or measurements of wounds. On 1/27/26 an NP visit note indicated dressings intact and change dressings daily. The record lacked documentation of an assessment of the wounds under the dressings. A Physician order, dated 1/29/26, indicated wound care left lower leg, cleanse open area with normal saline NO WOUND CLEANSER, pat dry, skin prep peri wound, apply Santyl (topical medication to remove dead tissue) to wound bed, pack lightly with Calcium Alginate (a highly absorbent, biodegradable wound dressing derived from brown seaweed, designed for moderate-to-heavy draining wounds), cover. Change daily and PRN every day shift for skin impairment and as needed for soilage/dislodgement. On 1/29/26 an NP visit note indicated, The chief complaint for this visit is wound follow up. This visit is requested by the patient. [Resident B] is here for Long Term Care. Resident.seen for wound follow up. Visit requested by [Resident B] and her sister due to concerns regarding wound to BLE. Seen in bed .Alert and oriented. BLE with wound dressing in place. RLE [right lower extremity] with quarter size ulceration to mid shin. No signs of infection. Nursing dresses areas daily. LLE [left lower extremity] with large ulceration with slough [soft, moist, stringy, and usually yellow or white] and eschar [eschar is dead] tissue. No signs of infection. Assessed with wound nurse. Plan to add Santyl ointment to debride LLE wound. [Resident B] to be placed on wound team rounds with wound NP.BLE wound dressing in place. RLE quarter size open area on right shin. Large ulceration on the LLE with slough in wound bed. Ordered Santyl ointment for debridement. Indicated heavy edema. A Physician order, dated 1/29/25, indicated wound care right lower leg. Cleanse with normal saline, pat dry, apply Medihoney (a medical-grade, antibacterial honey used for managing acute and chronic wounds, burns, and ulcers) to wound beds, cover with foam dressing, change daily and PRN every day shift for skin impairment and as needed for soilage/dislodgement. A Physician order, dated 1/29/26, indicated to refer to consultant wound care to evaluate and treat. A Physician order, dated 1/30/26, indicated Santyl ointment 250 grams apply to left lower leg topically, every day shift for skin impairment. On 1/30/26, 1/31/26, and 2/3/26 a skilled nurse note indicated no changes in skin integrity. Dressing changes per treatment orders. Preventive skin cream/ointment. On 2/4/26 a daily skilled nurse note indicated treatable wound, dressing changes as ordered. A Physician order, dated 2/4/26, indicated doxycycline hyclate (antibiotic) 100 milligram by mouth two times a day for LLE cellulitis (bacteria infection) for 7 days. On 2/5/26 an NP visit note indicated cellulitis and extreme edema. The record lacked documentation of assessment of wounds or of interventions or initiation of antibiotic. On 2/10/26 a physician visit note indicated, the resident requires ongoing skilled medical management due to persistent erythema [redness], drainage, and slow healing of bilateral lower extremity wounds, despite current antibiotic therapy and wound care interventions. She is under the care of the wound team and is receiving doxycycline for cellulitis. Antibiotic medication ordered. On 2/11/26 a wound assessment was completed by the facility wound nurse. The assessment indicated a wound was observed on the right lower extremity. The wound was identified as a Venous Stasis Ulcer (a shallow, slow-healing open sore, usually on the lower leg or ankle, caused by chronic poor circulation) and indicated it was present on admission to the facility. The wound measured 3 cm (centimeters) long by (x) 2.5 cm wide x 1cm deep. The record lacked documentation of wounds on the left lower extremity. On 2/11/26 the NP from the wound care service provider visited the resident. Assessment note indicated four wounds on the BLE. The NP identified wounds as abscesses. She indicated wound measurements were as follows:Right lower leg proximal (closer to the upper leg) 3 cm wide x 2.5 cm long x 1 cm deep.Right distal lower leg (closer to the lower leg) 2.5 cm wide x 2.5 cm long x 2.5 cm deep.Right proximal medial lower leg (middle front of the leg) 1 cm wide x 1.5 cm long x 0.1 cm deep.Left lower leg wound measurements were 13 cm wide x 11 cm long x 0.3 cm deep. Review of the February TAR indicated a weekly skin assessment was documented as been completed on 2/12/26 and 2/19/26. The medical record lacked documentation of skin assessments. On 2/11/26 at 10:20 a.m., Resident B's blood pressure was extremely low and she was experiencing difficulty breathing. The resident was sent to the emergency room of a local hospital and admitted into intensive care unit (ICU) for care. An infectious disease physician consult indicated the resident had septic shock (a life-threatening medical emergency caused by the body's extreme, dysfunctional response to an infection, leading to tissue damage, organ failure, and potential death) secondary to her wounds. admission final diagnoses included, but were not limited to, pulmonary embolism (blood clot in the lung), multiple wounds on the lower extremities, cellulitis, significant hypotension (low blood pressure). Wounds were assessed, and the following measurements were obtained on 2/11/26:Lower right leg 11.5 cm x 10 cm x 1 cm with 3 cm tunneling (open under the skin like a tunnel)Lower left leg wound proximal to knee 14.5 cm x 13 cm x1 cm.Lower left leg wound distal to the knee. 16 cm x 10 cmx 1.5 cmRight pretibial (top of leg) 12 cm x 9 cm x 1 cmLeft pretibial 13 cm x 10 cm x 0.7 cm On 3/11/26 at 11:07 a.m., during a phone interview the former facility NP indicated when she visited Resident B on 1/9/26 the resident had a lot of pink foam dressings on her leg she indicated she referred the facility wound care nurse to contact the consultant wound service provider. She indicated she peaked under the dressings but did not assess the wounds. She indicated the wounds were decent, then they got bad quickly. She indicated she did not always look at wounds when visiting residents. She indicated the documentation by the facility staff was not good and a lot of things fell through the cracks. She indicated the facility nurse should assess wounds and enter information under the wound documentation tab of the electronic record. She acknowledged documentation should include pictures and measurements of all wounds on admission and in the weekly wound assessments. On 3/11/26 at 11:55 a.m., during a phone interview, Resident B's responsible indicated when the resident left the hospital on 1/8/26, she had wounds on her legs. She had received treatments in the hospital. Her legs were not wrapped but she had large bandages on them. She indicated the resident would not be returning to the facility. On 3/11/26 at 3:20 during an interview, Licensed Practical Nurse (LPN) 6 indicated if a resident was admitted to the facility with wounds she would remove the dressings and assess the wounds. She would record wounds on the skin assessment, notify family and physician to obtain treatment orders. On 3/11/26 at 3:23 p.m., during an interview LPN 7 indicated the regular nurse practitioner did not look at wounds when she was in the facility. On 3/11/26 at 3:43 p.m., during an interview LPN 5 who was formerly the wound nurse indicated if a nurse advised her a resident had wounds she would see the resident and assess them. She indicated most of the time the wound information was in the wound record within the electronic medical record. She indicated the nurses were to complete skin assessments for all residents weekly. She indicated she was advised Resident B did not have any wounds on admission. On 3/11/26 at 2:50 p.m., the Regional Nurse indicated all residents were to have a weekly skin assessment completed. On 3/11/26 at 3:01 p.m., the Director of Nursing provided a document titled, Wound Management, dated 1/2025, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: A resident who has a wound will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing. Residents with wounds will receive individualized care to support healing and prevent complications. Wound management will include thorough assessment, evidence-based interventions, ongoing monitoring, and interdisciplinary collaboration. Wound Management Principles.I. Assessment.1. A Licensed Nurse will conduct skin assessments. Upon admission and re-admission. Weekly and as needed. Document findings in PointClickCare (PCC) or the facility's electronic health record (EHR). 2. When a new wound is identified measure the wound (length, width, depth in cm).implement physician-ordered treatment immediately.II. Wound Treatment & Management. 7. The Attending Physician & IDT will be notified of new wounds or pressure injuries. This citation relates to Intake 2794977. 410 Indiana Administrative Code (IAC) 3.1-37

Based on record review and interview, the facility failed to ensure documentation of assessment and treatment progress of pressure ulcers (localized damage to the skin and underlying soft tissue, usually over a bony prominence, caused by prolonged pressure, shear, or friction) were completed for 1 of 3 residents reviewed for wounds (Resident C). Findings include:Resident C's record was reviewed on 3/10/26 at 2:15 p.m. The profile indicated the resident's diagnoses included, but were not limited to, dislocation of internal left hip prosthesis (the artificial ball has popped out of the artificial socket), age-related osteoporosis (a common condition, particularly in adults over 50, where bones naturally lose density, becoming porous, brittle, and weak), and unspecified protein-calorie malnutrition (a medical condition where the body does not get enough protein and energy [calories] to function properly, resulting in muscle wasting, weight loss, and weakened immunity). An admission skins assessment, dated 1/23/26, indicated the resident had re-admitted to the facility from the hospital with open area to her coccyx and an open area on her left thigh. A care plan, dated 1/22/26, and revised on 2/11/26, indicated the resident had actual impairment to skin integrity related to pressure ulcer stage 3 (a deep, full-thickness wound where the skin is gone, exposing the subcutaneous fat layer) to her coccyx (the small, triangular bone located at the very bottom of the spine) and a stage 2 pressure ulcer (a shallow, open wound caused by prolonged pressure, resulting in partial-thickness skin loss) to her left thigh. Interventions included, but were not limited to, follow facility protocols for treatment of pressure ulcer injury and monitor/document location, size and treatment of skin injury. A 5-day Medicare Minimum Data Set (MDS) assessment, dated 2/11/26, indicated the resident had severe cognitive deficit and had unhealed pressure ulcers. The record lacked documentation of any weekly skin assessments. A facility wound report, dated 3/11/26 at 10:47 a.m., indicated the resident had the following wounds: a. Stage 3 pressure wound to her coccyx. The report documented the last wound assessment date was 1/23/26. b. Stage 2 pressure wound to her left thigh. The report documented the last wound assessment date was 1/23/26. c. Unstageable pressure wound (a severe sore where the depth cannot be determined because the wound base is completely covered by dead, damaged tissue). The report indicated the wound had been assessed on 3/11/26 at 9:21 a.m. During an interview, on 3/11/26 at 9:37 a.m., the Regional Clinical Consultant indicated that the wound Nurse Practitioner (NP), who came to the facility, did not have access to documents in the facility's electronic medical record (EMR) system. Access had been requested but had not yet been set up. During an interview, on 3/11/26 at 10:00 a.m., the wound NP indicated Resident C had just been referred to her to see a couple of weeks ago and she had started seeing the resident at that time. She did not have access to the facility's EMR and was unable to review any of the resident's documentation or to document directly into the EMR. When she began to see the resident, she did not find any ulcerations on her coccyx or left knee area. Because she could not review the resident's wound history, she did not know what wounds she had in the past or how they were treated and healed. She had been shown the wound rounds report and had observed that the last time an assessment had been documented was on 1/23/26. She had only seen the resident's heel wound. She wanted to order some tests related to the heel wound but wanted to review the resident's wound history first. She was hopeful that she would be provided with access to the EMR system soon. It was very hard for her to provide proper care without having full access to the resident's information. During an interview, on 3/11/25 at 10:43 a.m., the Administrator indicated she and the Director of Nursing (DON) had only been at the facility for a short time. To her knowledge, there was not currently a wound nurse on staff at the facility. The wound NP did come weekly, and a staff nurse wound round with her. Staff nurses working on the halls were responsible for providing the wound dressing treatments as ordered. She was not familiar with what wounds notes were available in the EMR or where they would be located. On 3/11/26 at 3:31 p.m., the Regional Clinical Nurse provided a document, with a revision date of 6/2020, titled, Pressure Injury Prevention, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure.I. Risk Identification and Assessment: .B.Results of weekly skin assessments will be documented.III. Ongoing Monitoring.B. The Licensed Nurse will document effectiveness of pressure injury prevention techniques in the resident's medical record on a weekly basis. This citation relates to intake 2794977. 410 Indiana Administrative Code (IAC) 16.2-3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to provide supervision and interventions for an aggressive dementia resident (Resident L) on the locked dementia unit resulting in the resident forcibly removing another resident (Resident N) out of her wheelchair causing bruising to her eye and nose. This deficiency had the ability to affect 21 of the 21 residents residing on the locked dementia unit. The immediate jeopardy began on 12/30/25 when Resident L wanted Resident N's wheelchair and forcibly removed her from the wheelchair resulting in bruising and swelling to Resident N's right eye and nose. Resident L had previously wandered into another resident's room and punched a staff member when they attempted to re-direct him on 12/12/25. On 1/8/26 the Nurse Practitioner documented that Resident L was a risk to himself and others. On 1/13/26 Resident L was found lying in a bed in a female resident's room while she was in her own bed. Resident L became aggressive to staff when they attempted to remove him. On 1/15/26 Resident L was observed with items from another resident's room and observed attempting to enter other residents' rooms. Resident L's care plans had not been updated to indicate the resident had been physically aggressive to staff or residents and his current care plans lacked interventions related to his physical aggression and wandering. The Director of Nursing and Regional Resource Nurse were notified of the Immediate Jeopardy on 1/16/26 at 2:44 p.m. The Immediate Jeopardy was removed on 1/18/26, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include:On 1/15/26 at 2:26 p.m., during a random observation, Resident L was observed to be a tall muscular man residing on the 500 hallway the Memory Care unit. Resident L was observed removing a wheelchair from a resident's room. He re-entered the room and rolled out an overbed table. CNA 11 asked an unidentified CNA to accompany her to re-direct Resident L. She approached the resident and indicated they needed to return the overbed table to the resident's room. Resident L continued to hold onto the table. CNA 11 repeated that the table would need to be returned to the other resident's room. He eventually let go of the table and she redirected him to his room. The unidentified CNA had remained at a small distance from the resident and returned the overbed table and wheelchair to the room after CNA 11 escorted Resident L down the hall. Following the observation, CNA 11 indicated Resident L could be unpredictable and violent. He had hit a CNA in the face on another occasion, so staff used caution when re-directing him. On 1/16/26 at 1:20 p.m., during an observation of the Memory Care unit, Resident L was seated at a table in the common area, finishing his lunch. He rose from his chair and walked to the locked unit doors. He pulled on the doors several times, becoming more aggressive with pulling on the door. CNA 8 asked if he would have a seat for her. The Memory Care Manager approached and asked if he would help her with something. The resident took her outstretched hand and moved to a table with magnetic plastic tiles on top. He sat down at the table and looked at them briefly, then stood from his chair and began to walk towards the locked unit doors. CNA 8 approached him and asked if he would come with her and began to walk toward the resident hallway. He eventually turned and followed her down the hallway. A review of Resident L's clinical record was completed on 1/16/26 at 2:00 p.m. Diagnoses included severe vascular dementia with other behavioral disturbance, anxiety disorder, history of alcohol dependence, and major depressive disorder. His record indicated he was 6 feet tall and weighed 219 pounds. A health care plan, dated 3/18/25, indicated the resident had behaviors of hiding and/or refusing medications in his pockets. Resident L could become verbally aggressive and stand by exit doors in an attempt to exit seek. Resident L refused showers, moved furniture around, and made comments such as: I'm going to hit you. Interventions included: Monitor behavioral episodes and attempt to determine underlying cause; consider location, time of day, persons involved, and situation; document behavior and potential causes; staff to intervene as needed to protect the rights and safety of others; and divert attention, remove from situation and take to alternate location as needed. A health care plan, dated 5/7/25, indicated the resident required psychotropic medications for the diagnosis of vascular dementia with aggressive behavior management. Interventions included: administer medications as ordered and monitor/document for side effects and effectiveness; monitor and record an occurrence of target behavior symptoms such as pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff and others; and document per facility protocol. A psychiatric progress note, dated 11/10/25, indicated Resident L was an Olympic boxer. An Adverse Incident Report, dated 12/12/25, indicated on 12/12/25 around 7:30 p.m. Resident L was observed attempting to enter another resident's room with a visitor present. Staff attempted to redirect the resident away from the doorway when Resident L balled up his fist and hit CNA 4 in the face and stated he was going to get them all. He proceeded into the room and sat in a chair. Another CNA attempted to approach the resident, and he balled up his fists and stood from the chair and attempted to hit the CNA. The nurse on the unit was able to get Resident L to sit back onto the chair and offered him snacks and a drink. After a period, Resident L allowed staff to remove him from the room and perform incontinent care when he proceeded to bed. An Incident Report, dated 12/30/25 at 5:00 p.m., indicated Resident N was in her wheelchair in the common area. Resident L believed she was in his car and grabbed the handles on her wheelchair and began to pull the wheelchair back at an angle causing Resident N to fall to the floor. Resident N hit her eyeglasses on the floor, and this caused bruising and swelling to her right eye and nose. A review of 15-minute Behavior Monitoring Sheets indicated Resident L displayed agitation as follows:On 12/30/25 from 7:45 p.m. to 8:30 p.m.On 1/1/26 from 9:45 a.m. to 10:00 a.m.On 1/2/26 from 7:30 p.m. to 8:00 p.m.On 1/3/26 from 7:45 a.m. to 8:00 a.m.On 1/5/26 from 6:15 p.m. to 8:00 p.m. On 1/5/26 from 8:15 p.m. to 10:15 p.m. A review of 15-minute Behavior Monitoring Sheets indicated Resident L displayed wandering into other resident's rooms as follows:On 1/1/26 from 9:15 a.m. to 9:45 a.m.On 1/3/26 from 9:45 a.m. to 10:00 a.m.On 1/6/26 from 9:00 a.m. to 9:30 a.m. A review of 15-minute Behavior Monitoring Sheets indicated Resident L displayed combativeness on 1/6/26 from 9:30 a.m. to 9:45 a.m. A Nurse Practitioner's progress note, dated 1/8/26 entered on 1/12/26, indicated Resident L was being seen due to an incident when Resident L pulled a wheelchair out from under another resident resulting in the other resident falling to the floor. Resident L had a history of medication refusals which made care challenging for staff. The resident had been accepted to a neuropsychiatric unit for medication and psychiatric stabilization on 12/31/25. The resident's wife had initially agreed but changed her mind and refused. Resident L continued intermittent aggressive behaviors, resistance to staff assistance for care, and medication refusals. An on-call provider had ordered an as needed dose of injectable Haldol (a medication used to treat psychosis), but the resident's wife declined the order. The resident was at high risk to himself and others. If behaviors persisted, it may require a physician ordered emergency detention due to the resident's wife declining the resident to receive certain medications and declining the resident be treated at an inpatient neuropsychiatric facility. A general progress note, dated 1/13/26 at 5:36 a.m., indicated Resident L was roaming the common area and hallway on the 500 hall. CNA 10 reported to nurse that resident was in a female resident's room and had refused to come out. When the nurse arrived at the room, Resident L was in the other bed in the resident's room. When attempting to re-direct Resident L out of the bed, he became combative. CNA 10 went to another unit in the facility and asked two male CNAs for help. They were able to get the resident out of the female resident's room and to the common area. Resident L's record lacked documentation of care plans or interventions related to his aggressive physical behavior or the incidents from 12/12/25, 12/30/25, or 1/13/26. Resident L's record lacked documentation of behavior monitoring prior to the 15 minute monitoring. During a confidential interview on 1/15/26 at 1:42 p.m., another memory care resident's family member indicated she was afraid of Resident L and would ask for an escort off the unit after visiting her mother due to his aggressive behavior. During an interview on 1/16/26 at 12:50 p.m., QMA 9 indicated on 12/30/25 she had observed Resident N on the floor with Resident L holding onto her wheelchair handles. Resident L would not let go of the wheelchair. He was agitated and wanted the wheelchair. When Resident L got agitated, he yelled and cursed. He would get into a fighting stance. Residents stayed away from him. His aggression was worsening and incidents were occurring more frequently. The staff were scared of him. When Resident L said no to something, the staff would back off immediately, especially since he had hit a CNA. He would often refuse or spit out his medications. The staff kept other residents away when he became agitated. She observed today when a female resident approached the area where Resident L had rearranged some chairs and the staff moved the female resident out of the way quickly to assure her safety. During an interview on 1/16/26 at 1:59 p.m., the DON indicated Resident L frequently refused medication and redirection by staff. After the incident with Resident N, they attempted to send him to a neuropsychiatric facility for evaluation and treatment, but the resident's wife refused to send him out. They had him on one-to-one staff monitoring following the incident and staff had since been monitoring him more frequently. His care plan should have been updated to reflect his aggressive behaviors and updated interventions when dealing with those behaviors. He was unsure why the resident had no specific behavioral monitoring order. During an interview on 1/18/26 at 12:40 pm, with the Regional Resource Nurse and DON, the DON indicated the resident remained on one on one supervision and was currently calm. The Regional Resource Nurse indicated a care plan meeting was scheduled for Wednesday with Resident L's wife, but they were going to attempt to call Monday for an unofficial meeting to let her know that family needed to be with resident if he remained at the facility, or he could be sent to the neuropsychiatric hospital, or go home with her. The DON and the Regional Resource Nurse indicated the resident was sent to an acute care hospital emergency room (ER) instead because that was the only place the wife would allow the resident to go. Neither knew why the wife was allowed to make this decision if the resident was deemed to be a risk to himself and others. The resident went to the ER, but the wife refused care for the resident and he was returned to the facility. The acute care hospital would only admit if there was a medical reason to keep the resident. Since the wife refused care/denied concerns he was not admitted . The DON indicated the nurse from the ER reported the resident was aggressive to the ER doctor, but it was not documented. The bed hold policy was sent with the resident so when he was not admitted he was sent back to the facility despite the fact that the risk had not changed. The DON and the Regional Resource Nurse confirmed that the resident was currently doing ok with one on one supervision, but they were not sure how long they could provide this with staffing. They were not sure if he would become agitated with staff in the future. They were both concerned about staff safety as well as resident safety. The Regional Resource Nurse indicated they would call the wife to see if they could talk with her regarding the need to send him out to a neuropsychiatric hospital instead due to resident and staff safety. On 1/18/26 at 1:15 p.m., Resident L was observed walking down the hall with CNA 7. As he passed the cleaning cart, he attempted to take the cart. CNA 7 redirected him and indicated Housekeeper 1 needed to push the cart down the hall. The resident continued down the hall with CNA 7. On 1/18/26 at 1:37 p.m., Resident L was observed in the dining room refusing to take his medications. QMA 5 was seated with him and attempted to give him his medications that had been crushed and placed in applesauce using a spoon. The DON and QMA 5 continued to encourage him to take his medication, while he refused to open his mouth with a hand in front of his face. The DON indicated to Resident L that his wife would like him to take his medications while QMA 5 indicated the same. Resident L indicated he would like to call his wife. QMA 5 indicated to Resident L they would call her after he took his medication. The resident continued to refuse and lifted his right hand to his mouth, resting on his chin. QMA 5 waited and Resident L eventually allowed a spoonful in his mouth. During an interview on 1/18/26 at 2:20 pm the Regional Resource Nurse indicated she had done some digging and found the resident had attacked his wife with a pen before being admitted to the facility and that she was afraid of him. So, she was aware of his behaviors and aggression. She spoke with his wife and told her that the resident was a continued risk to himself, residents and staff. He would need to be transferred to a neuropsychiatric hospital, or a skilled facility with a locked psychiatric unit, or go home. The wife indicated she did not want him to go to the neuropsychiatric hospital, the skilled units with psychiatric care were too far away, and she refused to take him home because she could not care for him. She informed the wife they were making referrals and he would be sent out because he could not stay at the facility safely. The facility had placed eight referrals that afternoon. She indicated all staff were re-educated on dementia care and behavioral care on 1/17/26. When asked if the staff providing one on one were educated for aggressive behavior, no answer was given. During an interview on 1/19/26 at 10:30 a.m., the Corporate Nurse Consultant indicated the resident was sent out 1/18/26 around 7:45 p.m. to the acute care hospital. The Regional Resource Nurse indicated the management team was worried since the resident had been attempting to refuse medications during the day on 1/18/26 with extra management staff in the building that the regular night shift staff may not be enough to keep him and other residents safe. So, they called the acute care hospital and arranged for the resident to be admitted to an inpatient psychiatric bed. The Corporate Nurse Consultant indicated they had to provide the documentation to the hospital to prove that the resident was a risk for the residents at the facility and needed to be admitted . They made it clear that he was not safe to return to the facility and they were working on placement somewhere else more appropriate. The Regional Resource Nurse indicated as far as they knew the resident was admitted to the unit and was in four-point-restraints. The facility still did not have access to the resident's notes from the hospital. A current facility policy, revised 8/2020, titled, Violence Between Residents, provided by the Corporate Nurse Consultant on 1/17/26 at 11:40 a.m., included the following: Purpose To protect the health and safety of residents by ensuring that altercations between residents are promptly reported, investigated, and addressed by the Facility .Procedure.II. Response to an Altercation.J. If, after carefully evaluating the situation, it is determined that care cannot be readily given within the Facility, transfer the resident. The immediate jeopardy that began on 12/30/25 was removed on 1/18/26 when Resident L was admitted to an acute care hospital psychiatric unit. The facility ensured a systemic plan to include staff education and monitoring of residents to ensure staff provided dementia care and supervision. The noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. This citation relates to Intake 2718719. 3.1-37

Based on observation, record review, and interview, the facility failed to notify the physician or family following identifying an injury of unknown origin for 1 of 4 residents reviewed for accidents (Resident M).Findings include:During an interview on 1/15/26 at 2:53 p.m., Resident M's wife indicated on 1/10/26 at around 12:00 p.m., she visited her husband on the memory care unit. She found that he had a swollen, darkly bruised left eye. When she asked staff what had happened, they indicated to her they had no idea why he had a black eye. She had not received a call from the facility regarding his injury. It worried her that the staff was so dismissive about his injury. She had made arrangements for him to be discharged on 1/16/26 to another facility due to her fear for his safety and the lack of concern from the staff. There was another resident that resided at the facility who had been a boxer prior to being admitted to the memory care unit and was known to be violent. That resident made her feel unsafe when she visited. The staff also indicated they had not planned for any type of Xray or test to fully assess Resident M's injury. On 1/15/26 at 3:10 p.m., Resident M was observed seated in the common area at a table with another male resident talking. His left eye was observed to be swollen and discolored with varying shades of bruising. He appeared calm and engaged with his tablemate. The clinical record for Resident M was completed on 1/20/26 at 10:48 a.m. Diagnoses included Alzheimer's disease, anxiety disorder, major depressive disorder, and cognitive communication deficit. A quarterly Minimum Data Set (MDS) assessment, dated 12/16/25, indicated the resident had severe cognitive impairment. The resident displayed no verbal or physical behaviors and no rejection of care. The resident required partial to moderate assistance for toilet hygiene, transfer, and bed mobility. A health care plan, dated 8/20/25, indicated Resident M was a high risk for falls related to lack of safety awareness. Interventions included to encourage resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, ensure resident was wearing proper footwear and to review past falls, and attempt to determine cause of falls. A general progress note, dated 1/10/26 at 1:22 p.m., indicated the resident's left eye was puffed and was dark in color. Staff would continue to monitor. The clinical record lacked documented notification of black eye to the physician, appropriate personnel, or resident's spouse. During an interview on 1/21/26 at 12:07 p.m., the Director of Nursing (DON) indicated he had been covering for the Administrator who was on vacation beginning 1/9/26. He had not been informed about Resident M's injury until 1/12/26 in the morning meeting. He was not aware who discovered the resident's black eye; if it was the nurse or the resident's spouse. He had entered a Risk Management assessment on 1/12/26, but had not done any interviews or assessments. On 1/13/26, the staff talked about the injury again in morning meeting. No assessments or interviews had been completed on 1/13/26. On 1/14/26, he indicated he began to follow up on some suspicions it had been a fall. The facilities Clinical Education had begun interviewing staff regarding any injury seen on 1/9/26 or any report of the resident falling. All staff had responded with no. He counseled LPN 13 regarding her failure to report and assess Resident M's swollen, black eye. The clinical record had no assessment of the resident's injury. The incident had not been reported to the proper personnel and had not been thoroughly investigated. A current facility policy, revised 6/2011, titled, Incident/Accident Reporting, provided by the Regional Reimbursement Nurse on 1/17/26 at 11:40 a.m., included the following: Policy: It is the policy of this home for staff to report and investigate events, accidents or incidents. Definitions.3. Unexplained injury to a resident. No actual incident was observed, however, resident exhibits evidence of an injury such as a bruise or cut.Procedure-Resident.Notify physician and document the notification in the medical record. Cross Reference F609 and F610.This citation relates to Intake 2718719.

Based on observation, interview, and record review, the facility staff failed to implement policies and procedures to immediately report an injury of unknown origin to the Administrator or Director of Nursing for 1 of 11 residents reviewed for abuse and neglect (Residents M). Findings include:During an interview on 1/15/26 at 2:53 p.m., Resident M's wife indicated on 1/10/26 at around 12:00 p.m. she visited her husband on the memory care unit. She found that he had a swollen, darkly bruised left eye. When she asked staff what had happened, they indicated to her they had no idea why he had a black eye. The staff also indicated they had not planned for any type of Xray or test to fully assess his injury. It worried her that the staff was so dismissive about his injury. She had made arrangements for him to be discharged on 1/16/26 to another facility due to her fear for his safety and the lack of concern from the staff. On 1/15/26 at 3:10 p.m., Resident M was observed seated in the common area at a table with another male resident talking. His left eye was observed to be swollen and discolored with varying shades of bruising. He appeared calm and engaged with his tablemate. The clinical record for Resident M was completed on 1/20/26 at 10:48 a.m. Diagnoses included Alzheimer's disease, anxiety disorder, major depressive disorder, and cognitive communication deficit. A quarterly Minimum Data Set (MDS) assessment, dated 12/16/25, indicated the resident had severe cognitive impairment. The resident displayed no verbal or physical behaviors and no rejection of care. The resident required partial to moderate assistance for toilet hygiene, transfer, and bed mobility. A health care plan, dated 8/20/25, indicated Resident M was a high risk for falls related to lack of safety awareness. Interventions included to encourage resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, ensure resident was wearing proper footwear and to review past falls and attempt to determine cause of falls. A health care plan, revised 11/28/25, indicated Resident M had a behavior of wandering and would go in other's rooms to use the bathroom and was non-compliant with wearing shoes and socks. Interventions included to anticipate and meet his needs, and to provide a program of activities of interest and accommodate resident.A general progress note, dated 1/10/26 at 1:22 p.m., indicated the resident's left eye was puffed and was dark in color; will continue to monitor. During an interview on 1/21/26 at 12:07 p.m., the Director of Nursing (DON) indicated he had been covering for the Administrator who was on vacation beginning 1/9/26. He had not been informed about Resident M's injury until 1/12/26 in the morning meeting. He was not aware who discovered the resident's black eye; if it was the nurse or the resident's spouse. He had entered a Risk Management assessment on 1/12/26, but had not done any interviews or assessments. He counseled LPN 13 regarding her failure to report and assess Resident M's swollen, black eye. The clinical record had no assessment of the resident's injury. The incident had not been reported to the proper personnel. A current facility policy, revised 6/2011, titled, Incident/Accident Reporting, provided by the Regional Reimbursement Nurse on 1/17/26 at 11:40 a.m., included the following: Policy.It is the policy of this home for staff to report and investigate events, accidents or incidents. Definitions.3. Unexplained injury to a resident. No actual incident was observed, however, resident exhibits evidence of an injury such as a bruise or cut.Procedure-Resident.The Administrator, Director of Nursing, or Department Head on Duty should be notified promptly if abuse or neglect is suspected or if there is a complaint of abuse or neglect. Cross reference F580 and F610.This citation relates to 2718719.3.1-28(c)

Based on observation, interview, and record review, the facility failed to investigate an injury of unknown origin following observation of a resident with swelling and discoloration of his left eye for 1 of 11 residents reviewed for abuse and neglect (Resident M).Findings include:During an interview on 1/15/26 at 2:53 p.m., Resident M's wife indicated on 1/10/26 at around 12:00 p.m., she visited her husband on the memory care unit. She found that he had a swollen, darkly bruised left eye. When she asked staff what had happened, they indicated to her they had no idea why he had a black eye. The staff also indicated they had not planned for any type of Xray or test to fully assess his injury. It worried her that the staff was so dismissive about his injury. She had made arrangements for him to be discharged on 1/16/26 to another facility due to her fear for his safety and the lack of concern from the staff. On 1/15/26 at 3:10 p.m., Resident M was observed seated in the common area at a table with another male resident talking. His left eye was observed to be swollen and discolored with varying shades of bruising. He appeared calm and engaged with his tablemate. The clinical record for Resident M was completed on 1/20/26 at 10:48 a.m. Diagnoses included Alzheimer's disease, anxiety disorder, major depressive disorder, and cognitive communication deficit. A quarterly Minimum Data Set (MDS) assessment, dated 12/16/25, indicated the resident had severe cognitive impairment. The resident displayed no verbal or physical behaviors and no rejection of care. The resident required partial to moderate assistance for toilet hygiene, transfer, and bed mobility. A health care plan, dated 8/20/25, indicated Resident M was a high risk for falls related to lack of safety awareness. Interventions included to encourage resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, ensure resident was wearing proper footwear, and to review past falls and attempt to determine cause of falls. A health care plan, revised 11/28/25, indicated Resident M had a behavior of wandering and would go in other's rooms to use the bathroom and was non-compliant with wearing shoes and socks. Interventions included to anticipate and meet his needs, and to provide a program of activities of interest and accommodate resident.A Skilled Evaluation progress note, dated 1/10/26 at 1:22 a.m. indicated there were no changes in skin integrity. A general progress note, dated 1/10/26 at 1:22 p.m., indicated the resident's left eye was puffed and was dark in color. Staff would continue to monitor. A Skilled Evaluation progress note, dated 1/11/26 at 9:28 p.m., indicated there were no changes in skin integrity. The clinical record lacked any assessment of the resident's vital signs, neurological status, or left orbital area upon discovery of the resident's injury. The record lacked documented notification of the physician, appropriate personnel, or resident's spouse. During an interview on 1/21/26 at 12:07 p.m., the Director of Nursing (DON) indicated he had been covering for the Administrator who was on vacation beginning 1/9/26. He had not been informed about Resident M's injury until 1/12/26 in the morning meeting. He was not aware who discovered the resident's black eye; if it was the nurse or the resident's spouse. He had entered a Risk Management assessment on 1/12/26, but had not done any interviews or assessments. On 1/13/26, the staff talked about the injury again in morning meeting. No assessments or interviews had been completed on 1/13/26. On 1/14/26, he indicated he began to follow up on some suspicions it had been a fall. The facilities Clinical Education had begun interviewing staff regarding any injury seen on 1/9/26 or any report of the resident falling. All staff had responded with no. He counseled LPN 13 regarding her failure to report and assess Resident M's swollen, black eye. The clinical record had no assessment of the resident's injury. The incident had not been reported to the proper personnel and had not been thoroughly investigated. A current facility policy, revised 6/2011, titled, Incident/Accident Reporting, provided by the Regional Reimbursement Nurse on 1/17/26 at 11:40 a.m., included the following: Policy It is the policy of this home for staff to report and investigate events, accidents or incidents. Definitions.3. Unexplained injury to a resident. No actual incident was observed, however, resident exhibits evidence of an injury such as a bruise or cut .Procedure-Resident .The Administrator, Director of Nursing, or Department Head on Duty should be notified promptly if abuse or neglect is suspected or if there is a complaint of abuse or neglect.Complete the Incident/Accident Report. The Incident Investigation should be initiated.The Director of Nursing and the Administrator will review the incident. The Administrator will coordinate an investigation of the event as needed. Cross reference F580 and F609.This citation relates to 2718719.3.1-28(d)3.1-28(e)

A. Based on record review and interview, the facility failed to follow physician ordered parameters regarding medication administration of blood pressure medication for 2 of 11 residents reviewed for abuse and neglect (Residents E and L). B. Based on observation, interview, and record review, the facility failed to perform assessments following observation of a resident with swelling and discoloration of his left eye for 1 of 11 residents reviewed for abuse and neglect (Resident M). Findings include:A. 1. The clinical record for Resident E was completed on 1/15/26 at 11:12 a.m. Diagnoses included type two diabetes mellitus, stage three chronic kidney disease, heart failure, edema, and presence of a cardiac pacemaker. A current physician's order, dated 3/18/25, indicated to check heart rate daily and monitor for signs and symptoms of altered cardiac output or pacemaker malfunction. The resident's clinical record lacked a recorded heart rate for the reviewed months of November 2025, December 2025, and January 2026. During an interview on 1/15/26 at 12:42, the Regional Reimbursement Nurse (RRN) indicated the clinical record lacked the ordered heart rate and should have been completed daily per physician's order. A. 2. The clinical record for Resident L was completed on 1/16/26 at 2:00 p.m. Diagnoses included vascular dementia, essential hypertension, and stage two chronic kidney disease. A current physician's order, dated 3/18/25, indicated to administer losartan potassium (to treat high blood pressure) 100 mg (milligram) daily. Hold dose for systolic blood pressure less than 110. The electronic Medication Administration Record (eMAR) for December 2025 indicated Resident L's systolic blood pressure on 12/6/25 was 106; on 12/8/25 was 103; and on 12/10/25 was 104. The eMAR indicated the medication had been administered. The eMAR for January 2026 indicated Resident L's systolic blood pressure on 1/3/26 was 107; on 1/9/26 was 94; and on 1/14/26 was 106. The eMAR indicated the medication was administered. The eMAR for January 2026 indicated Resident L's systolic blood pressure on 1/3/26 was 107; on 1/9/26 was 94; and on 1/14/26 was 106. The eMAR indicated the medication had been administered. A current physician's order, dated 5/8/25, indicated to administer Metoprolol Tartrate (to treat high blood pressure) 25 mg, half tablet (12.5 mg) two times a day. Hold dose for a systolic blood pressure less than 100 or a heart rate less than 60. The eMAR for January 2026, indicated on 1/9/26, Resident L's systolic blood pressure was 96. The medication had been administered. During an interview on 1/16/26 at 1:59 p.m., the Director of Nursing (DON) indicated the resident's medication should have been held when a physician ordered parameters to do so. A current facility policy, revised 6/2020, titled, Physician Orders, provided by the Regional Reimbursement Nurse on 1/17/26 at 11:40 a.m., included the following: Purpose.This will ensure that all physician orders are complete and accurate.Procedure.II. Orders will include a description complete enough to ensure clarity of the physician's plan of care .VI. Documentation pertaining to physician orders will be maintained in the resident's medical record. Current month's administration records will be maintained in the MAR/TAR. B. During an interview on 1/15/26 at 2:53 p.m., Resident M's wife indicated on 1/10/26 at around 12:00 p.m., she visited her husband in the memory care unit. She found that he had a swollen, darkly bruised left eye. When she asked staff what had happened, they indicated to her they had no idea why he had a black eye. She had not received a call from the facility regarding his injury. It worried her that the staff was so dismissive about his injury. There was another resident that resided at the facility who had been a boxer prior to being admitted to the memory care unit and was known to be violent. The staff also indicated they had not planned for any type of Xray or test to fully assess his injury. On 1/15/26 at 3:10 p.m., Resident M was observed seated in the common area at a table with another male resident talking. His left eye was observed to be swollen and discolored with varying shades of bruising. He appeared calm and engaged with his tablemate. The clinical record for Resident M was completed on 1/20/26 at 10:48 a.m. Diagnoses included Alzheimer's disease, anxiety disorder, major depressive disorder, and cognitive communication deficit. A quarterly Minimum Data Set (MDS) assessment, dated 12/16/25, indicated the resident had severe cognitive impairment. The resident displayed no verbal or physical behaviors and no rejection of care. The resident required partial to moderate assistance for toilet hygiene, transfer, and bed mobility. A general progress note, dated 1/10/26 at 1:22 p.m., indicated the resident's left eye was puffed and was dark in color. Staff would continue to monitor. The clinical record lacked any assessment of the resident's vital signs, neurological status, or left orbital area upon discovery of the resident's injury. The record lacked documented notification of the physician, appropriate personnel, or resident's spouse. During an interview on 1/21/26 at 12:07 p.m., the Director of Nursing (DON) indicated he had been covering for the Administrator who was on vacation beginning 1/9/26. He had not been informed about Resident M's injury until 1/12/26 in the morning meeting. He was not aware who discovered the resident's black eye; if it was the nurse or the resident's spouse. He had entered a Risk Management assessment on 1/12/26, but had not done any interviews or assessments. On 1/13/26, the staff talked about the injury again in morning meeting. No assessments or interviews had been completed on 1/13/26. On 1/14/26, he indicated he began to follow up on some suspicions it had been a fall. The facilities Clinical Education had begun interviewing staff regarding any injury seen on 1/9/26 or any report of the resident falling. All staff had responded with no. He counseled LPN 13 regarding her failure to report and assess Resident M's swollen, black eye. The clinical record had no assessment of the resident's injury. The incident had not been reported to the proper personnel or the physician and had not been thoroughly investigated. A current facility policy, revised 6/2011, titled, Incident/Accident Reporting, provided by the Regional Reimbursement Nurse on 1/17/26 at 11:40 a.m., included the following: Policy It is the policy of this home for staff to report and investigate events, accidents or incidents. Definitions.3. Unexplained injury to a resident. No actual incident was observed, however, resident exhibits evidence of an injury such as a bruise or cut.Procedure-Resident.Immediately assess the condition of the resident involved. Initiate emergency first aid, and when necessary, transfer to hospital. The Neurological Assessment will be used immediately following any injury resulting in actual or suspected head trauma, or un-witnessed falls.Document medical facts of the incident and follow up in the medical record. (Notifications will be made at least every shift for a minimum of 72 hours, or longer as appropriate, until such time as the resident is deemed stable and/or has returned to their previous level of functioning.) Cross reference F609 and F610. This citation relates to Intakes 2671298 and 2718719. 3.1-37(a)

Based on record review and interview, the facility failed to complete an Interdisciplinary Team (IDT) post fall assessment and implement post fall interventions for 3 of 3 residents reviewed for accidents. (Resident B, E, and F) Findings include:1. The clinical record for Resident B was reviewed on 11/6/25 at 10:21 a.m. Diagnoses included history of stroke affecting left side, epilepsy, and dementia with behavioral disturbance.A health care plan, dated 6/22/25, indicated the resident was a high risk for falls related to confusion, incontinence and poor comprehension/communication.Resident B's progress notes lacked documentation of an IDT review of falls on 8/13/25, 8/17/25, 8/21/25, 8/22/25, and 8/23/25. The resident's care plan lacked an added intervention for the fall on 8/23/25.2. The clinical record for Resident E was reviewed on 11/6/25 at 12:05 p.m. Diagnoses included senile degeneration of the brain, convulsions, dementia, and difficulty walking.A health care plan, revised on 9/5/25, indicated the resident was a high risk for falls related to gait/balance problems, incontinence, safety awareness, and medication side effects.Resident E's progress notes lacked documentation of an IDT review of falls on 8/15/25, 9/2/25, 9/4/25, 9/5/25, 9/17/25, and two falls on 9/18/25. The resident's care plan lacked added interventions for the falls on 8/15/25 and 9/2/25.3. The clinical record for Resident F was reviewed on 11/6/25 at 12:57 p.m. Diagnoses included intercranial injury with loss of consciousness, difficulty walking, repeated falls, dementia, and Parkinson's disease.A health care plan, revised 10/13/25, indicated the resident was a high risk for falls related to an unsteady gait, walking too fast, Parkinson's disease, and a history of traumatic brain injury.Resident F's progress notes lacked documentation of an IDT review of a fall on 8/12/25, 8/13/25, 8/30/25, 10/6/25, 10/11/25, 10/15/25, and 10/18/25. The resident's care plan lacked an added intervention for falls on 10/6/25.During an interview on 11/6/25 at 1:39 p.m., the Director of Nursing (DON) indicated an Interdisciplinary Team (IDT) review had been completed during the following morning meeting for the resident's falls, however, he had failed to document the root cause and review of the IDT and had also failed to add interventions for some of the falls. This should be completed and documented with each resident fall.A current facility policy, undated, titled, Response to Falls, provided by the Administrator on 11/7/25 at 9:20 a.m., included the following: Purpose To ensure the Facility responds quickly and appropriately to resident falls in a manner that addresses both the resident's immediate needs and longer-term fall prevention. Policy.V. The Interdisciplinary Team (IDT) will review the investigative reports on a regular basis, as they many occur, and make systemic changes to reasonably limit future occurrences, consider change in POC [plan of care] interventions, system changes, etc.II. Post-Fall Assessment and Monitoring.C. Following each resident fall, the Interdisciplinary Team (IDT)-Falls Committee will review the Post-Fall Assessment & Assessment within 72 hours, or as soon as practicable. i. Based on the Post-Fall Assessment & Investigation, the IDT Committee will review fall prevention interventions and modify the plan of care as indicated.This citation relates to Intake 2659706.3.1-45(a)

Based on observation, interview, and record review, the facility failed to provide individualized dementia care and supervision of a newly admitted resident with Alzheimer's dementia for 1 of 3 residents reviewed for dementia care (Resident B) which resulted in the resident exiting the locked memory care unit through a second story window approximately 13 feet above the ground and fracturing her left heel, left ankle, two sacral vertebrae, and a thoracic vertebra. The immediate jeopardy began on 3/15/24 when a cognitively impaired resident with a diagnosis of Alzheimer's dementia was admitted to the nonsmoking locked memory care unit. Resident B was admitted from an assisted living facility, required minimal assistance with ADLs (Activities of Daily Living), and required no supervision when smoking cigarettes. Resident B was observed by facility staff to exhibit exit seeking behaviors throughout the day on 3/15/24 and 3/16/24. Resident B was observed to attempt to leave the unit, attempting to follow residents' family off the unit, and asking to leave the facility. Resident B refused her nicotine patch on 3/16/24 and indicated it did not work for her. On 3/16/24 at 8:30 p.m. staff observed a window on the unit's second story sunroom, that was 13 feet above ground level, was open and staff observed a 2 (two) foot gait belt was attached to a chair located in the interior of the facility and hanging out the window on the exterior of the building, the window and Resident B was missing. Resident B was found outside the facility below the open window in the parking lot. She was taken to the hospital and diagnosed with a fracture of the left calcaneal (heel), a fracture of the left malleolus (ankle), a fracture of two sacral vertebrae (S2 and S3), and a burst fracture of the thoracic spine vertebra at T12. The Administrator (ADM) was notified of the immediate jeopardy at 5:01 p.m. on 3/20/24. The immediate jeopardy was removed on 3/21/24, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: During an interview, on 3/19/24 at 12:58 p.m., Resident B's family indicated they did not know too much about what happened on 3/16/24, but the family feared the resident would not survive the injuries from the fall. Resident B told the family she had been pushed out the window. The facility had contacted Resident B's family and indicated the resident had tied a gait belt to a chair, climbed out of the window on the second story sunroom and fell on a car below. The resident's hand was bleeding, and she was transported to the hospital. Resident B had multiple injuries, fractured vertebra, fractured pelvis, fractured left foot and 2 fractures in the right foot with possible surgery on the left foot. The hospital was still completing assessments on her. The family had noticed a small scratch on the resident's right hand. When she resided in the assisted living (AL) facility prior to the admission to the skilled nursing facility, Resident B had not exhibited exit seeking behaviors, because she could go outside as she wished. Resident B had vision deficits and dementia, so the AL facility and the family felt that Resident B would be safer residing in a secured memory care unit. Resident B had aggressively grabbed her cell phone from staff when they were speaking to the family. We thought we were putting her somewhere where she would be safe and 36 hours later she was injured. Resident B kept telling the family that she was pushed by 3 waitresses out the window and believed she was a waitress also. The resident believed she gotten a job at the facility as a waitress. The family had questioned the facility, of how and why the incident had happened and did anyone see the resident go out the window. An Indiana State Department of Health Survey System report, dated 3/16/24 at 8:40 p.m., indicated Resident B had exited the second story of the facility through a window. Resident B unlocked the safety latch of the window and utilized a gait belt tied to a chair to lower herself to the ground. Resident B was observed in the parking lot by Licensed Practical Nurse (LPN) 5. The resident refused to allow facility staff to perform an assessment or provide treatment and no injuries were identified. Resident B was extremely combative and made multiple attempts to make physical contact towards staff. The resident was transferred by EMS (Emergency Medical Services) and admitted to a local hospital. Record review was completed for Resident B, on 3/19/24 at 2:00 p.m. Diagnosis upon admission to the facility on [DATE] included, but was not limited to, Alzheimer's dementia disease. An Admission Evaluation record for Resident B, dated 3/15/24 at 12:14 p.m., indicated the resident was alert and oriented to person and situation and ambulated without assistance. The assessment lacked documentation that the resident wandered or had exit-seeking behaviors. A progress note, dated 3/16/2024 at 9:43 a.m., indicated the resident was saying she did not live at the facility and that she was trying to go home. The resident refused her nicotine patch and was exit seeking. The progress note did not include documentation to show the facility provided effective treatment or services to ensure the cognitively impaired resident did not leave the facility unattended after the resident verbalized the intent to leave the facility. A late entry progress note, created by LPN 11, on 3/17/24 at 10:38 a.m., with effective date of 3/16/24 at 10:24 a.m., indicated on 3/16/2024 at 10:40 a.m., Resident B was standing against the wall with her arms crossed and her jacket in her hand at the end of the 400 hallway by the locked door. Resident B was not pushing on the door or touching the door but was standing near it. LPN 11 approached the resident and asked if everything was ok. Resident stated, as soon as this door opens, I have to get out of here and get to my apartment that's 10 minutes away to feed my dog. LPN 11 informed the resident that those doors did not open and asked if the resident would like to call someone to make sure her dog was getting fed. Resident agreed and walked with the nurse to the 400 hallway nurses' station to the facility phone. The resident asked me to call her granddaughter. I looked up the granddaughter's phone number, dialed the number, and handed the phone to the resident. The granddaughter did not answer the phone at that time and the resident left a voicemail asking the granddaughter why she was not picking up the phone, why was she still here, and asked when she was getting picked up before she hung up the phone. LPN 11 asked the resident if she ate breakfast, and the resident told LPN 11 yes. LPN 11 asked the resident if she would like a cup of coffee and the resident said that would be great. Resident B walked with LPN 11 to the dining room area where she got the resident a cup of coffee. LPN 11 asked the resident where she would like to sit and drink her coffee. Resident B stated she preferred to go to her room and drink her coffee. LPN 11 walked with the resident back to her room and put her coffee into her personal thermal cup and asked if she needed anything else. Resident B said no and thanked the nurse for the cup of coffee. Resident B was sitting on her bed drinking her coffee with no signs or symptoms of agitation when the nurse exited the room. The progress note did not include documentation to show the facility provided effective treatment or services to ensure the cognitively impaired resident did not leave the facility unattended after the resident verbalized the intent to leave the facility. A progress note, dated 3/16/2024 at 1:11 p.m., indicated the resident was refusing lunch and continued to exit seek, nothing redirected the resident. The resident was stating that she had dogs dying at home and she would be calling 911. The resident continued to sit by the exit doors waiting for her ride. The progress note did not include sufficient documentation to determine the interventions attempted by staff to re-direct the exit seeking behaviors and did not include documentation to show the facility provided effective treatment or services to ensure the cognitively impaired resident did not leave the facility unattended. A progress note, dated 3/16/2024 at 1:21 p.m., indicated the resident's granddaughter arrived and asked about the resident's day. The nurse informed her of the resident being anxious, exit seeking and upset about being here. The granddaughter decided to leave due to the fact that she felt her presence would make the situation worse, so she stated that her sister would come visit tomorrow. A progress note, dated 3/16/2024 at 5:30 p.m., indicated the resident ate dinner on the porch stating that she would only eat if staff allowed her to eat there. The resident ate her meal and wandered around some more but was okay. A progress note, dated 3/16/2024 at 7:45 p.m., created by LPN 6 indicated, this nurse was informed by another resident's family member that Resident B had opened a window on the porch. An aide got to the window before LPN 6 and told LPN 6 that the window only opened a few inches. LPN 6 also confirmed that the window did not open that much. LPN 6 had been assisting another resident with eating supper at the time, so she continued assisting the other resident. The note lacked documentation Resident B was re-directed or had additional one to one continuous supervision by facility staff. The note lacked documentation on how LPN 6 confirmed the window did not open fully. A progress note, dated 3/16/2024 at 7:45 p.m., indicated while assisting another resident with her medications the nurse was informed by a coworker that the resident was witnessed sitting on the ground on the sunroom porch and had laid down. The nurse stated that she looked like she was trying to fall asleep. Once the nurse finished giving the medication and assisting the other resident, she went into the sunroom. At the time the resident was sitting on the chair, and the nurse asked Resident B if she wanted to watch a movie with other residents. Resident B started to explain that her dogs were not being fed at home and how they would die. The nurse told the resident she would see what she could do. The nurse started the movie for the other residents in the main area and was getting things together so that she could start charting. She heard one of the high fall risk patients and saw him down the hall walking. The nurse grabbed the aide for her assistance, and they went down the 500 hall. The progress note lacked documentation to determine if additional interventions were attempted by staff to re-direct the exit-seeking behaviors. Resident B's record lacked documentation of progress notes or any other documentation between 3/16/2024 at 7:45 p.m. through 3/16/2024 at 8:29 p.m. to show the facility provided effective treatment or services to ensure the cognitively impaired resident did not exit the second story of the facility through an open, unattended window. A progress note, dated 3/16/2024 at 8:29 p.m., indicated LPN 6 was coming up the 500 hall after helping another resident and heard LPN 5 yell out that the porch window was opened and Resident B was gone. LPN 6 yelled for Certified Nursing Aide (CNA) 7 and CNA 8 to help find Resident B. LPN 6 ran outside with CNA 8 right behind. When LPN 6 got outside she immediately looked to the left, towards the opened window. LPN 6 saw Resident B crawling on her hands and knees on the gravel between the car and the building right under the window. Resident B was dragging a pillow with her. LPN 6 and CNA 8 immediately approached Resident B and tried to assist her. Resident B refused to let anyone get close to her and was hitting staff with the pillow. LPN 6 did not see any obvious signs of injury. The resident was not complaining of any pain. She was yelling at everyone, Get away from me, leave me alone, I am only 10 minutes away from the apartment. LPN 6 called 911 at 8:39 p.m. and staff stayed with the resident as Resident B continued to crawl up the grass hill. Resident B continued to refuse to let anyone get near her or help her. She continued to violently swing with the pillow at anyone that got too close to her. Resident B tried to stand up a few times and would get to her feet and then fall back down on the grass. The resident did not complain of any pain, and we never saw any blood other than the drops on the pillow. Resident B continued to crawl up the hill yelling at us the whole way until EMS arrived. When EMS arrived, the resident had crawled all the way up the hill to the parking lot. When EMS approached her, she laid down flat on her back and started telling them that staff would not let her out and locked her up there. EMS asked Resident B if she had jumped out the window and she told them yes, because staff would not let her get to the apartment that was 10 minutes away. She did not complain of pain until EMS asked and she told them her left foot was hurt. The resident's record was reviewed to include physician orders, plan of care, baseline plans of care, assessments, events, progress notes, nursing notes, IDT notes, physician notes, admission notes, and scanned documents. Resident B's record lacked documentation of a physician's order to reside in a secured memory care unit, a wandering/elopement assessment, an admission minimum data set assessment, a care plan to indicate the resident had wandering and exit seeking behaviors had been completed at the time of the resident's elopement on 3/16/24. The resident record also lacked documentation additional interventions were put into place when the resident had made multiple statements she was going home, actions of opening the porch window, and holding the door open attempting to get out as visitors left the unit, and lacked documentation staff had notified the physician, Director of Nursing (DON), Administrator (ADM), nor a nurse manager of the resident's exit seeking behaviors. The resident's medical record lacked documentation of pre-admission screening. The pre-admission screening and any additional documentation not in the electronic medical record was requested from management throughout the survey and was not provided during the survey process or upon exit of the survey. An Elopement Risk Evaluation form, signed and dated 3/19/24, (3 days after the resident eloped) LPN 6 documented Resident B was able to make decisions regarding tasks of daily living, e.g. decisions were consistent and reasonable. Resident was cognitively impaired and ambulated or propelled self. Patient may go outdoors on occasion but makes no attempt to leave grounds. The form indicated the resident ambulated and propelled herself, and or wandered, had made no attempt to leave the community, and had not verbalized a plan to elope from the community. A local hospital Emergency Department (ED) report, dated 3/16/24 at 9:35 p.m., indicated Resident B, a [AGE] year-old female, with diagnosis of Alzheimer's disease, resided at a (former Assisted Living facility name) center was found down in the parking lot and assumed that she jumped versus possible fall from the second floor window and crawled to the parking lot. The fall was not witnessed and unknown time of fall or level of consciousness. Diagnoses and Plan indicated Resident B had a burst fracture of the thoracic T12 vertebral body, transverse sacral fracture at S2-S3 with suspected bilateral neural foraminal involvement, fracture of the left calcaneal body with a left ankle deformity and diffuse pain down the spine. On 3/19/24 at 8:50 a.m., the Administrator (ADM) indicated the granddaughter of Resident B had contacted him about the incident of Resident B exiting through the porch window and had 'cussed' him out and threatened to contact the news media about the event. Since the incident, the memory care unit porch windows have been secured and reinforced with steel brackets, catch plates and window alarms. On 3/19/24 at 12:06 p.m., the Director of Nursing (DON) indicated Resident B never came back into the building after the incident. On 3/16/24 at 8:20 p.m., the resident was observed on the porch by staff. At 8:30 p.m., Licensed Practical Nurse (LPN) 5 did not see the resident nor hear anything but noticed the porch window wide open and saw the gait belt attached to a chair and hanging out the window. LPN 5 did not see anyone outside and had 2 Certified Nursing Aides (CNA) and another nurse (LPN 6) look for Resident B. They went downstairs to the ground floor and outside to find the resident in the parking lot. On 3/20/24 at 8:55 a.m., DON indicated they did not have an elopement care plan on 3/16/24. They developed an elopement care plan, dated 3/19/24, when LPN 6 completed the elopement assessment and signed it on 3/19/24. On 3/20/24 at 2:43 p.m. LPN 6 indicated on 3/16/24 she was providing care in the memory care unit and was assigned Resident B. Prior to the resident going out the window, Resident B had indicated to LPN 6 that she needed to go home to feed her pet and was sitting on a chair in the porch. LPN 6 asked her to watch a movie and Resident B indicated she wanted to go home. Another resident was calling for staff and LPN 6 went down the hall with the other resident to help. LPN 5 called out from the porch and indicated the porch window was open and she did not see Resident B. LPN 6 went down the stairs and outside and observed Resident B on the blacktop driveway on her hands and knees. It was dark on the sunroom porch without any lights on and dark outside. Resident B was found by the car on the passenger side by the tire in the parking lot. On 3/21/24 at 8:45 a.m., DON indicated ideally, the staff should have notified her when the resident opened the sunroom window the first time and had displayed exit seeking behaviors. Unfortunately, staff did not inform DON on 3/16/24 of the resident's first time opening the window nor her exit-seeking behaviors. On 3/21/24 at 9:53 a.m., Certified Nursing Aide (CNA) 9 indicated she met the resident on 3/16/24 at 3 p.m. at the beginning of her shift on the secured memory care unit. CNA 9 was not told why the resident was on the secured wing. She did not help the resident much except to talk with her. The resident was particularly upset at someone, wanting to go home, was suspicious of staff, and would spout profanities at them. Resident B seemed to be higher functioning than most residents to be on the unit and walked around the unit looking at windows and doors trying to find a way out, got the other residents upset, and asking for the train or bus to leave. Resident B would at times have a garment or personal item in her arms as she walked a lot around the unit. CNA 9 was not successful offering diversions, and the resident would say you're on her side. The resident worried about her animals. CNA 9 indicated she usually could divert a resident by offering to introduce to a friend. Resident B was not diverting with this technique. Around 5:00 - 5:30 p.m. as the residents were getting ready for supper, a family member alerted CNA 9 to the fact Resident B had opened a window a few inches on the porch. CNA 9 jerked the window up roughly a few times and it would only open a few inches. The front half of porch windows did not open, only a few side windows would open for ventilation. CNA 9 understood Resident B had been told that she was just staying for one night and was brought to the facility by a family member, but the next morning, when the resident realized she was not going home she became very upset. The resident had spent most of the evening on the porch, which was not unusual as the residents thought there was an exit door out there. There was a ceiling light on the porch, but after the resident had been taken to the hospital, CNA 9 tried the light switch, and the light would not turn on. There was a light in the parking lot, but CNA 9 did not see the resident in the parking lot as the resident had already crawled off. At the time the resident was found outside around 8:34 p.m., CNA 9 had been out taking out the trash, and co-worker CNA 7 had called and said Resident B was out. CNA 9 was in the back of the building taking trash to the dumpster, not near the side of the facility where the resident had got out on the parking lot, immediately CNA 9 came back inside the building. When she got back inside, CNA 7, CNA 8, and LPN 6 were outside with the resident, and LPN 5 was inside. LPN 5 asked CNA 9 if she would watch the unit so LPN 5 could go outside and help the resident. CNA 9 indicated she had been an aide for [AGE] years in this facility. She had not gotten all her training finished last year. She could not specifically remember having elopement/wandering training at this facility, it was just common sense. In her opinion, the secured memory care unit could use more staff members, 3 aides and 2 nurses were not enough eyes and hands, there was a lot to take care of that population and keep eyes on everyone. On 3/21/24 at 10:30 a.m., LPN 5 was observed working on the secured memory care unit and indicated she had worked on the unit full time since before the COVID-19 pandemic. Resident B had been admitted to the facility, on Friday afternoon 3/15/24 and LPN 5 met her on Saturday morning on 3/16/24. She had no knowledge of why the resident was in the secured memory care unit. LPN 6 was the direct nurse for Resident B. The resident was observed to wander around the common areas. The resident would approach LPN 5 and asked her to unlock the doors, when told she could not, the resident usually walked off. Resident B did not like attempts to divert her behavior and would walk off. Resident B was observed to go out onto the porch but was not observed attempting to open the windows. LPN 5 indicated she had received on-going education electronically but did not specifically remember having wandering/elopement training. On 3/21/24 at 10:45 a.m., the Memory Care Social Services (MSS) indicated she had worked at the facility for 7 years and as the MSS for about a year. The Interdisciplinary Team (IDT) made determination of who qualified to live on the secured memory care unit. Resident B had a dementia diagnosis, but MSS was not sure why the resident was admitted directly into a secured unit from assisted living versus being in general population at the facility. On 3/15/24 MSS was on the unit for about an hour after Resident B was admitted in the afternoon. Resident B was with her granddaughter in her room, eating donuts. She was unsure if the resident was okay with being admitted . MSS was not made aware on Saturday 3/16/24 of the resident wanting to go home and exit seeking. She was not notified that evening after the resident had eloped. Staff tried diversion if residents needed re-direction. On 3/20/24 at 2:30 p.m., the DON provided and identified a document as a current facility policy, titled Secure Care Neighborhood, dated 08/2020. The policy indicated, .The goal of the Secure Care Neighborhood is to meet the individual needs of residents with dementia related illnesses. The Secure Care Neighborhood will provide a safe environment that maximizes independence and provides an activity intensive atmosphere .The secure care neighborhood may be used to keep residents who are a high risk for elopement safe from exiting the facility. The resident should have an Elopement Risk Assessment completed with a physician order completed .The need for admission to the Secure Care Neighborhood must have a physician order .The resident must have a diagnosis of dementia related illness .The resident must be a high-risk wanderer The immediate jeopardy that began on 3/15/24 was removed 3/21/24 when the facility assessed all residents at risk for wandering and elopement, and if at risk, interventions were implemented and residents with current wandering and elopement risk were reviewed for appropriate care and interventions, and care plans updated. Nursing staff were in-serviced regarding residents with wandering and elopement behaviors. The noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. This citation relates to Complaint IN00430651. 3.1-37

Based on observation, interview, and record review, the facility failed to provide effective supervision to prevent a cognitively impaired resident from exiting the second story locked memory care unit through an open window located approximately 13 feet above the ground by using a gait belt and failed to conduct an elopement assessment when the cognitively impaired resident verbalized the intention to elope from the facility for 1 of 3 residents reviewed for accidents. Resident B sustained a fractured left heel, a fractured left ankle, two fractures of the sacral vertebras, and a thoracic vertebra fracture (Resident B). The immediate jeopardy began on 3/16/24 when a cognitively impaired resident with a diagnosis of Alzheimer's, who was admitted on e day before to the locked memory care unit, was observed with exit seeking behaviors throughout the day on 3/16/24. Resident B was observed to attempt to leave the unit, opening a window on the unit's second story porch, taking her belongings to the porch, and asking to leave the facility. On 3/16/24 at 8:30 p.m. staff observed an opened window on the unit's sunroom [ROOM NUMBER] feet above ground with a 2 foot gait belt hanging out the window. The gait belt was tied to a chair next to the window and Resident B was missing. Resident B was found outside crawling in the parking lot and holding a pillow with blood on it. ER documentation indicated Resident B's left foot was deformed and she complained of back pain. She was diagnosed with a fracture of the left calcaneal (heel), fracture of the left malleolus (ankle), fracture of two sacral vertebras (S2 and S3), and a burst thoracic spine vertebra at T12. The Administrator (ADM) was notified of the immediate jeopardy at 5:01 p.m. on 3/20/24. The immediate jeopardy was removed on 3/21/24, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: An Indiana State Department of Health Survey System report, dated 3/16/24 at 8:40 p.m., indicated Resident B had exited the second story of the facility through a window. Resident B unlocked the safety latch of the window and utilized a gait belt tied/anchored to a sitting chair to lower herself to the ground. Resident B was observed in the parking lot by Licensed Practical Nurse (LPN) 5. LPN 5 informed onsite staff and initiated the elopement protocol. The report indicated that visual line of sight of the resident was never broken. The resident had refused an assessment and treatment by facility staff and was extremely combative. Resident B made multiple attempts of physical contact towards staff. The resident was transferred and admitted to a local hospital, no injuries were known. The report did not include sufficient documentation to indicate the facility provided effective supervision to prevent the resident from exiting the facility through an open, unsecured second story window. On 3/19/24 at 12:58 p.m., Resident B's family indicated they did not know too much about what happened on 3/16/24, but the family feared the resident would not survive the injuries from the fall. Resident B told the family she had been pushed out the window. The facility had contacted Resident B's family and indicated the resident had tied a gait belt to a chair, climbed out of the window on the second story sunroom and fell on a car below. The resident's hand was bleeding, and she was transported to the hospital. Resident B had multiple injuries which included fractured vertebra, fractured pelvis, 2 fractures in the right foot, and a fractured left foot with possible required surgery. The hospital was still completing assessments on her. The family had noticed a small scratch on the resident's right hand. When she resided in the assisted living (AL) facility prior to the admission to the skilled nursing facility, Resident B had not exhibited exit seeking behaviors, because she could go outside as she wished. Resident B had vision deficits and dementia, so the AL facility and the family felt that Resident B would be safer residing in a secured memory care unit. The family thought they were putting her somewhere where she would be safe and 36 hours later she was injured. Resident B kept telling the family that she was pushed by 3 waitresses out the window and believed she was a waitress also. The resident believed she had a job at the facility as a waitress. The family had questioned the facility, of how and why the incident had happened, and did anyone see the resident go out the window. A local hospital Emergency Department (ED) report, dated 3/16/24 at 9:35 p.m., indicated Resident B, a [AGE] year old, female with a diagnosis of Alzheimer's disease, who resided at a (former Assisted Living facility name) center was found down in the parking lot. It was assumed that she jumped versus a possible fall from the second floor window and crawled to the parking lot. The fall was not witnessed and unknown time of fall or level of consciousness. Diagnoses and Plan indicated Resident B had a burst fracture of the thoracic T12 vertebral body, transverse sacral fracture at S2-S3 with suspected bilateral neural foraminal involvement, fracture of the left calcaneal body with a left ankle deformity and diffuse pain down the spine. On 3/19/24 at 11:00 a.m., the Administrator (ADM) provided pictures of the gait belt tied to the chair, the manufacturer window latch, and manufacturer safeguard spring-loaded window guard which prevented the window from being raised more than a few inches on the sunroom windows. A record review was completed for Resident B on 3/19/24 at 2:00 p.m. Diagnosis upon admission on 3/15/24, included but was not limited to Alzheimer's dementia disease. An Admission Evaluation record for Resident B, dated 3/15/24 at 12:14 p.m., indicated the resident was alert and oriented to person and situation, and ambulated without assistance. The assessment lacked documentation the resident wandered or had exit seeking behaviors. A progress note, dated 3/16/2024 at 9:43 a.m., indicated the resident was saying she did not live at the facility and that she was trying to go home. The progress note lacked documentation of assessing the resident's risk for elopement. A progress note, dated 3/16/2024 at 10:35 a.m., indicated the resident was upset and the charge nurse came to talk to her and called her granddaughter to calm her down. This only worked for a little while and the resident continued to wander. The progress note lacked documentation assessing the resident's risk for elopement or additional interventions attempted. A late entry progress note, created by LPN 11, on 3/17/24 at 10:38 a.m., with effective date of 3/16/24 at 10:24 a.m., indicated on 3/16/2024 at 10:40 a.m., Resident B was standing against the wall with her arms crossed and her jacket in her hand at the end of the 400 hallway by the locked door. Resident B was not pushing on the door or touching the door but was standing near it. Resident stated, as soon as this door opens, I have to get out of here and get to my apartment that's 10 minutes away to feed my dog. LPN 11 informed the resident that those doors did not open and asked if the resident would like to call someone to make sure her dog was getting fed. Resident agreed and walked with the nurse to the 400 hallway nurses' station to the facility phone. The progress note lacked documentation of assessing the resident's risk for elopement. A progress note, dated 3/16/2024 at 1:11 p.m., indicated the resident was refusing lunch and continued to exit seek, nothing seemed to redirect her. The resident was stating that she had dogs dying at home and she would be calling 911. The resident continued to sit by the exit doors waiting for her ride. The progress note lacked documentation of assessing the resident's risk for elopement. A progress note, dated 3/16/2024 at 1:21 p.m., indicated the resident's granddaughter arrived and asked about the resident's day. The nurse informed her of the resident being anxious, exit seeking and upset about being at the facility. The granddaughter decided to leave due to the fact that she felt her presence would make the situation worse, so she stated that her sister would come visit 3/17/24. The progress note lacked documentation of assessing the resident's risk for elopement. A progress note, dated 3/16/2024 at 5:30 p.m., indicated the resident ate dinner on the sunroom porch stating that she would only eat if staff allowed her to eat there. The resident ate her meal and wandered around some more but was okay. The progress note lacked documentation of assessing the resident's risk for elopement. A progress note, dated 3/16/2024 at 7:45 p.m., created by LPN 6 indicated this nurse was informed by another resident's family member that Resident B had opened a window on the porch. An aide got to the window before LPN 6 and told LPN 6 that the window only opened a few inches. LPN 6 also confirmed that the window did not open fully. LPN 6 had been assisting another resident with eating supper at the time, so she continued assisting the other resident. The progress note lacked documentation of assessing the resident's risk for elopement. A progress note, dated 3/16/2024 at 7:45 p.m., indicated while assisting another resident with her medications the nurse was informed by a coworker that the resident was witnessed sitting on the ground on the sunroom porch and had laid down. The nurse stated that she looked like she was trying to fall asleep. Once the nurse finished giving the medication and assisting the other resident, she went into the sunroom. At the time the resident was sitting on the chair, and the nurse asked Resident B if she wanted to watch a movie with other residents. Resident B started to explain that her dogs were not being fed at home and how they would die. The nurse told the resident she would see what she could do. The nurse started the movie for the other residents in the main area and was getting things together so that she could start charting. She heard one of the high fall risk patients and saw him down the hall walking. The nurse grabbed the aide for her assistance, and they went down the 500 hall. A progress note, dated 3/16/2024 at 8:29 p.m., indicated LPN 6 was coming up the 500 hall after helping another resident and heard LPN 5 yell out that the porch window was open, and Resident B was gone. LPN 6 yelled for Certified Nursing Aide (CNA) 7 and CNA 8 to help find Resident B. LPN 6 ran outside with CNA 8 right behind. When LPN 6 got outside she immediately looked to the left, towards the opened window. LPN 6 saw Resident B crawling on her hands and knees on the gravel between the car and the building right under the window. Resident B was dragging a pillow with her. LPN 6 and CNA 8 immediately approached Resident B and tried to assist her. We told her to stay still in case she was hurt from the fall. Resident B refused to let anyone get close to her and was hitting staff with the pillow. LPN 6 did not see any obvious signs of injury. The resident was not complaining of any pain. She was yelling at everyone, Get away from me, leave me alone, I am only 10 minutes away from the apartment. LPN 6 called 911 at 8:39 p.m. and stayed with the resident as Resident B continued to crawl up the grass hill. Resident B continued to refuse to let anyone get near her or help her. She continued to violently swing with the pillow at anyone that got too close to her. Resident B tried to stand up a few times and would get to her feet and then fall back down on the grass. Again, staff attempted to help her and again she refused. The resident did not complain of any pain, and staff never saw any blood other than the drops on the pillow. Resident B continued to crawl up the hill yelling at us the whole way until EMS (emergency medical services) arrived. When EMS arrived, the resident had crawled all the way up the hill to the parking lot. When EMS approached her, she laid down flat on her back and started telling them that we would not let her out and locked her up there. EMS asked Resident B if she had jumped out the window and she told them yes, because we would not let her get to the apartment that was 10 minutes away. She did not complain of pain until EMS asked and she told them her left foot was hurt. The resident's record lacked documentation of a physician's order to reside in a secured memory care unit, a wandering/elopement assessment, a baseline care plan to indicate the resident had wandering and exit seeking behaviors had been completed at the time of the resident's elopement on 3/16/24. The resident's medical record lacked documentation of pre-admission screening. The documentation was requested from management and was not provided during the survey process. On 3/19/24 at 8:50 a.m., the Administrator (ADM) indicated the family of Resident B had contacted him about the incident of Resident B exiting through the window and had cussed him out and threatened to contact the news media about the event. Since the incident, the memory care unit porch windows had been secured and reinforced with steel brackets, catch plates and window alarms. On 3/19/24 at 12:06 p.m., the Director of Nursing (DON) indicated Resident B never came back into the building after the incident. On 3/16/24 at 8:20 p.m., the resident was observed on the porch by staff. At 8:30 p.m., Licensed Practical Nurse (LPN) 5 did not see the resident nor hear anything but noticed the porch window wide open and saw the gait belt attached to a chair and hanging out the window. LPN 5 did not see anyone outside and had 2 CNAs and another nurse (LPN 6) look for Resident B. They went downstairs to the ground floor and outside to find the resident in the parking lot. LPN 6 observed the resident on the ground in the parking lot crawling, between a vehicle and the building. Resident B held a pillow with blood spots on it. The resident would not let staff near her and kept swinging the pillow at the staff, if they approached her, saying Get away from me! Staff stayed with her, while the resident crawled up on the grassy hill with staff following her and got to the edge of the parking lot, when the ambulance (EMS) arrived. The resident was happy to see EMS and willing to cooperate with EMS. EMS did an evaluation of the resident, put a neck collar on the resident, placed the resident on the stretcher, and took the resident to the hospital. The sunroom porch used to be open for all the residents. The alarm was placed on the porch door after the incident, the same night. There were no obvious signs of where the blood came from that was on the pillow. On 3/20/24 at 8:55 a.m., DON indicated there was no damage to the vehicle parked next to the building in the parking lot. They were unsure where the resident landed from the window. The old window safety latches were still on the windows, but with the newly installed window brackets, the windows could not be opened more than a few inches. They developed an elopement care plan, dated 3/19/24, when LPN 6 completed the elopement assessment and signed it on 3/19/24. On 3/20/24 at 2:43 p.m. LPN 6 indicated on 3/16/24 she was providing care in the memory care unit and was assigned Resident B. Prior to the resident going out the window, Resident B had indicated to LPN 6 that she needed to go home to feed her pet and was sitting on a chair in the porch. LPN 6 asked her to watch a movie and Resident B indicated she wanted to go home. Another resident was calling for staff and LPN 6 went down the hall with the other resident to help. LPN 5 called out from the porch and indicated the porch window was open and she did not see Resident B. LPN 6 went down the stairs and outside and observed Resident B on the blacktop driveway on her hands and knees. LPN 6 came towards the resident and told Resident B that she needed to check her out. Resident B was holding a pillow and swinging the pillow at the LPN. The pillow had drops of blood on it. The closer she got to the resident; the resident would crawl away. The resident tried to stand twice and fell down. At 8:39 p.m., LPN 6 was dialing 911 from her cell phone to get assistance. There were 2 CNAs with the LPN and the resident in the parking lot. The resident crawled up the grassy area to the front parking lot when EMS arrived. When EMS arrived, the resident told EMS that the three ladies would not let her leave and go home. EMS assessed the resident, and asked if she had any pain. Resident B replied that her left ankle was hurting. The resident was placed on a stretcher and was sent to the hospital. The resident was easily redirectable and was not showing aggressive behaviors with EMS. It was dark on the sunroom porch without any lights on and dark outside. Resident B was found by the car on the passenger side by the tire in the parking lot. On 3/20/24 at 3:25 p.m. the area where the resident had landed on the paved parking lot and grass area where resident had crawled up to the front parking lot were observed with the ADM, DON, and LPN 6. The ADM indicated LPN 6 found the resident in the parking lot and stayed with her until EMS came to the facility. On 3/21/24 at 8:45 a.m., DON indicated ideally, the staff should have notified her when the resident had opened the sunroom window the first time and had displayed exit seeking behaviors. On 3/21/24 at 9:53 a.m., Certified Nursing Aide (CNA) 9 indicated she met the resident on 3/16/24 at 3 p.m. at the beginning of her shift on the secured memory care unit. CNA 9 was not told why the resident was on the secured wing. She did not help the resident much except to talk with her. The resident was particularly upset at someone, wanting to go home, was suspicious of staff, and would spout profanities at them. Resident B seemed to be higher functioning than most residents on the unit and walked around the unit looking at windows and doors trying to find a way out which got the other residents upset, and asked for the train or bus to leave. Resident B would at times have a garment or personal item in her arms as she walked a lot around the unit. CNA 9 was not successful offering diversions, and the resident would say you're on her side. The resident worried about her animals. CNA 9 indicated she usually could divert a resident by offering to introduce to a friend. Resident B was not diverting with this technique. Around 5:00 - 5:30 p.m. as the residents were getting ready for supper, a family member alerted CNA 9 to the fact Resident B had opened a window a few inches on the porch. CNA 9 jerked the window up roughly a few times and it would only open a few inches. The front half of porch windows did not open, only a few side windows would open for ventilation. CNA 9 understood Resident B had been told that she was just staying for one night and was brought to the facility by a family member, but the next morning, when the resident realized she was not going home she became very upset. The resident had spent most of the evening on the porch, which was not unusual as the residents thought there was an exit door out there. There was a ceiling light on the porch, but after the resident had been taken to the hospital, CNA 9 tried the light switch, and the light would not turn on. There was a light in the parking lot, but CNA 9 did not see the resident in the parking lot as the resident had already crawled off. At the time the resident was found outside around 8:34 p.m., CNA 9 had been out taking out the trash, and co-worker CNA 7 had called and said Resident B was out. CNA 9 was in the back of the building taking trash to the dumpster, not near the side of the facility where the resident had got out on the parking lot, immediately CNA 9 came back inside the building. When she got back inside, CNA 7, CNA 8, and LPN 6 were outside with the resident, and LPN 5 was inside. LPN 5 asked CNA 9 if she would watch the unit so LPN 5 could go outside and help the resident. On 3/21/24 at 10:30 a.m., LPN 5 was observed working on the secured memory care unit and indicated she had worked on the unit full time since before covid. Resident B had been admitted to the facility Friday afternoon on 3/15/24 and LPN 5 met her on Saturday morning on 3/16/24. LPN 6 was the direct nurse for Resident B. The resident was observed to wander around the common areas. The resident would approach LPN 5 and asked her to unlock the doors, when told she could not, the resident usually walked off. Resident B did not like attempts to divert with activities and would walk off. Resident B was observed to go out onto the porch but was not observed attempting to open the windows. On 3/20/24 at 2:30 p.m., the DON provided and identified a document as a current facility policy, titled Secure Care Neighborhood, dated 08/2020. The policy indicated, .The goal of the Secure Care Neighborhood is to meet the individual needs of residents with dementia related illnesses. The Secure Care Neighborhood will provide a safe environment that maximizes independence and provides an activity intensive atmosphere .The secure care neighborhood may be used to keep residents who are a high risk for elopement safe from exiting the facility. The resident should have an Elopement Risk Assessment completed with a physician order completed .The need for admission to the Secure Care Neighborhood must have a physician order .The resident must have a diagnosis of dementia related illness .The resident must be a high-risk wanderer The immediate jeopardy that began on 3/16/24 was removed 3/21/24 when the facility assessed all residents at risk for wandering and elopement, and if at risk, interventions were implemented and residents with current wandering and elopement risk were reviewed for appropriate care and interventions, and care plans updated. Nursing staff were in-serviced regarding residents with wandering and elopement behaviors. The noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. This citation relates to Complaint IN00430651. 3.1-45(a)

Based on observation, interview, and record review, the facility failed to ensure residents received assistance, supplements, and appetite stimulants to maintain for weight for 2 of 4 residents reviewed for nutritional status (Residents 70 and 58) resulting in harm due to significant weight loss for both residents; and the facility failed to maintain hydration resulting in abnormal lab values for 1 of 4 residents reviewed for assessments (Resident 58). Findings include: 1. On 12/2/22 at 11:46 a.m., Resident 70's medical record was reviewed. The medical record indicated on 8/9/22 she weighed 107.2 pounds and on 8/15/22 she weighed 106.8 pounds. A physician's progress note, on 8/11/22 at 3:03 p.m., indicated Resident 70's weight and blood pressure remain stable at 107 pounds. Her musculoskeletal system was debilitated with decreased muscle tone. Neurologically, she follows simple commands. The medical record indicated the following weights: a. On 8/24/22, she weighed 108.5 pounds. b. On 8/30/22, she weighed 107.1 pounds. c. On 9/7/22, she weighed 103.8 pounds. d. On 9/13/22, she weighed 103.6 pounds. e. On 9/20/22, she weighed 102.8 pounds. f. On 9/27/22, she weighed 103.0 pounds. g. On 10/6/22, she weighed 101.4 pounds On 10/5/22 at 5:08 p.m., the Nurse Practitioner (NP) 30 charted Resident 70 height was 67 inches, and her weight was 102.8 pounds. She was being seen today for ongoing management of her psychiatric disorders. No psychotic symptoms. Her Brief Interview for Mental Status (BIMS) indicated she had severe cognitive impairment. The NP would continue to monitor her for medication effectiveness, drug reactions, and significant weight fluctuations. On 10/14/22 at 1:18 p.m., the Registered Dietitian (RD) progress note indicated Resident 70's current body weight was 101.4 pounds. Her body weight a year ago was 133 pounds. Her Body Mass Index (BMI) was 15.9, severely underweight. She triggers for significant weight loss. Her weight reflects insidious (gradual with harmful effects) weight loss for 180 days. Start House shake BID for insidious weight loss. The goal was for weight maintenance within 5%, resolve skin integrity, and stabilize meal intakes. A nutrition care plan, dated 10/14/22, indicated Resident 70 was at nutritional risk related to particular nutritional uses (PNU), Alzheimer's disease, dementia, pain, insomnia, hypothyroidism, hypertension, gastric reflux disease, depression, fatigue, dysphagia (difficulty swallowing), history of covid. pressure injuries, and a Vitamin D deficiency. She received a regular/puree diet. She was experiencing an insidious weight loss. Her BMI indicated she was underweight. The goal was to ensure the resident would consume an adequate diet to meet her estimated caloric needs. The interventions included provided the diet as ordered, honor her foods preferences, offer a substitute if she refused her meal or ate less than 50%, and provided supplements as ordered. On 10/26/22 at 8:39 p.m., the NP 30 charted Resident 70 height was 67 inches, and her weight was 102.8 pounds. She was being seen today for ongoing management of psychiatric disorders. Her level of function for eating was an extensive one person assist. She was total dependent for activities. Her BIMS indicated she had severe cognitive impairment. The NP would continue to monitor her for medication effectiveness, drug reactions, and significant weight fluctuations. On 11/7/22 at 6:31 p.m., the NP 30 charted Resident 70 height was 67 inches, and her weight was 102.8 pounds. She was being seen today for ongoing management of her psychiatric disorders. No psychotic symptoms. Her BIMS indicated she had severe cognitive impairment. The NP would continue to monitor her for medication effectiveness, drug reactions, and significant weight fluctuations. On 11/9/22 at 3:35 p.m., the RD progress note indicated charted Resident 70's current body weight was 89.9 pounds. She showed a significant weight loss of 11.3% in the last 3 months. Her BMI was down to 14.1, very much underweight for her age. She recommended weekly weights for 4 weeks, and to start liquid protein, 30 ml BID. The medical record indicated the following weights: a. On 11/9/22, she weighed 89.9 pounds. b. On 11/16/22, she weighed 85.4 pounds. c. On 11/22/22, she weighed 91.0 pounds. On 11/29/22 at 8:48 a.m., the Nurse Practitioner (NP) 30 charted Resident 70 height was 67 inches, and her weight was 91 pounds. Her chart was reviewed for medication changes, labs, and behaviors with no significant findings. She was taking Zoloft 100 mg for anxiety. She was referred for Alzheimer's disease, dementia, difficulty sleeping, and major depression disorder. Her level of function for eating was an extensive one person assist. She was total dependent for activities. No information was found on her psychiatric history prior to her current stay. Her Brief Interview for Mental Status (BIMS) indicated a score of zero, meaning she had severe cognitive impairment. The NP would continue to monitor her for medication effectiveness, drug reactions, and significant weight fluctuations. On 12/2/22 at 12:10 p.m., the RD progress note indicated Resident 70's current body weight was 89.4 pounds. She was down 1.6 pounds this week. She shows a significant weight loss of 13.9% in the last 3 months. Her BMI was down to 14, very much underweight. On 12/6/22 at 9:34 a.m., Resident 70's care plans were reviewed. A nutrition care plan, indicated Resident 70 required set-up, cues, supervision, and assist with activities of daily living (ADLs): hygiene, dressing, grooming, bed mobility, toileting, transfers, locomotion, and eating. During an interview, on 12/5/22 at 1:07 p.m., the RD indicated she did not know why Resident 70 dropped the weight, possibly variable food intake. She did not know why the house shakes were discontinued. The resident could have had a bad month. Her body mass index (BMI) was really low, it should be 23 or above. On 12/2/22, she requested the physician add an appetite stimulant, possibly Remeron. It had been 3 days and she had not received a response yet. On 12/5/22 at 1:28 p.m., an RD progress note indicated the Resident was on Zoloft for appetite. Recommend the physician consider a different medication to stimulate appetite. On 12/5/22 at 2:29 p.m., Resident 70's physician orders were reviewed with the RD. The RD indicated she was on Medpass, liquid protein and Juven for wound healing, they added incidental calories. a. In June, she was on fortified foods three times a day (TID), ice cream at lunch and dinner, and House shakes. The House shakes were discontinued on 6/27/22. b. In July, she was on fortified foods and ice cream at lunch and dinner. The fortified foods were discontinued on 7/21/22. The Medpass was discontinued on 7/1/22. c. In August, she had ice cream at lunch and dinner. d. In September, she had ice cream at lunch and dinner. Liquid protein was added on 9/22/22. e. In October, she had ice cream at lunch and dinner. The House shake was ordered again, starting 10/14/22 twice a day (BID) and the liquid protein was discontinued on 10/24/22. f. In November, she had House shake BID, ice cream at lunch and dinner, and one Juven packet starting 11/29/22 for wound healing. g. In December, she had House shake on 12/1/22, then to discontinue them from 12/2/22 to 12/7/22 to be replaced with Magic cup BID for 5 days starting on 12/3/22, and ice cream at lunch and dinner. The new order added on 12/6/22 was to add fortified foods. During an interview, on 12/6/22 at 10:20 a.m., the RD indicated she still had not heard from the physician about adding an appetite stimulant. During a meeting with the administrative staff, she provided them with the recommendation to add an appetite stimulant. She indicated the resident was on Zoloft (treats anxiety) as an appetite stimulant, but it is not something she usually saw for appetites. Usually, she saw Remeron. The RD indicated the resident had a new order on 12/6/22 for House shakes, but the facility was out of them. After searching Resident 70's medical chart, she indicated the previous RD discontinued the House shakes on 6/24/22 and not restarted until 10/24/22. She did not know why the House shake order had been discontinued. She did not know Resident 70 had stopped receiving fortified foods. After reviewing Resident 70's medical chart, she indicated she stopped receiving fortified foods on 7/21/22. A new order was started on 12/6/22 for fortified foods. On 12/2/22, an order was added for Magic cup from 12/2/22 to 12/8/22. During an interview, on 12/6/22 at 10:47 a.m., the RD indicated she tried to order fortified foods on 9/1/22. However, the order did not end up on the Medication Administration Record (MAR) because the order was under instructions. 46414 2. On 11/30/22 at 2:18 p.m., a record review was completed for Resident 58. Resident 58's MDS (Minimum Data Set), dated 11/3/22, was a significant change assessment. It indicated she required supervision and cueing with her meal consumption, did not have her own teeth, and did not wear dentures. Resident 58's care plan, dated 12/5/19, indicated that Resident 58 required a no added salt, regular diet with low potassium. On 10/31/22, the care plan was updated to reflect that Resident 58 was experiencing weight loss. Resident 58's care plan, dated 12/7/19, indicated that Resident 58 was at risk for dehydration related to a history of urinary tract infection, decreased intakes, dementia, and edema. The goal, dated 2/28/22, indicated that Resident 58's risk factor would be reduced to avoid dehydration. Interventions included encourage fluids, monitor for signs and symptoms of dehydration like poor skin turgor, dry mucous membranes, increase confusion, lethargy, decreased output, monitor labs as ordered. Resident 58 had a care plan, dated 12/7/19, indicating that she was at nutritional risk related to pneumonia (lung inflammation caused by bacterial or viral infection), COPD, edema, hyperlipidemia, dementia, CKD (chronic renal failure), hypothyroidism, diabetes, insomnia, depression, dehydration, hypocalcemia (low calcium), anxiety, vitamin deficiency, pain, GERD, protein-calorie malnutrition, and hypertension. The goal, dated 1/27/20, indicated Resident 58 would consume a diet adequate to meet estimated needs. Interventions included to serve diet as ordered, honor food preferences, monitor weight, offer menu substitution if meal was refused or less than 50% of meal consumed. Resident 58's care plan, initiated on 2/8/21 and revised on 5/19/22, indicated that Resident 58 used an antidepressant medication (Remeron) for depression and weight loss. Interventions included to observe, document, report as needed adverse reactions to antidepressant therapy, provide house shake with meals for nutritional supplement and Remeron 15milligrams (mg) in the evening for appetite stimulant, and encourage PO (by mouth) fluids. During an observation, on 11/30/22 at 10:45 a.m., Resident 58 was lying in her recliner with her eyes closed. Her breakfast tray was sitting on her bedside table in a Styrofoam container. A fork was in her scrambled eggs. Her food was untouched. She had coffee and a red juice in disposable cups on her Styrofoam tray. Her cup of coffee and red juice was untouched. She was not receiving supervision and cueing prior to an aide coming into the room. Certified Nursing Assistant (CNA) 8 entered the room and indicated that Resident 58 may be dehydrated. CNA 8 encouraged Resident 58 to drink her fluids without success. Resident 58 kept saying that she did not know what was wrong with her. Resident 58 was alert and oriented to her name and that she was in a nursing home. Resident 58 kept repeating, help me over and over and that she did not know what happened. CNA 8 left Resident 58's room to summon the nurse. On 11/30/22 at 11:00 a.m., Licensed Practical Nurse (LPN) 9 entered Resident 58's room. She indicated that she was an agency nurse and was not familiar with Resident 58. LPN 9 indicated that she would have to review Resident 58's medical record to familiarize herself with Resident 58. While waiting for the nurse to return, Resident 58 rested her head on the arm of the recliner. Resident 58 indicated that she felt like she was going to vomit. On 11/30/22 at 11:15 a.m., LPN 9 returned to Resident 58's room. LPN 9 indicated that this was Resident 58's usual behavior in the morning. LPN 9 indicated that Resident 58 was totally different in the afternoon. LPN 9 indicated that Resident 58 was a DNR (Do Not Resuscitate) and her son, who was her responsible person, did not want her sent out to the hospital. LPN 9 indicated that staff were encouraging her to drink fluids. LPN 9 did not obtain any vital signs or evaluate Resident 58. During an observation, on 11/30/22 at 2:00 p.m., Resident 58 was lying on her left side in her bed. Resident 58's tray was sitting on her bedside table. It was in a Styrofoam container and was untouched. She did not have 2% milk, 1 ounce of peanut butter or a house shake on her tray. No staff were present to provide supervision and cueing during the meal. During an observation, on 12/1/22 at 9:31 a.m., Resident 58 was lying in her bed with the covers over her head. She asked if somebody was going to help her. Her breakfast tray was in a Styrofoam container with most of her food uneaten. She did not have peanut butter, or a house shake on her tray. She had taken sips of her juice. Her coffee was untouched. Resident 58 asked if it was 10:00 in the morning or evening. She wanted to know if she had fallen. She yelled out ouch when attempting to reposition herself in bed. She indicated that her legs were hurting. Resident 58 indicated that she fell asleep and got confused. There were no staff present to provide supervision and cueing with her meal. During an observation, on 12/1/22 at 10:35 a.m., Resident 58's tray was still on her bedside table and has not taken any more of her food or fluids on the tray. There were no staff present to provide supervision and cueing with her meal. During an observation, on 12/1/22 at 10:45 a.m., LPN 9 took Resident 58's breakfast tray out of her room. LPN 9 did not provide any encouragement to eat or drink before removing Resident 58's tray from her room. During an observation on 12/1/22 at 2:24 p.m., Resident 58's lunch tray was removed from her room. Resident 58 indicated that she did not have much of an appetite. A house shake or peanut butter were not observed on her tray. During an observation, on 12/2/22 at 10:19 a.m., Resident 58's room was empty. Resident 58 was moved to another room the previous evening due to testing positive for COVID. Upon knocking on the door, staff yelled out patient care. Upon entering the room, three nursing staff were observed assessing Resident 58 indicating that Resident 58 had just fallen. Resident 58 was sitting up in her wheelchair. A portable vital signs machine was inside the room. Resident 58's new room was set up in the opposite direction of her previous room. Her door was also closed due to testing positive for COVID. The Regional Consultant indicated that the facility would be providing one on one supervision for Resident 58 due to the change in her room set up and the door being closed. Resident 58's breakfast tray was sitting on her bedside table at the end of her bed. Resident 58 had taken bites of her food. She consumed 2, 120 milliliter cups of fluid. During an observation, on 12/2/22 at 1:39 p.m., observed Resident 58's lunch tray at the end of her bed on the bedside table. She had consumed 1 cup (120 milliliters) of a fluid. She did not have any peanut butter or house shake on her tray. Resident 58's son was in her room with her. During an interview, with Resident 58's son on 12/2/22 at 1:40 p.m., he indicated when Resident 58 admitted to the facility she weighed around 143 pounds. Prior to admission Resident 58 weighed around 200 pounds. He indicated that they have been trying to get Resident 58 to eat for the past year. Resident 58's son indicated that he visits during lunch and dinner time for Resident 58 and when he visits, Resident 58 did not have house shakes on her trays. He had recently informed the DON about Resident 58 was not receiving her house shakes anymore. He was unsure of how long she had not received them, but it had been a while. Resident 58's son indicated that she would refuse to eat, and her kidney was not good. He indicated that he brought her a boost (a liquid nutritional supplement) to drink. The facility had not spoken to him about alternate interventions for nutrition and hydration. He did not feel Resident 58 would be able to tolerate a feeding tube. During an interview with the Registered Dietician (RD) on 12/2/22 at 2:14 p.m., she indicated the facility ran out of house shakes and more would come in on Tuesday. She would obtain invoices from dietary to see how much and when the house shakes were ordered. During an interview with the RD on 12/5/22 at 11:11 a.m., the RD indicated that house shakes were not available since the last shipment received on 11/22/22. The RD indicated that the facility had a meeting for residents with weight loss called SWAT (Skin Weight Assessment Team). The team attempted to meet on a weekly basis. Resident 58 should have been weighed weekly. Resident 58 had a significant weight loss. Resident 58 received Remeron (an antidepressant often used at a dose of 7.5mg at bedtime to promote an appetite and given at bedtime due to increased sleepiness) to stimulate her appetite. The RD would consult with nursing to inquire about discontinuing the use of Remeron since it was not effective. The RD changed Resident 58's diet on 12/1/22 to a regular diet with no restrictions. Resident 58's previous diet was NAS (No Added Salt). On 12/2/22, the RD indicated she added ice cream to her meals two times per day. There had not been a meeting to discuss alternate options for the resident to receive nutrition and hydration because it was not time to have this conversation with Resident 58's son until now. The RD indicated that she would get a care plan meeting scheduled with Resident 58's son. During an interview, on 12/5/22 at 1:02 p.m., RD reported that she was going to attempt Glucerna (a nutritional supplement) for Resident 58 to consume to aid in her nutrition. During an observation, on 12/5/22 at 1:07 p.m., Resident 58 was observed sitting up on the side of the bed with her tray in front of her. She had taken only bites of her food. She had consumed the entire contents of a 750-milliliter bottle of Gatorade and was drinking her Glucerna. CNA 33 was providing 1:1 supervision of Resident 58 due to a fall. Observed untouched containers of ice cream and magic cup. The magic cup was provided in lieu of a house shake since the facility did not have house shakes to offer. During an interview with the Dietary Manager (DM) on 12/6/22 at 9:24 a.m., she indicated that the facility received their food from US Foods. She indicated that if house shakes were available to order, she ordered them. They were not always available. The DM indicated that they were available for her most recent order. She indicated that she ordered 3 cases. The Dietary Manager indicated that if they are out of a supplement they were permitted to substitute. House shakes were substituted with magic cups (a frozen supplement). On 11/30/22 at 2:18 p.m., a record review was completed for Resident 58. Her diagnoses included, but were not limited to, peripheral vascular disease (a slow and progressive circulation disorder), chronic obstructive pulmonary disease (a condition involving constriction of the airway and difficulty or discomfort in breathing), COVID 19, urinary tract infection, diabetes type 2 (an impairment in the way the body regulates and uses sugar as a fuel), unspecified dementia, hyperkalemia (low potassium), hypothyroidism (abnormally low activity of the thyroid gland), osteoarthritis, dysphagia (difficulty swallowing), pain, age related physical debility, hypertension (a blood pressure higher than normal) , GERD (gastroesophageal reflux disease), chronic kidney disease (means the kidneys are damaged and cannot filter blood the way they should), Alzheimer's disease (progressive mental deterioration), hyperlipidemia (an abnormally high concentration of fats or lipids in the blood), atrial fibrillation (an irregular and often very rapid heart rhythm), and muscle weakness. Resident 58 had the following weights reflecting a significant weight loss. a. On 7/25/22, she weighed 126 pounds. b. On 8/4/22, she weighed 124.6 pounds c. On 8/9/22, she weighed 123.8 pounds. d. On 8/17/22, she weighed 122.9 pounds. e. On 8/25/22, she weighed 121.3 pounds. f. On 8/30/22, she weighed 120.4 pounds. g. On 9/7/22, she weighed 121.8 pounds. h. On 9/13/22, she weighed 120.8 pounds. i. On 9/20/22, she weighed 121 pounds. j. On 9/27/22, she weighed 121.8 pounds. k. On 10/6/22, she weighed 118.8 pounds l. On 10//25/22, she weighed 112.8 pounds. m. On 11/9/22, she weighed 108.8 pounds. n. On 11/15/22, she weighed 103.4 pounds. o. On 11/29/22, she weighed 104.6 pounds. A review of the medical record indicated that Resident 58 was sent to the hospital on 10/23/22 and received treatment for dehydration. She received fluids while at the hospital. A RD progress note, dated 10/26/22, indicated to weight Resident 58 weekly for four weeks, nutrition monitoring using weight changes will be done through review of weight records. Nutrition monitoring will be done through review of meal and supplement intake. Nutrition monitoring of electrolyte or renal profiles will be completed through review of standard lab reference tools. A RD progress note, dated 11/9/22, indicated that Resident 58's weight was 108.8 pounds. Resident 58 continued to show weight loss, significant for 1 month, 3 months and 6 months. She lost another 4 pounds from her previous weight. To aid in improving appetite, she recommended consideration of appetite stimulate. A review of Resident 58's food consumption indicated that she consumed 50% or less of her meals over the past month from 11/1/22 through 11/30/22 Resident 58's medical record lacked documentation of how much fluids she should consume per day. A review of her fluid consumption logs over the past 14 days from 11/16/22 through 12/1/22 indicated that Resident 58 consumed less than 1200 milliliters of fluid per day. A RD progress note, dated 12/1/22, indicated Resident 58's weight was up from the previous week. Resident 58 required IV (intravenous) fluids for a couple of days recently. She continued a regular diet with no added salt, fortified foods, and house shakes with meals. Her food intake was often less than 50%. Her intake of house shakes generally varies from 50-100%. Resident 58 was recently started on Remeron to help with appetite. RD recommended to change diet from regular to liberalize diet and to continue with weekly weights. The DON provided a copy of the lab results for the 12/5/22 BMP on 12/6/22 at 2:15 p.m. The results were abnormal. Her glucose was 52 (normal is 65-125), BUN (blood urea nitrogen) was 52 (normal is 7-25), creatinine was 2.4 (normal is 0.6-1.2) and calcium was 7.7 (normal is 8.4-10.2), and her GFR (glomerular filtration rate) was 19 and the report indicated that GFR is reliable for adults 17-[AGE] years old with stable kidney function. The lab report indicated that her score of 19 was indicative of stage 4 chronic kidney disease. On 12/5/22, the Regional Consultant provided a list of all the residents that received house shakes. The facility residents required 119 house shakes weekly. For the month of November, an invoice dated 11/22/22, indicated the facility received 50 vanilla house shakes and 75 chocolate house shakes. Another invoice, dated 11/1/22, indicated the facility received 75 strawberry house shakes. The total number of house shakes received for the month of November was 200 total. The facility required 476 house shakes monthly to meet the needs of residents that had orders to receive house shakes. On 12/5/22 at 9:20 a.m., the Regional Consultant provided a policy, titled, Hydration-Clinical Protocol, dated September 2017. The policy indicated, .Cause identification, 1. The physician will help identify the cause(s) of any existing fluid and electrolyte imbalance or help the staff document why the resident should not be tested . A. A limited review for causes. Treatment/Management, 1. The physician will manage significant fluid and electrolyte imbalance and associated risks, appropriately, and in a timely manner. A. Timeliness depends on the severity, nature, and causes of the fluid and electrolyte imbalance. B. For minor, uncomplicated fluid and electrolyte imbalance, oral hydration may suffice. For more severe or complicated fluid and electrolyte imbalance, subcutaneous (hypodermoclysis) (administering fluids into subcutaneous tissue) or intravenous hydration may be needed. 2. The staff will provide supportive measures such as supplemental fluids and adjusting environmental temperature, where indicated On 12/5/22 at 9:20 a.m., the Regional Clinical Nurse provided a policy, titled, Nutrition (Impaired)/Unplanned Weight Loss- Clinical Protocol, dated September 2017. The policy indicated, .The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparison over time. The staff and physician will define the individual's current nutritional status (weight, food/fluid intake and pertinent laboratory values) and identify individuals with anorexia (an eating disorder characterized by restriction of food intake leading to low body weight), weight loss or gain, and significant risk for impaired nutrition. The physician will consider whether any assessment including additional diagnostic testing is indicated to help clarify the severity or consequences of weight loss and/or impaired nutrition. The staff will report to the physician significant weight gain or losses or any abrupt or persistent change from baseline appetite or food intake. For individuals with recent or rapid weight gain or loss, the staff will review for possible fluid and electrolyte imbalance as a cause. The physician and staff will collaborate to address any ethical issues related to weight and nutrition (use of artificial nutrition and hydration) related to severe or prolonged impairment of nutritional status and weight loss 3.1-46(a)(1) 3.1-46(a)(2) 3.1-46(b)

Based on interview and record review, the facility failed to ensure a resident maintained acceptable weight parameters. One of 4 residents, who were reviewed for weight loss in a Stage II sample of 31, had a 16 pound weight loss in 30 days. (Resident #93) Findings include: The record of Resident #93 was reviewed on 2-19-2014 at 10:00 a.m. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #93 was unable to complete the Brief Interview for Mental Status (BIMS). Resident #93 was indicated to be moderately impaired in cognitive skills for daily decision making, decisions were poor, and cues and supervision were required. A review of the Monthly Weight Record for Resident #93 included: 9-3-2013 weight 130 pounds, 10-4-2013 weight 126 pounds, 11-5-2013 weight 130.2 pounds, 12-4-2013 weight 114 pounds, 1-7-2014 weight 118 pounds, and 2-7-2014 weight 131 pounds. The most recent physician's recapitulation orders for Resident #93, signed and dated 1-26-2014, included orders for a regular diet with mighty shake and ice cream with all meals. physician's orders [REDACTED]. A dietary progress noted dated 12-16-2013 indicated "Wt (weight) 12/10/2013 = 114# (pounds) ... (decrease) 16# (12.26%) x (times)1 month; (decrease) 12# (9.5%) x 6 months...." Resident #93 was seen by a nurse practitioner on 1-2-2014. The Assessment and Plan indicated... "4. Wt (weight) loss 4. Add [MEDICATION NAME] - mighty shake...". A physician's orders [REDACTED]. A pre-[MEDICATION NAME] level was checked on 2-12-2014. Results were indicated to be low, at 14 mg/dl (milligrams/deciliter), with a reference range of 20-40 mg/dl. Medication administration records (MAR) for Resident #93 were reviewed on 2-20-2014 at 9:45 a.m., for the months of November 2013, December 2013, and January 2014. The MAR for the months of November and December lacked documentation of the administration of Ensure; the MAR for December also lacked documentation of the administration of mighty shakes with meals. The weight of the resident decreased from 130.2 pounds in November 2013 to 114 pounds in December 2013. Documentation of the administration of Ensure was noted on the MAR indicated [REDACTED]. The weight of Resident #93 was noted to increase to 131 pounds in February 2014. During an interview with LPN #5 on 2-20-2014 at 10:30 a.m., LPN #5 indicated "There was not documentation of the Ensure being administered for November or December. It was caught for January, and is on the sheets since then." In regards to the weight loss, LPN #5 indicated Resident #93, "Has refused meals, and needs encouragement to consume 25-50 percent when she eats." 3.1-46

Based on record review and interviews, the facility failed to ensure 1 of 3 residents sampled for medication errors in the total sample of 3 was free of significant medication error in that he received insulin which was not ordered for him, resulting in a hypoglycemic emergency. (Resident IP) Findings include: The closed medical record of Resident IP was reviewed on 9/7/11 at 2:40 p.m. It indicated this resident was alert and oriented and had been admitted from a hospital. His [DIAGNOSES REDACTED]. Review of the 8/17/11 Record of Inquiry form indicated Resident IP's weight was at 309 pounds. He arrived at the facility the evening of 8/17/11. Review of the hospital discharge summary,dated 8/17/11, indicated the physician made a special note about Resident IP's insulin regime: "of note, holding all his insulin at this time. I am doing this because of his blood sugars have been running somewhat low on significantly lower doses of insulin that (sic) he was requiring prior to admission." The actual admission insulin orders were: 1. NPH insulin regular, 40 units subcutaneously every evening with accucheck. Hold if blood sugar less than 200, resume if blood sugar greater than 200 2. NPH insulin regular, 65 units subcutaneously every morning with accucheck. Hold if blood sugar less than 200, resume if blood sugar greater than 200. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. His accucheck/capillary blood glucose reading had been 202. To be noted, it is acceptable practice for the medication to actually be given to the resident anytime between one hour prior and one hour after the documented time. Therefore resident IP's insulin was given between 6 a.m. and 8 a.m. The nurse (LPN #2) who administered the insulin remained unavailable for interview. The nursing notes indicated Resident IP was found cold and clammy at 11:20 a.m. on 8/18/11. Resident IP's family indicated during interview on 9/7/11 at 6:28 p.m., they found him unconscious and "sprawled sideways across his bed" when they arrived at 11:20 a.m. His blood sugar was at 61 then and 50 five minutes later. The physician was notified and ordered a tube of Instaglucin (a dose of 24 grams of carbohydrate gel designed to immediately impact low blood sugar). This was given and the blood sugar recheck was 51. The EMTs arrived and transported the resident to the emergency room . Review of the emergency room documentation for Resident IP on 8/18/11 indicated he arrived at 12:48 p.m. The EMT's reported an accucheck they did was at 30 and had given him an [MEDICATION NAME] of [MEDICATION NAME]-50 which raised the blood sugar to over 100, but a recheck was at 65 so another [MEDICATION NAME] of [MEDICATION NAME]-50 was given. His sugar then rose to 94. By the time he arrived in the emergency room , Resident IP was responding in one word sentences and was alert and oriented X 3. Review of the medication disposition sheet for Resident IP in his closed record indicated "9" Humalog insulin was destroyed upon his discharge from the facility on 8/24/11. Review of the shipping manifest form which recorded receipt from the pharmacy of medications for Resident IP on 8/17/11 at 11:41 p.m., indicated "10 cc" (cubic centimeters) of Humalog insulin, not NPH/regular insulin, had been delivered for this resident. One (1) cc of the Humalog insulin had been removed. This was documented on both forms as plain Humalog, not a combination product. WebMD referenced Humalog insulin as a rapid-acting insulin, beginning action within 15-30 minutes and with peak action 30-90 minutes after the injection, with a duration of 3-5 hours. NPH insulin was classified as a intermediate-acting insulin taking effect in 1-2 hours and peaking at 2-5 hours, with a duration of 18-24 hours. Resident IP's hypoglycemic event was approximately four hours after receiving the injection, coinciding with the actions of Humalog insulin. Four Registered Pharmacists were interviewed separately about this scenario. #1 on 9/11/11 at 4:36 p.m., #2 on 9/11/11 at 4:50 p.m., #3 on 9/11/11 at 8 p.m., and #4 on 9/12/11 at 8:28 a.m. Four of 4 individually indicated an NPH/regular insulin order would need further clarification before it could be filled. They indicated this would be a combination of NPH and regular insulin and would need the ratio specified. Pharmacist #3 indicated a 65 unit dose of plain Humalog would be a very large dose. "I don't think I've ever seen such a large dose of Humalog." The interview with Pharmacist #4 at the provider pharmacy indicated their documentation showed they had contacted the facility for clarification. A time was not documented, but it would have been before the order left their premises the evening of 8/17/11. He indicated there was a notation on the record, "Per (LPN#1's name)-insulin orders are Humalog." This form was reviewed on 9/13/11 at 9 p.m., and matched Pharmacist #4's information. Review of the shipping manifest, dated 8/17/11 at 11:41 p.m., indicated the pharmacy had shipped one 10 ml (milliliter) vial of "Humalog 100 units/ml" to the facility for Resident IP. It was not a combination of NPH and Humalog, but plain Humalog insulin. Attempts to interview Resident IP's attending physician were unsuccessful, but a non-involved physician (MD #2) agreed to interview about this scenario on 9/13/11 at 12:35 p.m. He indicated he thought the order needed to be clarified and changed to a combination product such as [MEDICATION NAME] 70/30, etc. He indicated 65 units of plain Humalog would be a huge dose and could have been fatal depending on the size of the recipient, with a smaller person being at the greatest risk. The resident's weight of 309 pounds and the fact he ate a good breakfast helped explain why his blood sugar didn't crash earlier in the morning. The Administrator and Director of Nursing were informed of the above findings on 9/8/11 at 1:50 p.m. They indicated this issue had not been identified by their staff and offered no rebuttal. This federal tag relates to complaint number IN 341. 3.1-25(b) 3.1-48(c)(2)

Based on record review and interviews, the facility failed to ensure LPN #2 followed the five rights of medication administration which resulted in giving the wrong type of insulin to a diabetic resident causing a hypoglycemic emergency. In addition, when the pharmacy contacted LPN #1 for clarification of the insulin order, evidence was lacking she contacted the attending physician, but instead, issued the clarification. This affected 1 of 3 residents in the sample of 3 reviewed for medication errors. (Resident IP) Findings include: Resident IP's closed medical record was reviewed on 9/7/11 at 2:40 p.m. The record indicated he was alert and oriented and had been admitted from a hospital. His [DIAGNOSES REDACTED]. He arrived at the facility the evening of 8/17/11. Amongst his medication orders were orders for NPH/regular insulin to be given according to the results of his capillary blood glucose monitoring results: 1. "NPH insulin/regular, 40 units subcutaneously every evening with accucheck. Hold if blood sugar less than 200, resume if blood sugar greater than 200 " 2. "NPH insulin/regular, 65 units subcutaneously every morning with accucheck. Hold if blood sugar less than 200, resume if blood sugar greater than 200. " During interviews, 4 of 4 Registered Pharmacists (#1 on 9/11/11 at 4:36 p.m., #2 on 9/11/11 at 4:50 p.m., #3 on 9/11/11 at 8 p.m. and #4 on 9/12/11 at 8:28 a.m.) individually indicated an NPH/regular insulin order would need further clarification before it could be filled. They indicated this would be a combination of NPH and regular insulin and would need the ratio specified. Pharmacist #3 indicated a 65 unit dose of plain Humalog would be a very large dose. "I don't think I've ever seen such a large dose of Humalog." The interview with Pharmacist #4 at the provider pharmacy on 9/12/11 at 8:28 a.m., indicated they had documentation they had contacted the facility for clarification. He indicated there was a notation on the record, "Per (LPN#1's name)-insulin orders are Humalog." This form was reviewed on 9/13/11 at 9 p.m., and matched Pharmacist #4 ' s information. Review of the shipping manifest, dated 8/17/11 at 11:41 p.m., indicated the pharmacy had shipped one 10 ml (milliliter) vial of "Humalog 100 units/ml" to the facility for Resident IP. It was not a combination of NPH and Humalog, but plain Humalog insulin. Interview of Physician #2 on 9/13/11 at 12:35 p.m., indicated he, too, thought the order needed to be clarified and changed to a combination product such as [MEDICATION NAME] 70/30, etc. He indicated 65 units of plain Humalog would be a huge dose and could have been fatal depending on the size of the recipient, with a smaller person being at the greatest risk. Review of the 8/17/11 Record of Inquiry form indicated Resident IP's weight was at 309 pounds. His weight and the fact he ate a good breakfast helped explain why his blood sugar didn't crash earlier in the morning. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. (The accepted practice is that the medication could be administered anytime in a period of 1 hour before to 1 hour after the documented administration time.) The nursing notes indicated he was found cold and clammy at 11:20 a.m. on 8/18/11. Interview with the family on 9/7/11 at 6:28 p.m., indicated they arrived and found the resident "sprawled sideways across his bed, unconscious." The nursing notes indicated his blood sugar was at 61 then and 50 five minutes later. The physician was notified and ordered a tube of Instaglucin (a dose of 24 grams of carbohydrate gel designed to immediately impact low blood sugar). This was given and the blood sugar recheck was at 51. The EMTs arrived and transported the resident to the emergency room . The hospital emergency room documentation was reviewed on 9/8/11 at 1 p.m. This documentation indicated the EMTs had obtained a blood sugar reading of 30 while en route to the emergency room . They had given Resident IP two doses of [MEDICATION NAME]-50 to counteract this low blood sugar. Interview with the Director of Nursing on 9/8/11 at 1:40 p.m., indicated their practice is to fax the physician's orders [REDACTED]. During interview on 9/13/11 at 2 p.m., LPN #1 indicated she could not specifically remember the phone call from the pharmacy "because it happens a lot" and could not say what she'd checked before authorizing the Humalog order. She said, "I always check the orders in the chart." She indicated she had no memory of having called the attending physician about it. WebMD referenced Humalog insulin as a rapid-acting insulin, beginning action within 15-30 minutes and with peak action 30-90 minutes after the injection, with a duration of 3-5 hours. NPH insulin was classified as a intermediate-acting insulin taking effect in 1-2 hours and peaking at 2-5 hours, with a duration of 18-24 hours. Resident IP's hypoglycemic event was approximately four hours after receiving the injection, coinciding with the actions of plain Humalog insulin and the fact he had eaten a good breakfast. Based on the actions of Humalog insulin verses NPH insulin and the amounts of Humalog documented as received the night of 8/17/11 and disposed of after one dose was given, it was determined the morning nurse (LPN#2) failed to check the type of insulin she was administering with the type of medication the physician had ordered. The Administrator and Director of Nursing were informed of the above findings on 9/8/11 at 1:50 p.m. They indicated this issue had not been identified by their staff and offered no rebuttal. Page 171 of the Geriatric Medication Handbook , eighth edition, indicated under "Steps of Medication Administration" included the five administration rights: "accurate medication administration (i.e., right drug, right patient, right dose, and dosage form, right time)" This federal tag relates to complaint number IN 341. 3.1-35(g)(1)