Every finding on record at Saint Anthony Rehab and Nursing Center

Based on observation, interview, and record review, the facility failed to ensure narcotic medications were free from theft of an employee for 1 of 3 residents reviewed for misappropriation of property. (Resident F) The deficient practice was corrected on 10/7/25, prior to the start of the survey, and was therefore past noncompliance.Findings include:During an interview, on 1/28/26 at 12:02 p.m., the Director of Nursing (DON) indicated LPN 6 reported, on 9/28/25, Resident F had a narcotic medication card and a narcotic count sheet missing. LPN 6 indicated when she last left the facility, there were 3 sheets and 3 medication cards for Resident F. On 9/28/25, there were only 2 sheets and 2 cards. The pharmacy was contacted and it was confirmed the resident should have had 3 sheets and 3 narcotic medication cards. The facility video from the weekend was reviewed and LPN 7 was seen removing one sheet and one narcotic medication card from the medication cart. The police were notified. LPN 7 was terminated and arrested by the local police department. The missing medication card was in LPN 7's home, according to the police investigation which continued to be ongoing.The clinical record for Resident F was reviewed on 1/28/26 at 4:03 p.m. The diagnoses included, but were not limited to, paranoid schizophrenia, hyperlipidemia, dementia, chronic pain, and anxiety.A physician's order, dated 5/25/25, indicated to administer hydrocodone acetaminophen (a narcotic pain medication) 7.5-325 milligram (mg) every 8 hours as needed for pain. During an observation, on 1/28/26 at 3:33 p.m., the Administrator showed a video on his computer of LPN 7 removing narcotics from the narcotic drawer of the medication cart. LPN 7 then removed the narcotic count sheet and placed them both between two other pieces of paper. She then went down the hallway to the employee exit and to her car. She exited the facility with the papers and medication then entered her car and returned to the facility with only 2 papers and no medications. LPN 7 was notified by the DON she was suspended due to the suspicious video of her at the medication cart. LPN 7 denied any wrongdoing and was informed the facility would be notifying the authorities.A facility documented telephone interview, on 10/1/25 at 2:23 p.m., indicated LPN 7 was notified and explained the reason for the phone call. She was asked to make a statement on the phone or to come to the facility for an interview. LPN 7 indicated she would come to facility to discuss the incident. LPN 7 did not come to the facility. A facility document indicated LPN 7 was terminated, on 10/2/25, and her license and the incident were reported to the state board of licensing.During an interview, on 1/29/26 at 11:59 a.m., LPN 6 indicated she had remembered Resident F had 3 narcotic medication cards and count sheets when she had left work on 9/26/25. She returned to work, on 9/29/25, and discovered one narcotic medication card and record was missing. LPN 6 reported the missing medication to her supervisor. Her supervisor reported the missing medication to the Director of Nursing. The DON called the pharmacy and confirmed Resident F had a medication card missing. A current facility policy, titled Abuse and Unusual Occurrence, dated 9/6/24 and provided by the DON on 1/29/26 at 4:00 p.m., indicated .Misappropriation of resident property-Deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent The deficient practice was corrected by 10/7/25, after the facility audited all the narcotic sheets, interviewed residents, LPN 7 was terminated, all nurses were re-educated on a new narcotic count system, and the pharmacy completed a house wide audit of narcotic medications.This citation relates to Intake 2634382.3.1-28(a)

Based on observation, interview and record review, the facility failed to ensure a physician's order for oxygen with an indication for use and the equipment setting for the flow rate was obtained for 1 of 1 resident reviewed for respiratory care. (Resident 47)Findings include:During an observation, on 9/15/25 at 11:00 a.m., Resident 47 was receiving oxygen via nasal cannula set at a flow rate of 2 liters per minute. During an observation, on 9/15/25 at 12:35 p.m., Resident 47 was receiving oxygen via nasal cannula set at a flow rate of 2 liters per minute. During an observation, on 9/16/25 at 9:47 a.m., Resident 47 was receiving oxygen via nasal cannula set at a flow rate of 2 liters per minute.The clinical record for Resident 47 was reviewed on 9/11/25 at 3:08 p.m. The diagnoses included, but were not limited to, diabetes, atrial fibrillation, macular degeneration, anxiety, chronic kidney disease stage 4, psychotic disorder with delusions, and dementia.There was no physician's order for the use of oxygen which included the equipment settings for the oxygen flow rate for Resident 47. During an interview, on 9/16/25 at 9:20 a.m., the Director of Nursing (DON) indicated a physician's order for the oxygen had not been transcribed.During an interview, on 9/16/25 at 9:54 a.m., RN 2 indicated when Resident 47 was readmitted from the hospital, the admitting nurse should have looked at the discharge orders from the hospital, compared them with the orders from the facility, and contacted the facility physician to change or add any new orders. A current facility policy, titled Medication Administration, dated 5/2021 and received from the DON on 9/16/25 at 9:20 a.m., indicated .Medications must be administered in accordance with the orders A current facility policy, titled Oxygen Administration, dated 8/2024 and received from the DON on 9/16/25 at 9:20 a.m., indicated .turn on the oxygen, start the flow of oxygen as ordered by the physician 31-47(a)(6)

Based on observation, interview and record review, the facility failed to ensure a staff member did not photograph or video tape a resident and post the video online on social media for 1 of 1 resident reviewed for respect and dignity. (Resident F) The deficient practice was corrected on 9/6/24, prior to the start of the survey, and therefore was past noncompliance. Finding includes: A document, titled Indiana State Department of Health Survey Report System, indicated Resident F was videotaped and photographed in the facility while she was sleeping by Staff Member 10. The video was posted online. On 9/24/24 at 2:29 p.m., an online video was reviewed with the Executive Director (ED). The video showed Resident F in her wheelchair at the facility asleep. A comment wake up Grandma was heard, and then a can of Red Bull drink appeared on the screen. The video was posted online on social media. The clinical record for Resident F was reviewed on 9/25/24 at 12:30 p.m. The diagnoses included, but were not limited to, unspecified dementia, difficulty walking, anemia, and depression. The resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated she had a severe cognitive deficit. A care plan indicated the resident had confusion and a memory deficit. She was forgetful and needed reminders. She needed assistance with activities of daily living, and she had an impaired thought process. She preferred to be called grandma. A nursing note, dated 8/17/24, indicated the resident was assessed and no injury was noted. Resident F's guardian was notified of the incident and had no concerns at this time. The resident was reassessed by the DON and the resident was found to be happy and content with no signs of distress. A nursing note, dated 8/22/24, indicated Staff Member 10 threatened Staff Member 11 and accused her of posting the video online. Staff Member 11 told the DON she did not see the video and she did not post the video. She indicated she was aware of the policy and procedure which indicated no photos of residents were to be taken in the facility. A nursing note, dated 9/5/24, indicated on 8/16/24 at 1:05 p.m., the Director of Nursing (DON) received a text message which she opened and saw a picture of Resident F on snapchat/social media. The correspondence did not reveal the texter's identity. A video was then sent to the DON with the resident on the video and a story line attached. The video had Staff Member 10 as the account holder. Staff member 10 denied posting the video. Staff Member 10 did admit the photo and video were on her camera roll. The guardian for the resident was advised of the investigation and the staff member's termination. During an interview, on 9/24/24 at 3:10 p.m., the DON indicated she was made aware of the video by an anonymous caller. Staff Member 10 was identified. The staff member denied posting the video. Staff Member 10 admitted the phone was her phone with the video on it. Staff Member 10 was fired from employment at the facility and the nursing board was notified. Staff Member 10 failed to follow facility policies and procedures. During an interview, on 9/24/24 at 12:57 p.m., Resident F indicated she did not know if anyone had taken her photo or had posted a video of her online. The resident was confused. During an interview, on 9/24/24 at 12:52 p.m., Staff Member 7 indicated she was aware Resident F's photo was posted online. She had been in-serviced on abuse and knew residents were not to be photographed by staff. During an interview, on 9/24/24 at 12:56 p.m., Staff Member 8 indicated she was aware Resident F's photo was posted online. She had been in-serviced on abuse and knew residents were not to be photographed by staff even if the resident said it was okay. During an interview, on 9/24/24 at 12:59 p.m., Staff Member 9 indicated he was aware Resident F's photo was posted online. He had been in-serviced on abuse and knew residents were not to be photographed by staff. Staff would be terminated if they posted photos of residents online. A current policy, titled Imaging of Residents, Videotaping, Photographing and Other, dated as revised 4/2021 and provided by ED on 9/25/24 at 3:10 p. m., indicated .Resident photographs are considered health care records and will be retained and released in accordance with current applicable regulations and statutes governing the release of protected health information The deficient practice was corrected by 9/6/2024, after the facility implemented a systemic plan which included the following: Staff Member 10 was terminated and all staff members were in-serviced/educated on Abuse and Imaging of Residents, Videotaping, Photographing and other policies and procedures. This citation relates to Complaint IN00441445. 3.1-3(a)

Based on observation, interview and record review, the facility failed to ensure a resident received adequate supervision when the resident exited the facility, without staff knowledge, and was found down the street 3 blocks away for 1 of 3 residents reviewed for accidents. (Resident B) The deficient practice was corrected on 9/20/24, prior to the start of the survey, and therefore was past noncompliance. Finding includes: An Indiana Department of Health Intake Information Form, dated 9/2/24, indicated a resident had eloped out of the facility, on 9/2/24 at 8:07 a.m., and was returned to the facility by the staff at 8:40 a.m. The clinical record for Resident B was reviewed on 9/24/24 at 1:04 p.m. The diagnoses included, but were not limited to, congestive heart failure, vascular dementia, anxiety disorder, and peripheral vascular disease. The resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated she had a severe cognitive deficit. A facility investigative report indicated the resident left the facility at 8:07 a.m., and she was last seen by the staff at 8:00 a.m. She traveled south with her walker as her mobile assist on 14th street (facility was located on 14th street) crossed 3 blocks and was seen by Staff Member 2 on her way to work at 8:23 a.m. Staff Member 2 notified the facility staff of the resident elopement. The resident was returned to the facility at 8:40 a.m. The resident had traveled 0.2 miles. The resident had been missing from the facility for 20 minutes. A nursing note indicated the resident was assessed with no injuries. The family and physician were notified. The resident indicated she wanted to go for a walk. She did not notify staff, nor did she sign the resident Leave of Absence (LOA) log book. A wandering tool assessment for elopement, dated 7/6/24, indicated the resident was not a risk for wandering behaviors or exit seeking. During an interview, on 9/24/24 at 1:03 p.m., Resident B indicated she was not aware she had eloped from the facility, she indicated she had gone for a walk and the staff helped her come back to the facility. She was not aware she had to tell anyone she was leaving the facility. She was not aware she had to sign in and out to leave the facility. The resident was observed to be independent with mobility. During an interview, on 9/24/24 at 2:00 p.m., the Executive Director (ED) indicated there was an alarm on the doors of the facility which was alarmed at night at 6:00 p.m., and was turned off at 8:00 a.m. There was a secondary alarm at the nursing station which remained on until the receptionist on duty turned it off when she arrived. On 9/2/24, the receptionist arrived at 9:00 a.m. The secondary alarm sounded at 8:07 a.m., when the resident left the facility. Staff Member 3 turned off the secondary alarm and did not look to see if a resident was missing. Staff Member 3 was terminated for not following policy and procedure. Staff member 3 should have looked for who left the facility and searched for all residents to see if the residents were all in the facility. During an interview, on 9/24/24 at 3:59 p.m., Staff Member 2 indicated she saw Resident B walking down 14th street to the corner of Salem Street at 8:23 a.m. She traveled to the facility and notified staff of the resident's location. She then returned to find the resident at 8:27 a.m. She found the resident between Salem and Union Streets walking towards Union Street. She stayed with the resident until the nursing staff arrived to transport the resident to the facility During an interview, on 9/24/24 at 4:13 p.m., Staff Member 4 indicated she received a call at 8:25 a.m. regarding the resident's elopement. She saw the resident back in the facility at 8:40 a.m. During an interview, on 9/24/24 at 4:20 p.m., the Director of Nursing (DON) indicated the resident was observed leaving the building per video surveillance at 8:07 a.m., then the resident was seen by Staff Member 2 while she was on her way to work at 8:23 a.m. Staff Member 2 notified staff at the facility and returned to find the resident at 8:27 a.m. Staff Member 2 stayed with the resident until nursing staff arrived to transport the resident to the facility. The resident arrived back at the facility at 8:40 a.m. The resident was gone from the facility from 8:07 a.m. until 8:27 a.m. 20 minutes. During an interview, on 9/24/24 at 1:12 p.m., the DON indicated Resident B was not an elopement risk. The nursing staff should have investigated the alarm sounding when the resident left the faciity on [DATE]. During an interview, on 9/24/24 at 12:52 p.m., Staff Member 7 indicated she was aware of Resident B's elopement. She had been in-serviced on the alarm system and to look for residents if the alarm sounded. During an interview, on 9/24/24 at 12:56 p.m., Staff Member 8 indicated she was aware of Resident B's elopement. She had been in-serviced on the alarm system and to look for residents if the alarm sounded. During an interview, on 9/24/24 at 12:59 p.m., Staff Member 9 indicated he was aware of Resident B's elopement. He had been in-serviced on the alarm system and to look for residents if the alarm sounded. He was the staff member conducting the weekly checks on the door alarms A current policy, titled Family Resident Orientation Guide, dated as revised 10/2023 and provided by ED on 9/25/24 at 3:15 p. m., indicated .If a resident leaves the building, it is a requirement to sign out and sign in at the nurse's station and notify the resident's nurse before leaving and upon return. This will allow the staff to know the whereabouts of the resident The deficient practice was corrected by 9/20/24, after the facility implemented a systemic plan which included the following: Staff Member 3 was terminated, all staff members were in serviced and educated on the alarm system, the alarm system had an ongoing audit for the exit door and the receptionist's schedule had been changed to coordinate with the automatic alarm door system. This citation relates to Complaint IN00442388. 3.1-45(a)

Based on observation, interview and record review, the facility failed to ensure all areas of the wireless call system were functioning properly for 5 of 5 halls reviewed for the call system. (Hall A, B, C, D and E) Finding includes: During a resident council meeting, on 8/15/24 at 2:03 p.m., Resident 56 indicated the call light notifications would go to the staff phones. The residents could not tell if the call request had been received since there was no light which turned on. Sometimes during the night, it would take a long time for her roommate's call light to get answered. Resident 56 would then call the nurses desk and the staff would respond to the request for help. 44598 During an observation, on 8/16/24 at 11:18 a.m., Registered Nurse (RN) 2 indicated the call system was new and the old call lights in the hallway no longer worked. If a resident activated a call light, the staff would get notification on their phone. The phone would make a noise or vibrate. The call light was tested in room [ROOM NUMBER]. RN 2 pressed the resident's call light button. RN 2 then turned up the volume on her phone and the phone made a ding sound. During an observation, on 8/16/24 at 11:26 a.m., RN 3 indicated she used her own phone for the call lights. The phone was in her pocket and was turned off. RN 3 turned on her phone and turned up the volume. During an interview, on 8/15/24 at 2:40 p.m., the Director of Nursing (DON) indicated the facility installed a new call light system. The residents could not see or hear the call lights and thought the lights did not work. The facility provided the residents with bells to ring. During an interview, on 8/16/24 at 11:18 a.m., RN 2 indicated the nurses, Certified Nursing Assistants (CNA), and the management team carried phones. The only way they were notified of a call lights were by their own phones or the staff could get a facility phone at the front desk. RN 2 indicated the staff could also check on an iPad (electronic device) on each hall. RN 2 opened the iPad screen and did not know the password to access the call light system. During an interview, on 8/16/24 at 11:28 a.m., RN 4 indicated the CNAs answered the call lights and she did other things. During an interview, on 8/16/24 at 11:36 a.m., the DON indicated anyone could answer a call light. She did not know what staff took the phones from the desk. A current policy, titled Call Lights, dated as revised 6/2024 and received from the Director of Nursing on 8/19/24 at 9:59 a.m., indicated .All personnel, unless otherwise directed by the Administrator or designee, must always be vigilant and aware of call lights. The notify app will be downloaded to the device being utilized for alerts. This would include personal phones, facility phones, and iPads. The call light button or pad will be accessible to the resident while in their bed or other sleeping accommodations, and/or while sitting in a chair in the resident's room .Answer all call lights promptly, regardless of the resident assignment .At the beginning of the shift, staff will log in to the Notifync app on their device. Scroll to username. Enter 6-digit PIN. Set your zone located under profile or wheel symbol in right lower corner. Go to alerts or lightning symbol in left lower corner. When the resident activates the call light within their living area, the device being used will receive an alert and the room number will appear on the device. It will appear as a red alert. Note what area the alert is coming from i.e. bed A, bed B, bathroom then Hit the green take button on the device .In the event of system or power failure: Each resident will be provided with a bell to ring manually. For those residents unable to utilize a bell, frequent and periodic rounds will be conducted 3.1-19(u)

Based on observation, interview and record review, the facility failed to ensure a resident was seated at a table with the height adjusted to accommodate the resident's needs for 1 of 1 resident reviewed for accommodation of needs. (Resident 3) Finding includes: During an observation, on 8/13/24 at 12:10 p.m., Resident 3 was sitting at the end of a long table with other residents who required assistance to eat. She was resting her head on the table during the meal. During an observation, on 8/15/24 at 11:56 a.m., Resident 3 was sitting in the dining room at a long table with other residents who were being assisted with meals. The table was at the level of the resident's chin. She was feeding herself. Her head was leaning to the left and forward. She had a clothing protector on, and a CNA was sitting next to the resident. During an observation, on 8/16/24 at 11:44 a.m., the resident was sitting at the long dining room table with other residents who required assistance with meals. Her chin was at the level of the table. She was leaning forward and looking down. She was not interacting with others. The clinical record for Resident 3 was reviewed on 8/15/24 at 10:28 a.m. The diagnoses included, but were not limited to, mild cognitive impairment of uncertain or unknown etiology, bipolar disorder, mild depression, and adjustment disorder with anxiety. A physician's order, dated 7/16/24, indicated occupational therapy (OT) was to evaluate and treat as indicated. OT was to treat the resident for 25 visits in 8 weeks addressing activities of daily living (ADL) retraining, therapeutic activity, therapeutic exercises, and resident/caregiver education. An OT progress note, dated 8/1/24 to 8/13/24, indicated the resident was being seen for active range of motion (AROM) for neck, shoulder, elbow and hand joints to encourage upright sitting, and retraining safety awareness education. On 8/13/24, a note indicated the therapist consulted with the dining room staff and daughter to try a lower dining table. The resident was able to reach food at the time and would continue to monitor. During an interview, on 8/16/24 at 11:53 a.m., RN 6 indicated there was one adjustable table and pointed to the table in the middle, near the half wall, where a patient and another staff member were sitting. During an interview, on 8/16/24 at 12:05 p.m., the Director of Nursing (DON) indicated the resident had been sitting at a lower table before, but the resident was moved due to therapy wanting the resident to improve her posture. A review of the resident's therapy notes did not indicate to seat the resident at a dining table which came to the level of her chin. A current facility policy, titled Resident Rights and Responsibilities, dated as last reviewed 5/2022 and received from DON on 8/19/24 at 10:01 a.m., indicated .You have the right to be treated with respect and dignity, including the right to .reside and receive services in the facility with reasonable accommodations of your needs and preferences 3.1-3(v)(1)

Based on observation, interview and record review, the facility failed to ensure a resident's functional limitation in range of motion was included in the comprehensive care plan for 1 of 2 residents reviewed for mobility. (Resident 53) Finding includes: During an observation, on 8/13/24 at 2:01 p.m., Resident 53 had contractures of the fingers on both hands. The clinical record for Resident 53 was reviewed on 8/15/24 at 12:15 p.m. The diagnoses included, but were not limited to, myoclonus (sudden, involuntary muscle jerks, shakes or spasm), polyosteoarthritis (arthritis affecting five or more joints at once), and right shoulder pain. An occupational therapy (OT) service note, dated 4/17/24, indicated both resident's hands had minimum to moderate arthritis deformities but were functional with maximum difficulty. A Minimum Data Set (MDS) assessment, dated 4/23/24, indicated the resident had a functional limitation in range of motion of her upper extremities which could include, the shoulders, elbows, wrists and hands. A care plan, initiated 4/16/24, indicated the resident had polyosteoarthritis. The care plan did not include the parts of the body affected by arthritis. During an interview, on 8/19/24 at 3:08 p.m., the Assistant Director of Nursing (ADON) indicated the occupational therapist note showed the resident had arthritic changes in her hands. A current policy, titled Care plan, Comprehensive, dated as last reviewed on 7/2021 and received from the Administrator on 8/20/24 at 11:47 a.m., indicated .The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS .Each resident's comprehensive care plan is designed to describe .Identified problem areas .Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change .The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans .After each assessment, including both the comprehensive and quarterly review assessments . 3.1-35(a)

Based on observation, interview and record review, the facility failed to ensure a resident's bruising was documented as being assessed and monitored and to ensure out of range glucometer readings were reported to the physician as ordered for 3 of 3 residents reviewed for quality of care. (Resident 124, 15 and 12) Findings include: 1. During an observation, on 8/13/24 at 1:43 p.m., Resident 124 had purple bruising on the left side of her face on her cheek. The bruising was the size of two 50 cent pieces put together. The clinical record for Resident 124 was reviewed on 8/13/24 at 1:43 p.m. The diagnoses included, but were not limited to, vascular dementia with other behavioral disturbance, severe major depressive disorder with psychotic symptoms, generalized anxiety disorder, and chronic obstructive pulmonary disease. A care plan, dated 7/18/24, indicated the resident had a potential for impaired skin integrity due to her poor physical condition, limited mobility, dementia, and incontinence. The goal included the resident would be free of injury. The interventions included, but were not limited to, provide skin hygiene every shift and report skin concerns to the nurse and physician. A progress note, dated 7/21/24 at 7:10 p.m., indicated the nurse was notified the resident was observed on the floor. The resident was sitting on the floor next to the bed. The resident stated she had rolled over. The resident had a hematoma and bruising to the left forehead and no other injuries were noted. The progress note did not include bruising to the left side of the resident's cheek. A progress note, dated 7/24/24, indicated the resident was noted to be sitting upright in front of the closet door to her room with her knees drawn up and her arms wrapped around them. The resident had bloody drainage from the left side of her head above the ear. There was a small laceration 1.2 centimeters long, 0.1 centimeters in depth, and 0.2 centimeters in width. A physician's order, dated 7/24/24, indicated to monitor a left forehead hematoma each shift for signs of infection. An interdisciplinary team (IDT) progress note, dated 7/25/24, indicated the resident was reviewed in the safety committee. The resident declined an interview to gather more information about the fall. The fall appeared to have happened while the resident was attempting to get in the closet. The IDT note did not include any information about the bruising on the resident's face. A Fall QS (every shift) documentation, dated 7/28/24, indicated the resident's hematoma was starting to resolve and bruising was noted down the side of the resident's face from the hematoma. The documentation did not include where the hematoma was located or the size of the bruising. A skin assessment, dated 7/31/24, indicated the resident's forehead hematoma had resolved. The resident had bruising on the left side of her cheek. The skin assessment did not include any measurements of the bruising or how much of the cheek was bruised. An occupational therapy daily note, dated 8/1/24, indicated the resident had a bruised left forehead and face. The therapy note did not include the size of the bruising or measurements of the area. A skin assessment, dated 8/16/24, indicated the resident had a left cheek bruise 3.3 centimeters in length and 4 centimeters in width. The area was dark purple in the center and the surrounding area had reddish hues on the edges. The skin assessment did not include how the bruising to the left side of the cheek occurred or the date the bruising was first located. During an interview, on 8/19/24 at 3:10 p.m., the Assistant Director of Nursing (ADON) indicated the resident had a fall on 7/21/24 and had bruising to the left forehead. The resident fell on [DATE] and had an abrasion to her ear. The resident was also on Xarelto (a blood thinner) and prednisone (for inflammation) during the time of the falls. Her healing was delayed due to the medications. The documentation did not show the bruising was being followed. 44598 2. The clinical record for Resident 12 was reviewed on 8/15/24 at 9:56 a.m. The diagnoses included, but were not limited to, diabetes mellitus, respiratory failure, chronic pulmonary edema, cognitive communication deficit, major depressive disorder, anxiety disorder, end stage renal disease, and hypertension. A physician's order, dated 8/3/24, indicated to obtain an Accu check (test used to estimate blood sugar levels) before meals and at bedtime. Call the physician if the blood sugar level was less than 60 or greater than 490. A Medication Administration Record (MAR), dated August 2024, indicated the following: a. On 8/3/24 at 8:00 p.m., the blood glucose level was 56. b. On 8/5/24 at 6:00 a.m., the blood glucose level was 51. c. On 8/5/24 at 4:00 p.m., the blood glucose level was 53. d. On 8/5/24 at 8:00 p.m., the blood glucose level was 51. e. On 8/7/24 at 4:00 p.m., the blood glucose level was 52. f. On 8/9/24 at 6:00 a.m., the blood glucose level was 56. g. On 8/11/24 at 6:00 a.m., the blood glucose level was 49. A care plan, dated 6/17/24 and last revised 8/12/24, indicated the resident had diabetes mellitus (DM). The interventions included, but were not limited to, monitor blood sugars and to notify the physician of results as ordered. There was no documentation, from 8/1/24 to 8/17/24, to indicate the physician was notified of the blood glucose levels less than 60. During an interview, on 8/15/24 at 2:37, the DON indicated it was her expectation the staff would follow the physician's order. When the blood glucose fell within the call range, the physician should be notified. The nurses should follow the physician's order. 3. The clinical record for Resident 15 was reviewed on 8/15/24 at 9:52 a.m. The diagnoses included, but were not limited to, diabetes mellitus, dementia, anxiety disorder, and cognitive communication deficit. A care plan, dated as revised 7/3/24, indicated the resident had diabetes mellitus (DM). The interventions included, but were not limited to, monitor blood sugars and to notify the physician of results as ordered and to monitor for hyperglycemia (high blood glucose level). A physician's order, dated 8/13/24, indicated to get an Accu-check before meals and at bedtime. Notify the physician for a blood sugar less than 60 or greater than 400. A Medication Administration Record (MAR), dated August 2024, indicated the following: a. On 8/7/24 at 6:00 p.m., the blood glucose level was 452. b. On 8/14/24 at 6:00 p.m., the blood glucose level was 454. There was no documentation, from 8/1/24 to 8/17/24, to indicate the physician was notified of the blood glucose levels out of range. During an interview, on 8/15/24 at 4:11 p.m., the DON indicated there was no documentation the physician was notified of the high blood glucose levels. 50956 A current policy, titled Physician Notification, Change in Condition, dated as last reviewed on 8/2021 and received from the DON on 8/15/24 at 4:00 p.m., indicated .To ensure that significant changes in resident status are based on the assessments which are to be documented in the medical record and medical care problems are communicated to the attending physician in a timely, thorough manner .When contacting physicians, the nurse should attempt to have the following information available .change in vital signs outside physician ordered parameters, general guidelines or normal parameters for the resident .Blood sugar >300 or <60 . Laboratory values .Any of the following abnormal reports unless otherwise directed by physician .Any of the following abnormal reports unless otherwise directed by physician .Glucose >300 or <60 in a diabetic on oral hypoglycemic medication, insulin or <60 for any resident (diabetic or non-diabetic) A current policy, titled Skin Condition Assessment, dated as last reviewed on 10/2022 and received from the DON on 8/19/24 at 3:15 p.m., indicated .Each resident will be observed for skin concerns daily during care and on the assigned bath day by nursing staff. Any concerns will be reported to the charge nurse who will assess the area and document accordingly .Skin observations that should be reported include .bruises . A separate skin report will be completed for each identified skin problem area .Previous measurements will be reviewed . 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure a staff member followed the policy and procedure when verifying the gastrostomy tube (g-tube) placement prior to medication administration for 1 of 1 resident reviewed for a gastrostomy tube. (Resident 9) Finding includes: During a medication administration observation, on 8/16/24 at 1:50 p.m., Registered Nurse (RN) 4 placed 60 milliliters (ml) of water into a piston and attached it to the resident's g-tube. RN 4 then pushed the 60 ml of water into the tube and pulled back on the syringe. She then indicated there was no tube feeding (residual). During an interview, on 8/19/24 at 12:45 p.m., RN 4 indicated she pushed the water into the g-tube first and then pulled back on the syringe. This was how she checked for the residual and did not know what the facility policy indicated. A current policy, titled Enteral Tube Medication Administration, not dated and received from the Director of Nursing on 8/16/24 at 2:21 p.m., indicated .With gloves on, check for proper tube placement by checking stomach contents (residual). Never check placement with water. Check gastric content for residual feeding. Return residual volumes to the stomach. Report any residual above 100ml 3.1-44(a)(1)

Based on interview and record review, the facility failed to accurately code a resident's discharge location on the Discharge Return not Anticipated MDS (Minimum Data Set) assessment for 1 of 6 residents reviewed for hospitalization (Resident 72). Finding includes: The record for Resident 72 was reviewed on 03/09/20 at 10:55 a.m. [DIAGNOSES REDACTED]. A progress note, dated 01/29/2020 at 10:00 a.m., indicated the resident was being discharged to an assisted living facility. The discharge instructions, dated 01/24/2020, indicated the resident was going to receive at home therapy services. The MDS Discharge Return not Anticipated assessment, dated 01/29/2020, indicated the resident was being discharged to an acute hospital. During an interview, on 03/09/20 at 11:10 a.m., the MDS Coordinator indicated the MDS assessment indicated the resident discharged to the hospital and it was not coded correctly. It should have indicated she went home and not to the hospital. During an interview, on 03/09/20 at 11:16 a.m., the MDS Coordinator indicated the facility followed the RAI (Resident Assessment Instrument) manual for all assessments. 3.1-31(d)

Based on interview and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASARR) Level II as directed by the PASARR Level I for 1 of 1 resident reviewed for PASARR (Resident 8). Finding includes: The record for Resident 8 was reviewed on 3/5/2020 at 3:49 p.m. [DIAGNOSES REDACTED]. A PASARR Level I, dated 4/8/19, indicated the resident had the mental health [DIAGNOSES REDACTED]. The Level I outcome was to refer for a PASARR Level II onsite. The PASARR Level II was to be completed as an onsite face to face evaluation. During an interview, on 3/5/2020 at 3:00 p.m., the Medical Records Coordinator indicated she did not tell the Social Services Director the resident needed to be referred for a PASARR Level II and it did not get completed. A current policy, titled Preadmission Screening and Resident Review (PASRR}, dated as revised 2/18/2020 and received from the Medical Records Coordinator on 3/5/2020 at 3:08 p.m., indicated, .The facility must coordinate assessments with the preadmission screening and resident review (PASRR) program under Medicaid to the maximum extent possible to avoid duplicative testing and effort. A PASRR Level I Mental Screening is required for all admissions .The Level I and II screening forms are placed in the resident's current medical record .The facility will follow the instructions outlined in the Indiana PASRR Level I &Level of Care Screening Procedures for Long Term Care Services Provider Manual for the completion of the PASARR review process 3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

Based on observation, interview and record review, the facility failed to ensure medications were appropriately labeled and stored in 1 of 4 medication carts observed for medication storage (D Hall Cart). Finding includes: During an observation, with LPN 2 on 03/06/20 at 9:16 a.m., the D Hall cart had an unlabeled, open medication cup with 10 pills. The cup was found in the top drawer of the medication cart. LPN 2 indicated she had pulled the medications for Resident 71 earlier, but the resident had gone to the dining hall. She realized she should have labeled the cup with a name and saved the pill wrappers. During an interview, on 03/06/20 at 9:18 a.m., LPN 2 indicated she should have labeled the medication cup with the resident's name, date and time and initialed. She should not have left the medications unlabeled in the medication cart. During an interview, on 03/06/20 at 9:29 a.m., the Assistant Director of Nursing (ADON) indicated the nurse should have covered the medication cup and labeled the cup with the resident's name. It should not be a common practice to leave unlabeled medications in the medication cart. A facility policy, titled Medication Storage in the Facility, dated 7/31/17, provided by the ADON, on 03/06/20 at 9:30 a.m., indicated .Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier .A. The provider pharmacy dispenses medications in containers that meet regulatory requirements, including standards set forth by the United States Pharmocopeia (USP). Medications are kept in these containers 3.1-25(k)(1)

Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) assessment related to a level 2 Preadmission Screening and Resident Review (PASARR) for 2 of 21 residents reviewed for MDS accuracy (Resident 12 and 64). Findings include: 1. The record for Resident 12 was reviewed on 02/12/19 at 1:54 p.m. [DIAGNOSES REDACTED]. An annual MDS assessment, dated 12/03/18, did not indicate the resident had a mental illness which required a PASARR level 2. During an interview, on 02/12/19 at 3:33 p.m., the MDS coordinator indicated Resident 12 should have been marked as having a mental illness which required a PASARR level 2, the facility did not have a MDS policy and followed the RAI manual. 2. The record for Resident 64 was reviewed on 02/15/19 at 8:38 a.m. [DIAGNOSES REDACTED]. An annual MDS assessment, dated 12/03/18, did not indicate the resident had a mental illness which required a PASARR level 2. During an interview, on 02/15/19 at 9:51 a.m., the Director of Nursing indicated Resident 64's MDS assessment was incorrect and should reflect she had a mental illness. 3.1-31(c)(7)

Based on observation, interview and record review, the facility failed to revise the comprehensive care plans related to the refusal to wear a physician's orders [REDACTED]. Findings include: 1. During an observation, on 02/12/19 at 2:35 p.m., Resident 18 was not wearing a torso brace. During an observation, on 02/13/19 at 9:39 a.m., Resident 18 was not wearing a torso brace. During an observation, on 02/13/19 at 11:02 a.m., Resident 18 was not wearing a torso brace. During an observation, on 02/14/19 at 9:33 a.m., Resident 18 was not wearing a torso brace. During an observation, on 02/14/19 at 1:18 p.m., Resident 18 was not wearing a torso brace. During an observation, on 02/14/19 at 3:16 p.m., Resident 18 was not wearing a torso brace. The record for Resident 18 was reviewed on 02/13/19 at 8:30 a.m., [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A care plan, addressed the problem the resident had an Activity of Daily Living (ADL) deficit with a [DIAGNOSES REDACTED]. Interventions included, but were not limited to, the torso brace should be removed for showers and skin checks only and to ensure the torso brace was in place immediately following the shower, she required an extensive assist at all times of 1 staff member for transfers and to ensure the torso brace was in place at all times. A care plan, addressed the problem the resident had the potential for skin breakdown. Interventions included but were not limited to, a brace to the torso at all times, remove only for showers and skin checks every shift, report any skin concerns to the nurse immediately and do not transfer/ambulate the resident without the torso brace in place. During an interview, on 02/14/19 at 11:23 a.m., the Director of Nursing (DON) indicated the resident refused to wear the torso brace and her care plans should have been updated to reflect the refusals. 2. During an interview on 02/14/19 at 10:36 a.m., LPN 1 indicated Resident 6 was being monitored for hallucinations and delusions. The record for Resident 6 was reviewed on 02/11/19 at 3:21 p.m. [DIAGNOSES REDACTED]. A care plan which addressed the resident's history of hallucinations and delusions was not located. During an interview on 02/15/19 at 10:41 a.m., the Director of Nursing indicated the resident was monitored for hallucinations and delusions because she had a history of [REDACTED]. A current facility policy, titled Care Plans, Comprehensive, dated as revised on 09/18/18, received from the DON on 02/15/19 at 9:51 a.m., indicated .Assessment of residents are ongoing and care plans are revised as information about the resident and the resident's condition change 3.1-35(d)(2)(B)

Based on interview and record review, the facility failed to ensure a resident with an unwitnessed fall received an appropriate neurological evaluation for 1 of 3 resident's reviewed for falls (Resident 9). Finding includes: The record for Resident 9 was reviewed on 02/14/19 at 01:02 PM. [DIAGNOSES REDACTED]. A care plan, dated 08/17/18 and last revised on 12/20/18, addressed the resident was a high risk for falls. Interventions included, but were not limited to, falling star status and one-on-one care at nights. A facility document titled Un-witnessed, dated 09/19/18, indicated the resident had an unwitnessed fall. A document titled Neurological Evaluation Flow Street (neuro-check), dated 09/19/18, indicated the resident had not been assessed for upper and lower extremities motor response as part of the Glasgow Coma Scale (a neurological series of tests used to determine the consciousness level). During an interview on 02/15/19 at 2:05 p.m., the Director of Nursing (DON) indicated residents are monitored with the Neurological Evaluation Flow Sheet for 72 hours after an unwitnessed fall and the assessment should be completed fully, which included extremity motor response because it could help indicate if the resident suffered a head injury. A current facility procedure, titled Neurological Assessment, not dated, received from the DON on 02/15/19 at 3:16 p.m., indicated the purpose of the assessment is to .recognize neurological trends and change in resident's condition by use of a standardized tool when evaluating the resident's neurological status .A change in the level of consciousness constitutes the most significant or earliest sign of neurological deterioration and must be assessed whenever neuro-checks are conducted A current facility policy, titled Post Fall Assessment, dated 06/28/18, received from the DON on 02/15/19 at 2:46 p.m., indicated .Nursing staff will be observed for delayed complications of a fall after a fall has occurred or a suspected fall. Findings will be documented in the medical record 3.1-45(a)(1)

Based on interview and record review, the facility failed to document non pharmacological interventions for pain relief and failed to accurately assess for pain medication effectiveness for 1 of 1 residents reviewed for pain (Resident 224). Finding includes: During an interview, on 2/11/19 at 10:55 a.m., Resident 224 indicated the pain medication did not ease the pain sometimes and the staff would give her an ice pack until she was due for the next pain medication. The resident did not know if the doctor had been contacted about her pain not being relieved by the pain medication. The record was reviewed on 2/12/19 at 1:13 p.m. [DIAGNOSES REDACTED]. A care plan, dated 2/14/19, indicated the resident had pain related to the fibula fracture, [MEDICAL CONDITION] and chronic low back pain. The interventions included, but were not limited to, attempt non pharmacological interventions prior to the administration of the as needed [MEDICATION NAME], monitor and record the resident's complaints of pain, notify the physician if the interventions are not successful and provide the resident with information about pain and the options for pain management. A physician's orders [REDACTED]. The Medication Administration Record, [REDACTED]. The Medication Administration Record, [REDACTED]. The Medication Administration Record, [REDACTED]. The resident rated the pain level at 3 on a scale of 0-10. A progress note, dated 2/11/19 at 6:31 p.m. indicated the as needed pain medication was effective and the resident's pain level was 3. There was only a 4 minute time span between the pain medication administration and the documentation of the pain medication effectiveness. There was no further documentation on the effectiveness of the pain medication administered at 6:27 p.m. During an interview, on 2/15/19 at 1:42 p.m., the Director of Nursing (DON) indicated there were not any non pharmacological interventions documented for the resident prior to the pain medication administration on 2/5/19 at 4:48 p.m. and on 2/5/19 at 10:49 p.m. and the interventions should have been included. A current policy, titled. Pain Management dated 6/28/19 and received from the DON on 2/15/19 at 2:22 p.m., indicated, .To ensure all residents throughout the facility have effective pain management programs/strategies in place to ensue pain does not affect their quality of life to the fullest extent possible while a resident is in the facility .To assess a resident's pain, a scale of 0-10 will be utilized with 0 being no pain and 10 being extreme/severe pain .Non-pharmacological interventions should also be attempted prior to and in conjunction with pharmacological approaches .After administration of pain medication, the licensed nurse will reassess the resident to determine if the medication was effective in treating the resident's pain 3.1-37(a)

Based on interview and record review, the facility failed to communicate with the [MEDICAL TREATMENT] center for the current diet orders for a resident who received [MEDICAL TREATMENT] for 1 of 1 residents reviewed for [MEDICAL TREATMENT] (Resident 225). Finding includes: The record for Resident 225 was reviewed on 2/12/19 at 10:59 a.m. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A Registered Dietician (RD) note, dated 2/13/19 indicated the recommendations for the resident's diet were a modified diet, regular texture, regular consistency and potassium restriction with no bananas, oranges, orange juice, non-boiled potatoes/sweet potatoes, melon, soup beans, tomatoes or tomato juice, prunes of prunes juice and no added salt. During an interview, on 2/14/19 at 2:39 p.m., the Registered Dietician (RD) indicated she had not talked to the [MEDICAL TREATMENT] dietician yet. The RD indicated on the previous day she had recommended a renal diet for the resident which would exclude potatoes and orange juice. During an interview, on 2/14/19 at 2:56 p.m., the Director of Nursing (DON) indicated the facility used the diet order from the hospital and did not call the [MEDICAL TREATMENT] clinic for diet recommendations. An RD note, dated 2/15/19, indicated the facility RD spoke with the [MEDICAL TREATMENT] dietician and the [MEDICAL TREATMENT] dietician recommended double portions of meat at meals and the supplement of Nepro (a supplement to meet the nutritional needs of people on [MEDICAL TREATMENT]) once daily. The [MEDICAL TREATMENT] dietician indicated a renal diet was not needed. The facility had not communicated with the [MEDICAL TREATMENT] dietician prior to 2/15/19. A Nursing Facility [MEDICAL TREATMENT] Agreement, dated 2/26/18, indicated . Nursing Facility retains primary responsibility for the development and implementation of each resident's care .Coordination of care may include the following .Information exchange between the parties The facility did not provide a [MEDICAL TREATMENT] policy. 3.1-37(a)

Based on interview and record review, the facility failed to ensure a resident was monitored for the appropriate behaviors related to the use of an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications (Resident 31). Finding includes: The record for Resident 31 was reviewed on 02/12/19 at 10:54 a.m. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A Behavior/Intervention Monthly Flow Record, dated 02/2019, indicated the resident was being monitored for being a threat to herself, for the use of [MEDICATION NAME]. Behavior monitoring for restlessness and agitation was not located in the resident record. During a review of the progress notes, the following behavior notes were located: a. A behavior note, dated 04/09/18 at 2:18 p.m., indicated the resident was watching television before she started hallucinating and became agitated when others did not see the people she was seeing. b. A behavior note, dated 10/26/18 at 1:29 p.m., indicated the resident was angry, wanted an onion from the kitchen, was refusing care and refusing to go to bed. A care plan, addressed the problem the resident received an antipsychotic medication for the [DIAGNOSES REDACTED]. Interventions included, but were not limited to, monitor and record target behavior symptoms and document per facility protocol. A care plan, addressed the problem the resident was at risk for falls and had a history of [REDACTED]. During an interview, on 02/15/19 at 1:40 p.m., the Director of Nursing (DON) indicated the resident should have been monitor for restlessness and agitation and not for being a threat to herself. She received the medication once a day between 11:00 a.m. and 2:00 p.m. A current facility policy, titled Behavior/Intervention Monthly Flow Record Protocol, dated as revised on 06/28/18 and received from the DON on 02/15/19 at 2:19 p.m., indicated .Resident's on [MEDICAL CONDITION] medications must be monitored daily for behaviors .The flow record indicates the behavior that should be monitored based on the [MEDICAL CONDITION] medication they are on .The flow records will be updated with resident-specific behaviors 3.1-48(a)(3)

Based on interview and record review, the facility failed to follow through with dental services for 1 of 1 resident reviewed for dental services (Resident 8). Finding includes: During an interview, on 02/11/19 at 9:09 a.m., Resident 8 indicated she had some broken and missing teeth, was supposed to have received a partial or dentures and she had not. The record for Resident 8 was reviewed on 02/14/19 at 10:59 a.m. [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) assessment, dated 11/14/18, indicated the resident had no concerns with her teeth. A care plan, addressed the problem the resident was at risk for alteration in nutritional status related to having her own teeth and several were missing and on 08/13/18 her right upper teeth were pulled. Interventions included, but were not limited to, offer dental consults as requested. During an interview, on 02/14/19 at 3:05 p.m., the Director of Nursing (DON) indicated on 08/13/18 the resident had her top teeth extracted and would have to look into what had happened next. During an interview, on 02/14/19 at 3:33 p.m., the Assistant Director of Nursing (ADON) indicated the oral surgeon note did not indicate the next step after the extractions. She could not locate documentation related to discussions about the next step with the oral surgeon, resident or the resident's representative in the resident's record. A current facility policy, titled Dental Services, dated as revised on 10/05/18 and received from the DON on 02/15/19 at 9:51 a.m., indicated .All dental services provided are recorded in the resident's medical record. The Social Service department will review the services and or recommendation of the dentist. Once reviewed by Social Service staff, the Unit Coordinator will receive a copy of the recommendation, if any, to ensure the recommendation is addressed. The Unit Coordinator will make an entry in the resident's medical record with the follow-up of the recommendation 3.1-24(a)(1)

Based on observation and interview, the facility failed to ensure sharp plastic guards were secured to the corners of the half walls at the nursing station. This deficient practice had the potential to effect 31 of 79 residents who reside in the facility. Finding includes: During initial tour on 02/10/19 at 11:45 a.m., three of the twelve dark brown plastic corner edge covers were broken, protruding away from the way and tearing away from the corner. During an interview on 02/10/19 at 11:51 a.m., the Director of Plant Operations (DOP) indicated the facility had been replacing some of the corners every year and painting them. She was unaware of the broken and protruding three corners. She indicated now that she was aware of them, they would be replaced. During an interview on 02/15/19 at 2:01 p.m., the DOP indicated anyone can complete a maintenance requisition, or if it is urgent, she can be notified by phone. During an interview on 02/15/19 at 2:03 p.m., the Director of Nursing indicated the facility did not have a policy for maintenance of the facility, just a preventive maintenance check list. 3.1-19(a)(4)

Based on observation, record review and interview, the facility failed to ensure a resident with [MEDICAL CONDITION] was monitored and physician response timely to prevent the resident from being hospitalized with generalized body [MEDICAL CONDITION] for 1 of 3 residents reviewed for quality of care. (Resident 80), and failed to ensure daily weights were completed and monitoring for complication of [MEDICAL CONDITIONS] and bilateral [MEDICAL CONDITION] embolisms (PE) for 2 of 3 resident reviewed for disease management. (Residents 84 and 67) Findings includes: 1. On 02/23/18 at 2:05 p.m., Resident 80 was observed to have [MEDICAL CONDITION] in his legs and feet. The record for Resident 80 was reviewed on 03/01/18 at 11:13 a.m. [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. An intervention for a care plan which addressed [MEDICAL CONDITION], initiated on 2/12/18, was to weigh the resident daily. The following weights were documented in the electronic medical record: 1. On 02/12/18, the resident's documented weight was 181 lbs 2. On 02/13/18, the resident's documented weight was 181 lbs. 3. On 02/15/18, the resident's documented weight was 187 lbs (a 6 lb weight gain). 4. On 02/17/18, the resident's documented weight was 196 lbs (a 9 lb weight gain). 5. On 02/18/18, the resident's documented weight was 193 lbs. 6. On 02/19/18, the resident's documented weight was 195 lbs. 7. On 02/20/18, the resident's documented weight was 198 lbs. 8. On 02/27/18, the resident's documented weight was 204 lbs (a 6 lb weight gain). There were no other weights provided for Resident 80 for 2/14 and 2/16. A document titled MD (medical doctor) Weight Notification, not dated, faxed on 02/15/18 at 5:10 p.m., indicated the doctor was notified of a 13.2 lb weight gain from 2/5-2/13 and an additional 6.8 lbs from 2/13-2/15. As well as, .4+ [MEDICAL CONDITION] to BLE (bilateral lower extremities) going up into thighs, per UC (unit coordinator) res (resident) started gaining weight when Foley catheter discontinued A Communication-with Physician note, dated 02/19/18 at 3:43 p.m. indicated, Resident 80 was started on 60 milligrams (mg) of [MEDICATION NAME] (diuretic) on Friday 02/16/18 and has continued to retain fluid with .4+ [MEDICAL CONDITION] on BLE (bilateral lower extremities) and abdomen, Bilat (bilateral) upper extremities, I/O (in and out) cath (catheterization) qid (three times a day)/ low output on each catheterization. No sob (shortness of breath) and (sic) lung sounds are diminished no adventitious sounds Please advise immediately A faxed response from the doctor, dated 02/19/18 at 5:06 p.m., indicated the resident had a doctor's appointment the next day. A document titled MD (medical doctor) Weight Notification, dated 02/23/18, indicated the resident had an additional weight gain of 10.2 pounds in one week from 187.4 to 197.6 pounds and he was .[MEDICAL CONDITION] in arms, legs, et (and) scrotum (without) difficulties breathing The physician response faxed on the same form, dated 02/23/18, indicated .Noted. Did Dr. (name of doctor) adjust [MEDICATION NAME] (diuretic) dose .? There was no response documented to address the question from the primary physician. A Health Status Note, dated 02/27/18, indicated .Nurse called to report (name of hospital) is admitting him with anasarca (generalized [MEDICAL CONDITION] all over the body) During an interview, on 03/01/18 at 1:07 p.m., the DON indicated the resident should have been weighed daily once the physician ordered a daily weight. During an interview, on 03/01/18 at 02:32 p.m., the Quality Assurance nurse indicated the first notification of the weight gain was on 2/15 and there was no follow-up to the physician's question on 02/23. During review of the Daily Medicare Skilled Charting documentation with the Director of Nursing (DON) on 03/01/18 at 2:40 p.m., she indicated the only time [MEDICAL CONDITION] was noted on the daily assessments was on 02/18 and 02/19, the rest of the daily charting showed no [MEDICAL CONDITION] and the staff should have marked the resident had [MEDICAL CONDITION]. 2. The record for Resident 84 was reviewed on 02/27/18 at 09:15 AM. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. An intervention for a care plan which addressed complications for diabetes, revised on 10/24/17, indicated the resident was a daily weight. A review of the Weights and Vitals Summary indicated weights were not completed on 12/02/17, 12/01/17, 11/24/17, 11/23/17, 11/21/17, 11/11/17, 11/07/17, 11/02/17, 11/01/17, 10/31/17, 10/30/17 or 10/29/17. During an interview, on 02/28/18 at 2:46 p.m., the Director of Nursing indicated no additional weights were found for the resident and she should have been weighed daily. A current facility policy, titled GUIDELINES FOR PHYSICIAN NOTIFICATION FOR CHANGE IN CONDITION, dated 11/2010, received from the Director of Nursing on 2/26/2018 at 1:00 p.m., indicated .The nurse should not hesitate to contact the attending physician at any time for a problem which in his or her judgment requires immediate assessment .NON-IMMEDIATE NOTIFICATION (SUBACUTE) PROBLEMS .The physician should be informed of the following problems or event during normal business hours .l. Significant weight change .NURSING D[NAME]UMENTATION .1. Documentation will address the following (not all inclusive): a. Communication between facility and physician A current facility policy, titled Weighing Residents, dated 11/11, received from the Corporate Compliance Nurse on 03/01/18 at 2:20 p.m., indicated .1. Upon (re)admission obtain an admission weight; 48 hours later obtain another weight. A 3rd weight in 48 hours to determine if variance is a procedural variation of inadequate nutritional intake .2. Re-weights will be obtained if there is a variance of 2.5% (percent) or more between weights in a one (1) week period 3. During an interview, on 2/22/18 at 2:37 p.m., Resident 67 indicated she received [MEDICAL CONDITION] and it caused her to have diarrhea. The record for Resident 67 was reviewed on 2/26/18 at 9:34 a.m. [DIAGNOSES REDACTED]. An oncology visit note, dated 12/8/17, indicated the resident was on apixaban (an anticoagulant) for the [MEDICAL CONDITION] and PE. An oncology center note, dated 1/16/18, indicated a CT (computerized tomography scan) of the chest completed on 11/19/17 showed the resident had bilateral large [MEDICAL CONDITION] emboli within the right and left [MEDICAL CONDITION] arteries. A lower extremity venous doppler (an ultrasound to show if there is blockage in a leg vein) completed on 11/19/17, indicated the resident had acute [MEDICAL CONDITION] in the left femoral vein, left popliteal vein and deep left calf veins. The [DIAGNOSES REDACTED]. The record did not include the use of [MEDICAL CONDITION], signs and symptoms to monitor or the interventions for the staff to provide regarding [MEDICAL CONDITION] administration. The record did not include the [DIAGNOSES REDACTED]. A physician order, dated 2/6/18 indicated apixaban 5 mg (milligram) two times a day for [MEDICAL CONDITION]. A physician order, dated 12/12/17 through 1/23/18, indicated apixaban 5 mg two times a day related to [MEDICAL CONDITION]. During an interview, on 2/26/18 at 2:05 p.m., the Director of Nursing (DON) indicated the facility was not aware of the resident's [DIAGNOSES REDACTED]. She indicated the resident's current physician was new to the resident when she was admitted to the facility. She also indicated there was no care plan in place for the [MEDICAL CONDITION] or the side effects to monitor. 3.1-37(a)

BASED ON OBSERVATION, RECORD REVIEW, AND INTERVIEW, THE FACILITY FAILED TO ENSURE INTERVENTIONS FOR PRESSURE ULCER PREVENTION WERE COMPLETED WHICH RESULTED IN THE FORMATION OF ONE UNSTAGEABLE AND ONE STAGE II PRESSURE ULCER. THIS DEFICIENT PRACTICE AFFECTED 1 OF 6 RESIDENTS WITH PRESSURE ULCERS IN A SAMPLE OF 20 RESIDENTS REVIEWED FOR PRESSURE ULCER PREVENTION. (RESIDENT #11) FINDINGS INCLUDE: DURING AN OBSERVATION ON 10/5/10 AT 10:48 P.M., WITH THE DIRECTOR OF NURSING (DON), THE UNIT COORDINATOR, AND THE PHYSICAL THERAPIST RESIDENT #11'S LEFT WRIST AND ELBOW WERE OBSERVED. THE PHYSICAL THERAPIST MEASURED RESIDENT #11'S PRESSURE ULCERS AS THE FOLLOWING: LEFT WRIST 0.3 CM (CENTIMETER) X 0.3 CM X < (LESS THAN) 0.1 CM STAGE II PRESSURE ULCER (PARTIAL THICKNESS LOSS OF DERMIS PRESENTING AS A SHALLOW OPEN ULCER WITH A RED PINK ULCER BED, WITHOUT SLOUGH (NECROTIC OR AVASCULAR TISSUE IN THE PROCESS OF SEPARATING FROM VIABLE TISSUE. USUALLY SOFT, MOIST AND LIGHT IN COLOR; MAY BE STRINGY) PRESENTS AS A SHINY OR DRY SHALLOW ULCER WITHOUT SLOUGH OR BRUISING) DRY WITH A PALE WHITE PERIWOUND. LEFT ELBOW 1.0 CM X 0.8 CM X < 0.1 CM UNSTAGEABLE PRESSURE ULCER (FULL THICKNESS TISSUE LOSS IN WHICH THE BASE OF THE ULCER IS COVERED BY SLOUGH (YELLOW, TAN, GRAY, GREEN, OR BROWN) AND/OR ESCHAR (TAN, BROWN, OR BLACK) IN THE ULCER BED) DUE TO THE SLOUGH, MOIST WOUND BED WITH 50% SLOUGH IN THE CENTER AND 50% GRANULATION SURROUNDING. PINK PERIWOUND WITH BLANCHING. RESIDENT #11'S RECORD WAS REVIEWED ON 10/4/10 AT 3:20 P.M. RESIDENT #11'S [DIAGNOSES REDACTED]. A QUARTERLY MINIMUM DATA SET assessment dated [DATE] INDICATED THE RESIDENT HAD NO MEMORY IMPAIRMENT, WAS INDEPENDENT IN DECISION MAKING SKILLS, AND REQUIRED EXTENSIVE ASSIST OF ONE STAFF MEMBER FOR PERSONAL HYGIENE AND DRESSING. AN INCIDENT REPORT DATED 8/13/10 INDICATED THE RESIDENT fell IN HIS ROOM. THE INCIDENT REPORT FURTHER INDICATED "...TYPE OF INJURY...ON 8/17/10, RESIDENT TRANSPORTED (NAME OF HOSPITAL) FOR X-RAY DUE TO SWELLING, BURNING AND PAIN IN LEFT ELBOW. X-RAY REPORT REVEALED...AT LEAST 2 FRACTURES: FRACTURE FRAGMENT LIES ANTERIOR TO THE ULNAR OLECRANON...AND NON-DISPLACED FRACTURE OF HUMERAL CAPITELLUM...." A PHYSICIAN ORDER [REDACTED].M., INDICATED "...SPLINT L (LEFT) ELBOW X (TIMES) 6 WKS (WEEKS) SPLINT CAN BE GENTLY REMOVED FOR HYGIENE, BUT NO ATTEMPT @ (AT) ELBOW MOTION. HAND [MEDICAL CONDITION] CONTROL WHEN PNT (PATIENT) LAYS DOWN, HAND IS ELEVATED...." A CARE PLAN DATED 8/17/10 AND LAST UPDATED ON 9/30/10 INDICATED "...POTENTIAL FOR ALTERATION IN TISSUE PERFUSION RELATED TO SPLINT WITH ACE WRAP TO LEFT ARM...GOALS RES WILL HAVE NO SIGNS OR SYMPTOMS OF ALTERED TISSUE PERFUSION...X 90 DAYS...INTERVENTIONS....OBSERVE RES...CIRCULATION, SENSORY, MOVEMENT CHECKS EVERY SHIFT AND AS NEEDED, NOTIFY MD AS NEEDED, 8/17/10 KEEP ELEVATED ON PILLOWS...8/19/10 MAY REMOVE SPLINT FOR HYGIENE, ELEVATE L HAND WHEN RES. LAYS DOWN...." DOCUMENTATION WAS LACKING TO INDICATE ANY INTERVENTION TO CHECK THE SKIN UNDER THE SPLINT IN AN EFFORT TO MAINTAIN SKIN INTEGRITY. THE MEDICATION ADMINISTRATION RECORDS (MARS) DATED 8/19/10 THROUGH 8/31/10 INDICATED "...SPLINT L ELBOW X 6 WKS SPLINT CAN BE REMOVED FOR HYGIENE - GENTLY FYI (FOR YOUR INFORMATION)...." DOCUMENTATION WAS LACKING TO INDICATE ANY NURSING STAFF INITIALS WERE PRESENT TO INDICATE THE SPLINT HAD BEEN REMOVED AND HYGIENE HAD BEEN PERFORMED. THE MARS DATED 9/1/10 THROUGH 9/24/10 INDICATED "8/17/10 SPLINT LEFT ARM W/ ACE WRAP..." HANDWRITTEN BELOW THE ORDER WAS A STATEMENT INDICATING "SPLINT MAY BE REMOVED FOR HYGIENE, BUT NO ATTEMPT AT ELBOW MOTION...." DOCUMENTATION INDICATED THE NURSING STAFF INITIALED EACH SHIFT FOR THE MONTH OF September. REVIEW OF THE NURSES' NOTES FROM 8/17/10 THROUGH 9/23/10 INDICATED THE ACE WRAP AND SPLINT HAD BEEN CONSISTENTLY DOCUMENTED AS IN PLACE AND CLEAN, DRY, AND INTACT. DOCUMENTATION WAS LACKING TO INDICATE THE SPLINT HAD BEEN REMOVED AND THE SKIN INTEGRITY OF THE LEFT ARM HAD BEEN ASSESSED. THE NURSES' NOTES INDICATED THE FOLLOWING: 9/24/10 AT 4:00 P.M., INDICATED "RES (RESIDENT) C/O (COMPLAINED OF) ODOR FROM L ELBOW SPLINT. ACE WRAP ET (AND) SPLINT REMOVED. OPEN AREAS NOTED OVER WRIST BONE PROMINENCE ET OVER ELBOW PROMINENCE. WRIST IS CRESCENT SHAPED MEASURING 1.0 X 1.6 X < 0.2 CM STAGE II. SCANT SEROSANGUINOUS DRAINAGE NOTED ON LINING OF SPLINT. DENIES PAIN. ELBOW HAS REDDENED AREA C OPENING IN CENTER MEASURING 2.0 X 1.6 X < 0.2 STAGE II. MODERATE AMT (AMOUNT) SANGUINOUS DRAINAGE NOTED ON SPLINT PADDING. ODOR PRESENT. BASE OF WOUND HAS YELLOW SLOUGH. AREAS CLEANSED ET PATTED DRY. DENIES PAIN. WOUNDS COVERED WITH MOIST GAUZE ET HELD IN PLACE C KERLIX (GAUZE WRAP). RES VERY PROTECTIVE OF ELBOW ET GUARDS AGAINST MOVING IT. MESSAGE LEFT ON VOICEMAIL FOR DR. (NAME) UPDATE...." 9/24/10 AT 5:00 P.M., "RES TRANSPORTED TO ER (emergency room ) BY FRIEND (NAME) PER DR (NAME) ORDER." A "HEALTH CARE WOUND ROUNDS" SHEETS DATED 9/24/10 INDICATED THE FOLLOWING: "...LOCATION L WRIST...DATE OF DISCOVERY 9/24/10 FACILITY ACQUIRED (CHECKMARK) WOUND TYPE PRESSURE (CHECKMARK)...STAGE 2 (PARTIAL THICKNESS LOSS OF DERMIS; PRESENTS AS SHALLOW OPEN ULCER WITH RED/PINK WOUND BED, NO SLOUGH; MAY BE INTACT, OPEN OR RUPTURED BLISTER)...WOUND SIZE 1.0 X 1.6 X < 0.2...." "...LOCATION L ELBOW...DATE OF DISCOVERY 9/24/10 FACILITY ACQUIRED (CHECKMARK) WOUND TYPE PRESSURE (CHECKMARK)...STAGE 5 (UNABLE TO STAGE...FULL THICKNESS TISSUE LOSS IN WHICH THE BASE OF THE ULCER IS COVERED BY SLOUGH AND/OR ESCHAR IN THE WOUND BED)...WOUND SIZE 2.0 X 1.6 X < 0.2...SLOUGH 100%...." AN "ED (EMERGENCY DEPARTMENT) PATIENT CARE RECORD" DATED 9/24/10 INDICATED "HERE TO HAVE A SPLINT RE-APPLIED FX (FRACTURE) L ELBOW...DISCHARGE DIAGNOSIS...SPLINT CHANGE FOR L ELBOW FX, PRESSURE SORES...." A PHYSICIAN ORDER [REDACTED].M., INDICATED "...KEFLEX (AN ANTIBIOTIC) 500 MG (MILLIGRAMS) i (ONE) CAP (CAPSULE) 4 TIMES A DAY PO (ORALLY) X 10 DAYS...." AN UNDATED "RESIDENT ASSIGNMENT KARDEX ADL (ACTIVITIES OF DAILY LIVING) PLAN OF CARE" INDICATED "...ADL CARE: REQUIRES ASSIST...DRESSING: ASSIST OF 1...8/19/10 ELEVATE LEFT HAND WHEN LAYING DOWN IN BED...." DOCUMENTATION WAS LACKING TO INDICATE THE SPLINT SHOULD HAVE BEEN REMOVED FOR HYGIENE. DURING AN INTERVIEW WITH RESIDENT #11 ON 10/5/10 AT 10:55 A.M., HE INDICATED THE STAFF WERE NOT COMING IN DAILY TO TAKE OFF THE SPLINT TO LOOK AT HIS SKIN OR PERFORM ANY HYGIENE TO HIS LEFT ARM. HE INDICATED "THEY WERE NOT DOING THAT AT ALL." DURING AN INTERVIEW WITH THE DON AND ASSISTANT DIRECTOR OF NURSING (ADON) ON 10/5/10 AT 1:15 P.M., THE DON INDICATED THE RESIDENT "SOMETIMES" REQUIRED ASSIST WITH DAILY HYGIENE. SHE INDICATED THE MARS WERE WRITTEN AS AN FYI BUT STAFF SHOULD HAVE BEEN REMOVING THE SPLINT AND LOOKING AT THE ARM EVERY DAY. SHE INDICATED THE STAFF WERE INITIALING THE MAR IDENTIFYING THE SPLINT WAS IN PLACE, NOT THAT THE SPLINT WAS REMOVED FOR HYGIENE. SHE INDICATED THE SKIN CHECKS SHOULD HAVE BEEN ADDED TO THE MAR AND SIGNED OF EVERY SHIFT. SHE INDICATED ALL NURSING STAFF WERE RESPONSIBLE FOR ENSURING THE SKIN INTEGRITY OF RESIDENT #11'S ARM. SHE INDICATED SHE DID NOT HAVE AN ANSWER AS TO WHY THE WOUNDS HAD NOT BEEN FOUND EARLIER. SHE INDICATED SHE "KNOWS THEY DIDN'T (DO THE SKIN CHECKS) OR WE WOULD HAVE FOUND THE AREAS" SOONER. SHE INDICATED IT WAS "OBVIOUS THEY WEREN'T" CHECKING HIS SKIN. DURING AN INTERVIEW WITH UNIT COORDINATOR ON 10/5/10 AT 2:10 P.M., SHE INDICATED THE STAFF "WERE SUPPOSED TO BE CHECKING THE SKIN UNDER THE SPLINT EVERYDAY AND THEY WERE NOT DOING IT. IF THEY WERE HE WOULD NOT HAVE BROKEN DOWN" UNDER THE SPLINT. SHE INDICATED ALL NURSING STAFF WERE RESPONSIBLE FOR CHECKING THE INTEGRITY OF THE SKIN. DURING AN INTERVIEW WITH CNA #2 ON 10/5/10 AT 2:15 P.M., SHE INDICATED SHE NEVER TOOK THE SPLINT OR THE ACE BANDAGE OFF OF RESIDENT #11 TO OBSERVE THE SKIN. DURING AN INTERVIEW WITH CNA #8 ON 10/5/10 AT 2:18 P.M., SHE INDICATED SHE NEVER TOOK THE SPLINT OR THE ACE BANDAGE OFF OF RESIDENT #11 TO OBSERVE THE SKIN. DURING AN INTERVIEW WITH CNA #9 ON 10/5/10 AT 2:20 P.M.,, SHE INDICATED SHE NEVER TOOK THE SPLINT OR THE ACE BANDAGE OFF OF RESIDENT #11 TO OBSERVE THE SKIN. DURING AN INTERVIEW WITH LPN #10 ON 10/5/10 AT 2:25 P.M., SHE INDICATED THE NURSING STAFF ARE RESPONSIBLE FOR TAKING OFF SPLINTS TO CHECK SKIN INTEGRITY. SHE INDICATED RESIDENT #11 HAD A BROKEN ARM AND "DIDN'T THINK WE WERE SUPPOSED TO REMOVE IT AT LEAST THAT WAS WHAT I WAS TOLD." DURING AN INTERVIEW WITH LPN #11 SHE INDICATED SHE "HAD AN ORDER NOT TO REMOVE THE SPLINT FOR ANY REASON. I GUESS MAYBE IT WAS A VERBAL ORDER. I WAS CHECKING CAPILLARY REFILL AND FINGER MOVEMENT, BUT I WAS NOT CHECKING THE SKIN UNDER THE SPLINT." SHE INDICATED THE PRESENCE OF THE SPLINT, CAPILLARY REFILL, AND FINGER MOVEMENT WAS WHAT SHE WAS INITIALING ON THE MAR. SHE FURTHER INDICATED "THE SKIN PROBABLY SHOULD HAVE BEEN ASSESSED EVERY DAY AT LEAST." AN UNDATED POLICY AND PROCEDURE TITLED "LICENSED NURSE OR TRAINED CNA APPLICATION OF SPLINTS" PROVIDED BY THE DON ON 10/6/10 AT 3:20 P.M., IDENTIFIED AS CURRENT INDICATED "...PURPOSE: TO PROPERLY APPLY A SPLINT FOR SUPPORT, COMFORT...EQUIPMENT: physician's orders [REDACTED]." 3.1-40(a)(1) 3.1-40(a)(2)