Every finding on record at Southwood Healthcare Center

Based on interview and record review, the facility failed to arrange transportation to an acute care hospital for a scheduled stay prior to a surgical procedure, causing cancellation of the surgical procedure, for 1 of 3 residents reviewed for quality of care and administration/personnel (Resident B).Findings include:During a telephone interview on 4/7/26 at 11:03 a.m., Resident B's resident representative indicated the resident had moved to the facility in December 2025. He had a surgical procedure scheduled to remove his bladder and divert his urinary function to be able to live without tubing exiting his back for urine drainage. In October of 2025, the surgery had been scheduled to be performed on 3/31/26. He was to be admitted to the acute care hospital on 3/29/26 to complete a neurology assessment prior to the surgery on 3/31/26. The hospital had called her on 3/29/26 at 3:40 p.m. and indicated Resident B's bed was ready for him to be transported. She asked them to call the facility so they could transport him. She had not called the facility to confirm, as she had stressed the importance in prior conversations with the Director of Nursing (DON) and had been assured that arrangements were in place. She received a call from the surgeon's office between 8:00 and 8:30 a.m. on the morning of 3/30/26 and was told the resident was not at the hospital. She had clearly communicated and confirmed with the DON regarding the need for Resident B to arrive on 3/29/26 and had stressed the importance of these procedures for Resident B. When she received the call the morning of 3/30/26, she was told by the hospital that they had spoken to the DON and were told the resident was not transferred on 3/29/26 and was preparing to leave the facility now. The hospital staff had told the DON to wait until they confirmed his procedures would remain on the schedule. The facility sent the resident to the hospital, and the resident was eventually returned to the facility due to the procedures being cancelled because the pre-surgical consultation with the neurologist could not be completed.A clinical record review for Resident B was completed on 4/7/26 at 10:14 a.m. Diagnoses included chronic kidney disease, obstructive and reflux uropathy, artificial openings of the urinary tract, and major depressive disorder.A significant change Minimum Data Set (MDS) assessment, dated 3/17/26, indicated the resident was cognitively intact and was dependent on staff for bathing, hygiene, dressing, and transfers. The resident had a urinary catheter.A current health care plan, revised 3/23/26, indicated Resident B had a communication problem. Interventions included allowing family support per resident's preference.A current health care plan, dated 1/1/26, indicated Resident B had a suprapubic catheter related to obstructive uropathy. Interventions included observing and document for pain or discomfort due to his catheter.A current health care plan, revised 3/23/26, included Resident B had impaired skin integrity and was at risk for altered skin integrity due to drains to his back. Interventions included to provide appropriate off-loading mattress and to encourage resident to turn and reposition.A nursing progress note, dated 3/30/26 at 9:31 a.m., indicated Resident B had been transported to an acute care hospital for admission for surgery tomorrow.A nursing progress note, dated 3/30/26 at 4:38 p.m., indicated Resident B had returned to the facility at this time. A neurology consultation was needed prior to surgery per urology.A review of the facility scheduling log lacked indication of any appointments on 3/29/26.During an interview on 4/7/26 at 1:08 p.m., the DON indicated Resident B's surgery was scheduled for 3/31/26, and the hospital wanted him to be admitted on [DATE]. The hospital called on 3/29/26 and indicated the resident's bed was ready. On 3/26/26, she spoke to the hospital's central scheduling and was clear with them that the facility would not be able to transport without a specific time due to arrangements for transport requiring a 24-48 hour notice. The hospital indicated they could not provide a specific time and would contact the facility when a bed was ready. The DON indicated she told them the resident had to be transported by stretcher and they would need to know a specific time. The nurse at the hospital indicated she would put it in the notes. The hospital called the facility and spoke to LPN 4 on 3/29/26 and said his bed was ready. LPN 4 had told the hospital that the facility would not be able to transport the resident 3/29/26, but that transportation had been set up for 3/30/26. The DON indicated she had not known the neurology consultation had been set up on 3/29/26 and thought the consultation was on 3/30/26 since his surgery was scheduled for 3/31/26. She had not realized he needed to be at the hospital on 3/29/26. The Resident Representative had told her the surgeon wanted Resident B to see neurology before surgery, and they would call when the bed's ready. She continued to think it was on that 3/30/26 and had not clarified a day or date with the scheduler or resident representative when speaking with them. She does not have a memory of the resident representative saying anything about 3/29/26. The facility staff had called her on 3/29/26 at 11:45 p.m. and said no transport had picked up the resident and taken him to the hospital. The Surgery Scheduler from the surgeon's office called on 3/30/26 at 8:29 a.m., and said, hey he's not here yet. She indicated to her not to send the resident until she heard back from her. She called again at 12:03 p.m. and indicated the surgery had been cancelled.During an interview on 4/7/26 at 2:38 p.m., LPN 4 indicated she was unaware that Resident B was supposed to be going out to the hospital on 3/29/26. There had been no entry in the scheduling log of any appointments for 3/29/26. The hospital had called the facility the afternoon of 3/29/26 and indicated Resident B's room was ready and provided a room number. She went to talk to Resident B, and he indicated, No, I'm going on Monday. She called the hospital back and indicated the facility had not arranged transportation for 3/29/26. She was told they would make a note and expect him on 3/30/26.During an interview on 4/7/26 at 3:20 p.m., Resident B indicated he was very upset about the whole situation. He had been dealing with the tubes coming out of his back and was looking forward to not having to be so uncomfortable. He believed the DON knew he was supposed to go to the hospital on 3/29/26 because his Resident Representative had told him all the arrangements had been made. When he was transferred to the hospital on 3/30/26, he was put into a hospital bed and he was changed into a gown, his wounds were checked and redressed and he was ready to go. The hospital staff then came in and told him the surgery had been cancelled because he had not arrived on 3/29/26. He was very disappointed. He was then transferred back to the facility. He blamed the DON for the cancellation and the need to reschedule his procedure. He believed it may not be until August. After waiting from October 2025 to now and then having to wait another lengthy time was so disappointing. The DON had not made the arrangements, so he had to wait again. She had not even apologized to him.During a telephone interview on 4/8/26 at 9:36 a.m., the Surgery Scheduler from the surgeon's office indicated the admission date for Resident B had been moved to 3/29/26 after determination that a neurological consultation would be required prior to the surgical procedures. She had called the facility and the resident representative on 3/13/26 and informed them of the change in admission date. She had spoken with the DON on 3/18/26 after receiving a call from her to confirm the resident's arrival time. She explained there was no specific arrival time, but that the hospital would call and let the facility staff know when the bed was ready. She confirmed with her that the resident needed to arrive on 3/29/26. She could not recall what was said specifically. She had spoken with LPN 4 on 3/29/26 at around 4:00 p.m., and had called the facility again at 11:30 p.m., requesting information on the resident's arrival time. She was told that transport was picking the resident up on 3/30/26 at 9:00 a.m. She spoke with the DON on 3/30/26 around 8:30 a.m. and told her the procedure was cancelled. The DON had not indicated if the resident had already left the facility. She called the DON again when transport had dropped Resident B off at the hospital and left. The DON indicated to her that she had called transport and cancelled the pick-up. Transport had dropped him off at the hospital between 11:00 and 11:30 a.m. They returned to the hospital to pick up Resident B at 1:42 p.m. to return to the facility. Resident B was to see the neurologist first thing on 3/30/26. It had been made clear to the DON and the resident representative that he needed to be admitted 48 hours prior to surgery because it could take 24 hours for neurology to clear him for surgery.During an interview on 4/8/26 at 10:27 a.m., the DON indicated she had received a call from the Surgery Scheduler from the surgeon's office at 8:30 a.m., who indicated not to transport Resident B to the hospital. She had been in the waiting room for a family member's appointment and sent a text to the facility not to send the resident out until further notice. She had not called the facility. After the appointment, she went to the facility at 11:00 a.m. and found the resident had been transferred out to the hospital. She realized at that time that her text message had not gone through to the facility. The Surgical Scheduler called her again sometime after 12:00 p.m. and indicated the surgery had been cancelled and would need to be rescheduled. She had since learned the transport company can arrange quick transport for an extra fee. She had not been aware this was an option and felt she had no way to arrange for transportation on 3/29/26 without a specific time. She did not recall talking to the Surgical Scheduler on 3/18/26, but it probably had happened because she had spoken to her several times. She does not recall being told the date of the transport being changed to 3/29/26. She indicated after the resident returned, she had attempted to speak with him and was asked to get out of his room. She had spoken to his resident representative several times to inform her of status of getting his procedures re-scheduled. A current facility policy, undated, titled, Resident Transportation, provided by the Administrator on 4/7/26 at 2:40 p.m., included the following: Policy: It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. The facility will assist the resident in making transportation arrangements to and from the source of any needed service, such as dental visits, or physician visits in the event the resident requires such assistance.This citation relates to Intake 2972240.410 IAC (Indiana Administrative Code) 16.2-3.1-37(b)

Based on record review and interview, the facility failed to prepare a resident's food according to a physician's ordered modified diet for 1 of 3 residents reviewed for death (Resident B). This deficient practice was corrected by 2/20/26 prior to the start of the survey and was therefore Past Noncompliance. Findings include:A clinical record review for Resident B was completed on 2/25/26 at 11:01 a.m. Diagnoses included dementia, oropharyngeal phase dysphagia (difficulty swallowing due to problems in the mouth and throat), and protein-calorie malnutrition. A quarterly Minimum Data Set assessment, dated 1/19/26, indicated Resident B had severe cognitive impairment. She was rarely and/or never understood when expressing ideas or wants, and she could sometimes understand others. She required supervision and/or touching assistance for eating. A current physician's order, dated 10/30/25, indicated regular diet, dysphagia advanced texture, regular consistency. During an interview 2/25/26 at 1:36 p.m., CNA 1 indicated on 1/19/26 at approximately 12:00 p.m., the staff was passing the lunch trays. She looked around the dining room and noticed Resident B was shoving food into her mouth and pocketing food in her cheeks. She would normally feed herself and was a slow eater, so this was unusual. She went over to Resident B and sat next to her to assist her to slow down her eating. She was not chewing the food, just shoving into her mouth. CNA 1 moved her plate out of reach, in an attempt to get her to slow down and address the food in her mouth. Her lips were turning bluish in color. Resident B continued to reach for her plate to get more food. CNA 1 noted her bluish lip color and felt the resident was choking and performed the Heimlich Maneuver using two thrusts, positioning her clasped hands below her sternum with the resident seated. A whole Brussel sprout was expelled. LPN 2 arrived and took over care of Resident B. A lunch tray ticket, dated 2/19/26, Thursday lunch, for Resident B, indicated regular dysphagia advance diet. Roasted Brussels Sprouts, Chop was listed on the resident's menu. A Preliminary Autopsy Report, provided by the coroner's office, completed 2/21/26, indicated the cause of death as acute pulmonary thromboembolism (blood clot in the lungs). During an interview on 2/25/26 at 11:47 a.m., the Corporate Risk Management Nurse (CRMN) indicated the resident had been served whole Brussel sprouts, but according to her ordered diet, should have been served chopped Brussel sprouts. A current facility policy, undated, titled, Textures, provided by the Administrator on 2/26/26 at 10:24 a.m., included the following: .2. Dysphagia advanced .Listed as dys adv on the meal ticket .Foods allowed: .Vegetables: soft, well-cooked. This deficient practice was corrected by 2/20/26 prior to the start of the survey and was therefore Past Noncompliance. The facility implemented a systemic plan that included monitoring meal tray/diet accuracy and staff education regarding accurate modified diet service, and ongoing monitoring by Quality Assurance and Performance Improvement (QAPI). This citation relates to Intake 2748939. These deficiencies reflect State Findings cited in accordance with 410 Indiana Administrative Code (IAC) 16.2-3.1-20(a).

A. Based on observation, interview, and record review, the facility failed to ensure paper towels at handwashing areas were maintained in a sanitary manner for 1 of 2 kitchen observations and 1 of 1 dining observation. B. Based on observation, interview, and record review, the facility failed to ensure food was distributed in a safe and sanity manner and failed to ensure staff assisted residents with their meal in a safe and sanitary manner for 1 of 2 dining observations in the activity room (Residents 59, 1, 19, and 109). Findings include:A. During the initial kitchen observation, on 1/20/26 at 9:52 a.m., a commercial-sized roll of paper towel was sitting on a table next to the handwash sink. Visible wet marks were observed on the side and top of the paper towel roll. At the same time, the Culinary Director indicated the dispenser was out of towels and housekeeping had not been into the kitchen to refill the dispenser. The kitchen staff did not have the ability to load new towels into the dispenser; it had to be done by housekeeping. During an observation of the lunch meal service on the Memory Care Unit, on 1/20/26 at 11:40 a.m., the staff were observed performing handwashing prior to serving the resident meal trays. A commercial size roll of paper towels was observed sitting on the counter next to the handwash sink. The employees were observed to touch the paper towel roll with their wet hands and wet marks were observed on the side and top of the paper towel roll. At the same time, the Resident Services Director indicated the towel dispenser was broken. During an interview, on 1/20/26 at 12:00 p.m., the Housekeeping Director indicated the brown and white towels for the dispensers were on recall. He was waiting on the recall to be over, and they could hopefully get the dispensers filled and working. During an interview, on 1/22/26 at 1:21 p.m., the Regional Director of Clinical Operations (RDCO) indicated she was not aware of any recall on paper towels used by the facility. The expectation was that paper towels should be available and maintained in a clean manner to be used by staff and residents. On 1/23/26 at 9:13 a.m., the RDCO provided an undated document, titled, Standard Precautions, and indicated it was the policy currently used by the facility. The policy indicated, .Procedures: .III. Procedure for Hand Hygiene.B. Using liquid soap and water.6. Dry hands thoroughly with clean paper towel. 7. Turn off faucet with clean, dry paper towel-discard. B1. The following observations were observed in the activity room during lunch meal service on 1/20/26 at 11:32 a.m. thru 11:49 a.m.: The Certified Nurse Aide (CNA) 10 adjusted Resident 59's clothing protector at the table and re-adjusted her wheelchair closer to the table. CNA 10 uncovered a peanut butter and jelly sandwich from a plastic wrap and picked up half the sandwich with her bare hands and placed it in Resident 59's left hand. The resident was having a hard time eating the sandwich and the CNA moved the sandwich with her bare hands from the resident's left hand to her right hand. CNA 11 picked up half of a peanut butter sandwich with her bare hands and fed it to Resident 1. The resident took the sandwich with her right hand from the CNA. During an interview, on 1/20/26 at 12:03 p.m., Licensed Practical Nurse (LPN) 7 indicated staff should not touch the residents' food with their bare hands at any time. On 1/20/26 at 2:05 p.m., the Regional Director of Clinical Operations (RDCO) indicated the facility did not have a policy for the staff not touching food with bare hands but followed the State guidelines in the Retail Food Establishment Sanitation Requirements, which indicated, .TITLE 410 IAC 7-24 Section 131 (2) .no direct contact with food by the bare hands.Section 153. ii) prohibits contacting ready-to-eat food with bare hands. 2. On 1/20/26 at 11:15 a.m., observed CNA 19 pass food trays and set up meals for the residents and failed to sanitize her hands between residents. On 1/20/26 at 11:15 a.m., observed noon meal service in the activity room with residents who required assistance. Observed Certified Nurse Aide (CNA) 10, assisting Resident 59 with meal. She assisted another resident and returned to resident to help with meal and did not sanitize her hands. On 1/20/26 at 11:49 a.m., observed CNA 18 assisting Resident 19 and Resident 109 at the same time. The CNA failed to sanitize her hands while alternating between the two residents. On 1/20/26 at 12:09 a.m., during an interview CNA 8 indicated if she were assisting two residents she would sanitize her hands after every third bite. She was unsure if she would sanitize her hands between residents. On 1/27/26 at 1:00 p.m., during an interview the Regional Director Clinical Operations (RDCO) indicated the facility did not have a policy for assisting the residents with meals. 3.1-21(i)(1) 3.1-21(i)(3)

Based on record review and interview, the facility failed to ensure consent documents had been obtained for antipsychotics (medications used to manage symptoms of psychosis [a loss of contact with reality], such as delusions [a firmly held false belief that does not match reality], hallucinations [seeing or hearing things that are not there], insomnia [persistent difficulty falling asleep, staying asleep, or waking up too early], and severe agitation) medications for 3 of 5 residents reviewed for unnecessary medications (Residents 11, 59, and 62). Findings include:1. Resident 11's record was reviewed on 1/21/26 at 2:54 p.m. The profile indicated the resident's diagnoses included, but were not limited to, severe manic episode without psychotic symptoms (a week-long [or longer] period of extremely elevated, euphoric, or irritable mood and excessive energy that severely disrupts daily life) and unspecified psychosis (a diagnostic label for psychotic symptoms that don't fit a specific disorder). A significant change Minimum Data Set (MDS) assessment, dated 12/24/25, indicated the resident had severe cognitive deficit and received antipsychotic medications on a routine basis. A physician's order, dated 2/26/25 with a discontinued date of 10/7/25, indicated to administer one 200 milligram (mg) tablet of Seroquel (antipsychotic medication) at bedtime for mania. A signed consent, dated 3/27/25, was observed for the Seroquel, but lacked documentation of the required black box warning information (the Food and Drug Administration's [FDA's] strictest warning for prescription drug labeling, highlighting severe, life-threatening, or permanently disabling adverse reactions). A physician's order, dated 8/12/25 with a discontinuation date of 8/13/25, indicated to administer one 200 mg tablet of Seroquel on the morning of 8/13/25 for mania. The record lacked documentation of consent for the initiation of the additional 200 mg of Seroquel administration order. A physician's order, dated 10/7/25, indicated to administer one 200 mg tablet of Seroquel, in addition to a 50 mg tablet, to equal total dose of 250 mg, at bedtime for insomnia. The record lacked documentation of consent for the increase in dose and initiation of the antipsychotic medication. During an interview, on 1/22/26 at 12:01 p.m., the Regional Director of Clinical Operations (RDCO) indicated they were unable to find any consent documentation for the residents' medication increases and/or initiations. The consent forms needed to be updated to include the proper verbiage on black box warnings. To her knowledge, there was not a specific policy for consents. The expectation was that the facility would follow federal guidance. 2. Resident 59's record was reviewed on 1/22/26 at 11:14 a.m. The profile indicated the resident's diagnoses included, but were not limited to, unspecified dementia (when confusion or mild cognitive impairment can't be clearly diagnosed as a specific type of dementia), major depressive disorder (a serious mood disorder causing persistent sadness, loss of interest, and impacts daily life through symptoms like sleep/appetite changes, fatigue, and concentration issues), and psychotic disorder with hallucinations (psychotic disorders involving losing touch with reality, with common symptoms including hallucinations [seeing, hearing, feeling things not there] and delusions [false beliefs]). Facility census information indicated Resident 59 was admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment, dated 1/2/26, indicated the resident was rarely understood and received anti-psychotic medication during the look back period. A physician order, dated 11/25/25 and discontinued on 12/17/25, indicated to administer risperidone (anti-psychotic medication) 0.25 mg by mouth two times a day for hallucinations. A physician order, dated 12/17/25, indicated to administer risperidone 0.5 mg (milligram) by mouth two times a day for delusional disorder. The electronic record lacked documentation that a psychotropic informed consent was obtained when there was an increase in the dose of the risperidone medication. During an interview on 1/22/26 at 11:15 a.m., the Regional Director of Clinical Operations (RDCO) indicated she was unable to find the psychotropic consent for when Resident 59 was ordered an increased dose of risperidone by the physician. Staff had missed getting the consents when the doses were increased. She indicated a consent should have been completed with any changes to the psychotropic medications. During an interview on 1/22/26 at 2:49 p.m., the RDCO indicated they were unable to find a policy regarding psychotropic consents, but it was the expectation that the facility would follow state and federal regulations. 3. On 1/22/26 at 1:41p.m., The medical record of Resident 62 was reviewed. The resident was admitted to the facility on [DATE]. Diagnosis included, but were not limited to, congestive heart failure (CHF) (a condition that develops when your heart doesn't pump enough blood for your body's needs), dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), anxiety (a feeling of fear, dread, and uneasiness), and depression (an illness characterized by persistent sadness and a loss of interest in activities that you normally enjoy, accompanied by an inability to carry out daily activities, for at least two weeks). A physician order, dated 3/2/25, indicated to administer Effexor (antidepressant) 75 mg 1 tablet daily. On 3/2/25 and 9/25/25 the medication dose was decreased to 37.5 mg daily. The medical record lacked consent for psychotropic medication. A physician order, dated 7/23/25, indicated administer Paxil (antidepressant) 10 mg daily. On 8/7/25 the medication dose was increased to 20 mg daily. On 9/25/25 the medication dose was increased to 30 mg daily. The medical record lacked consent for psychotropic medication for the Paxil medication orders. A physician order, dated 8/20/25, indicated administer Buspirone (antianxiety medication) 5 mg twice daily. The consent did not include black box warning information being provided to resident and resident's responsible party. A physician order, dated 10/29/25, indicated administer Buspirone 10 mg twice daily. The record lacked evidence of psychotropic consent. A physician order, dated 12/2/25, indicated administer Buspirone 10 mg three times a day. The record lacked evidence of psychotropic consent. A physician order, dated 6/30/25, indicated administer Lorazepam (antianxiety medication) 0.5 mg daily. The medical record lacked documentation of black box warning information being provided to resident and resident's responsible party for Lorazepam and Paxil medications. An annual MDS, dated [DATE], indicated the resident was cognitively impaired and was administered antipsychotic, antianxiety, and antidepressant medications during the assessment period. On 1/22/26 at 2:49 p.m., during an interview, the Regional Nurse Consultant indicated the facility did not have the psychotropic medication consents for the dates and medications indicated. She indicated the facility did not have a policy for psychotropic consents and the facility should follow the federal guidelines. 3.1-3(n)(2) 3.1-3(n)(3)

Based on record review and interview, the facility failed to ensure accurate advance directives were ordered when the POST form was not the same as the physician order and care plan for 1 of 32 residents reviewed for advanced directives (Resident 15). Findings include:On [DATE] at 10:00 a.m., the medical record of Resident 15 was reviewed. The resident was admitted to the facility on [DATE]. Diagnosis included but was not limited to multiple myeloma (a cancer of plasma cells (a type of white blood cell) that grow out of control in the bone marrow), dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities) and diabetes, (a disease that occurs when your blood glucose, also called blood sugar, is too high). An admission Minimum Data Set Assessment (MDS) dated [DATE] indicated that the resident was cognitively impaired. A Physician Orders for Scope of Treatment (POST) form (a legally recognized medical order document designed for individuals that translates a patient's treatment preferences regarding end-of-life care into actionable medical orders that must be followed by healthcare providers), dated [DATE], indicated Resident 15 had a Do Not Resuscitate (DNR) status. A care plan, dated [DATE], indicated that the resident had a CPR code Status. Interventions included, but not limited to, code status would be established at time of admission,re-admission, and would be reviewed quarterly and as needed. A physician order, dated [DATE], indicated to administer CPR (cardiopulmonary resuscitation). The physician order did not match the POST form. A Physician order, dated [DATE], indicated DNR. On [DATE] at 10:50 a.m., during an interview the Regional Director Clinical Operations (RDCO) indicated the facility had identified the discrepancy with the POST form and physician order and had corrected the order on [DATE].On [DATE] at 11:40 a.m., the RDCO provided an undated document titled, Cardiopulmonary Resuscitation, and indicated it was the policy currently being used by the facility. The policy indicated, . 2. Facility staff should verify the presence of advanced directives or the resident's wishes with regard to CPR, upon admission. If the resident's wishes are different than the admission orders, or if the admission orders do not address the resident's code status and the resident does not want to receive CPR, facility staff should document the resident's wishes in the medical record and contact the physician to obtain the order. 3.1-4(c)(6)

Based record review and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) (screening for serious mental illness and intellectual disability required before admission to a long term care facility) was updated when a psychiatric diagnosis was added to a resident's profile for 1 of 1 residents reviewed for PASRR (Resident 55). Findings include:Resident 55's record was reviewed on 1/23/26 at 9:46 a.m. Census information indicated the resident was admitted to the facility on [DATE]. An annual Minimum Data Set (MDS) assessment, dated 11/12/25, indicated the resident was not considered by the state to have a Level II PASRR (an in-depth, mandatory federal evaluation for individuals suspected of having serious mental illness) with a serious mental illness. A Notice of PASRR Level I Screen Outcome, dated 4/10/24, indicated no Level II was required because the resident did not have a serious mental illness. The resident's profile indicated a diagnosis of bipolar II disorder (a chronic mental health condition characterized by a pattern of recurring, severe depressive episodes and milder elevated mood episodes known as hypomania, without ever experiencing full mania) was added on 8/28/24. The resident's record lacked documentation the PASRR was re-assessed for the possible necessity of a Level II after the addition of the bipolar diagnosis. On 1/27/26 at 10:05 a.m., Risk Management 13 provided an updated Notice of PASRR Level I Screen Outcome, dated 1/23/26. The document included the resident's bipolar II disorder diagnosis and indicated the resident was referred for an on-site Level II evaluation. At the same time, Risk Management 13 indicated the PASRR should have been re-evaluated when the resident received the new bipolar diagnosis, in August 2024, but it was missed. On 1/27/26 at 10:32 a.m., the Regional Director of Clinical Operations (RDCO) provided an undated document titled, Indiana PASRR, and indicated it was the policy currently being used by the facility. The policy indicated, .PASRR: The preadmission screening and resident review process, otherwise known as PASRR, is a federally mandated process to ensure nursing facility applicants and residents with serious mental illness.are identified and placed appropriately in the least restrictive setting.8. Level-of-Care Assessment Requirements: a) For NF applicants, a LOC [level of care] determination is required for the following.(2) Residents who experience a significant change in medical condition.10. Level I Screen Requirements.(2) For NF residents who have a significant change in mental status indicating the need for an updated Level I screen, a subsequent Level I screen, or an updated Level II evaluation.

Based on interview, observation, and record review, the facility failed to ensure safe smoking protocols were followed for 1 of 1 residents reviewed for smoking (Resident 9). Findings include:During an interview, on 1/21/26 at 9:38 a.m., Resident 9 indicated she smoked one or two cigarettes at a time when she went outside. Resident 9 indicated she was able to go out and smoke whenever she liked and was allowed to keep her own cigarettes and lighter in her room. The resident indicated the facility had not provided her with anything to lock her cigarettes and lighter inside, and she kept them in her purse. The resident indicated she had a history of seizures. During a continuous observation, on 1/22/26 from 2:32 p.m. to 2:40 p.m., the following was observed. Resident 9 exited her room pushing her wheelchair down the hallway, proceeded down two hallways towards the smoking exit door, exited the building, removed cigarettes and lighter from her purse, lit a cigarette and smoked. The cigarettes and lighter were kept freely in the resident's purse and were not secured in a locked bag. During the continuous observation, no staff offered or provided assistance or supervision. During an observation, on 1/23/26 at 9:26 a.m., Resident 9 was observed up in the wheelchair, in the hallway, with no oxygen tank. At the same time, the resident indicated she did not always use oxygen and just needed it sometimes in her room. Resident 9's record was reviewed on 1/22/26 at 1:33 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, Alzheimer's disease unspecified (a brain disorder that slowly destroys a person's memory and thinking skills), chronic obstructive pulmonary disease (COPD) unspecified (progressive, but treatable, group of lung diseases), epilepsy (seizure disorder) unspecified, and cigarette nicotine dependence. A significant change Minimum Data Set (MDS) assessment, dated 12/19/25, indicated the resident was cognitively intact, used tobacco, and received oxygen therapy. A smoking assessment, dated 9/16/25, indicated the resident smoked cigarettes and had a diagnosis of Alzheimer's or other dementia. The assessment determined the resident was a safe, independent smoker. A physician's order, dated 12/16/25, indicated to administer oxygen via nasal cannula at two liters (l) continuously for COPD. A post fall assessment, dated 12/22/25, indicated the resident fell coming back into the facility from the smoking area. A post fall assessment, dated 12/27/25, indicated the resident was found on her knees outside the smoking door. A smoking assessment, dated 12/27/25, indicated smoked cigarettes and had a diagnosis of Alzheimer's or other dementia. The assessment narrative indicated, [Resident name] is not currently an independent smoker. She has difficulty getting in and out of smoking area. She has poor safety awareness. She has had falls out in smoking area. She is currently not safe to smoke. The assessment lacked documentation the resident's inability to smoke safely was communicated to other staff members or the resident. A post fall assessment, dated 1/1/26, indicated the resident fell outside the door to the smoking area. A care plan, last revised on 11/20/24, indicated the resident smoked cigarettes independently and followed the facility's smoking protocols. Interventions included, but were not limited to, provide a locked bag/box for safe storage of smoking materials. The care plan lacked documentation it was updated when the smoking assessment, dated 12/27/25, showed the resident to be unsafe to smoke. A resident smoker list, last updated on 1/8/26 and provided at survey entrance, indicated Resident 9 was an independent smoker and had been provided with a lockbox for smoking material storage. During an interview, on 1/23/26 at 9:28 a.m., Certified Nurse Aide (CNA) 14 indicated Resident 9 was able to go out to smoke independently. The resident was able to store her own cigarettes, but CNA 14 was not sure where she kept them. Some residents were able to keep their own cigarettes, and the nurses held cigarettes for some of the other residents and gave them a couple of cigarettes at a time. CNA 14 indicated she would find out if residents were able to keep their own cigarettes from the nurse. During an interview, on 1/23/26 at 9:37 a.m., Licensed Practical Nurse (LPN) 9 indicated smoking assessments were completed upon admission and periodically. Nursing completed smoking assessments at admission and hospital returns, and sometimes activities staff also completed assessments. If a smoking assessment showed a change, then it should have been communicated to the staff. Residents who were able to smoke independently kept their own cigarettes and lighter, and she did not think there was a requirement to lock them up. LPN 14 thought Resident 9 was assessed as being able to smoke safely. On 1/23/26 at 10:23 a.m., the Regional Director of Clinical Operations (RDCO) provided an undated document titled, Resident Smoking Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: It is the policy of this facility to promote resident centered care by providing a safe smoking area for residents that request to smoke and are capable of safe smoking behaviors either independently or with supervision.Procedure: 1. Assessment, observation and designation of independent or supervised smoker will be made by the IDT [interdisciplinary team] recommendations, the designation may be changed based on recent assessments by the team and will include: a. Documentation in the resident medical records including reason for change. b. Update Care Plan to reflect changes. c. Resident/family notification. A document titled, Facility Specific Smoking Policy Addendum, was attached to and provided with the facility's smoking policy. The addendum indicated, This smoking policy for Independent Smokers is made by [facility name] and all smoking residents/parties to agreement September 2021. The Addendum follows: a. Secure smoking materials in locked area when not used by resident/patient for dependent smokers. b. Independent smokers will secure their own smoking materials in a locked bag when not in use.Smoking safety instructions for Independent smokers will include: a. Facility will provide locked bag for independent smokers to secure all smoking materials when not in use. 3.1-45(a)(1)

Based on observations, record review, and interview, the facility failed to ensure that nebulizer equipment was properly cleaned and stored after each use for 2 of 2 residents reviewed for oxygen and nebulizer use (Residents 12 and 63). Findings include:1. On 1/21/26 at 9:57 a.m., during an initial observation, Resident 12 was lying in bed. She indicated she had received a nebulizer treatment. A nebulizer is (an electrically powered machine that turns liquid medication into a mist so that it can be breathed directly into the lungs through a face mask or mouthpiece). The nebulizer tubing and mask were lying on the bedside nightstand on top of a clear plastic bag dated 1/19/26. The medication chamber was observed to have clear liquid inside. On 1/21/26 at 10:15 a.m., the medical record of Resident 12 was reviewed. The resident was admitted to the facility on [DATE]. Diagnosis included, but were not limited to, diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), hypertension (high blood pressure), anxiety (a feeling of fear, dread, and uneasiness), and osteomyelitis (a painful bone infection that causes inflammation and swelling in the bone) of the left foot. The medical record lacked supporting documentation of respiratory diagnosis. A physician order, dated 12/18/25, indicated to administer ipratropium-albuterol 0.5-2.5 (3) mg/3ml (milligram/milliliter) solution inhale contents of 1 vial by mouth three times daily for respiratory. An annual Minimum Data Set Assessment (MDS), dated [DATE], indicated the resident was cognitively intact and required extensive to maximum assistance for daily care needs. A care plan, dated 1/20/26, indicated the resident received oxygen therapy. Interventions included, but was not limited to, give medications as ordered by physician. The care plan record lacked documentation of an intervention to administer respiratory nebulizer treatments. On 1/21/26 at 2:54 p.m., during a routine observation of Resident 12, noted the nebulizer tubing, mask and medication chamber were lying on the bedside nightstand on top of a plastic storage bag. A clear liquid was observed inside of the medication chamber. On 1/22/26 at 10:05 a.m., during a routine observation of Resident 12, noted the nebulizer equipment was lying on top of a clear plastic bag on the bedside nightstand. Clear liquid was noted in the medication chamber. On 1/22/26 at 2:48 during a routine observation of Resident 12, noted the nebulizer tubing, mask and chamber were lying on a plastic storage bag on top of the bedside nightstand. The medication chamber contained clear liquid. On 1/23/26 at 9:15 a.m., during an interview Licensed Practical Nurse (LPN) 7, indicated she would wash the nebulizer equipment, place it on a paper towel to dry, and once dried she would place it in a bag. On 1/23/26 at 9:25 a.m., during a routine observation of Resident 12, noted the nebulizer equipment inside of storage bag lying on top of the bedside nightstand. Observed a small amount of clear liquid in the medication chamber. 2. On 1/20/26 at 2:43 p.m., Resident 63's unbagged nebulizer mouthpiece and tubing were observed on the seat of the chair next to the resident's bed. The medication chamber contained a clear liquid in it along with small bubbles on the inside of the chamber. Resident 63 indicated she was prescribed nebulizer breathing treatments as needed for shortness of breath. On 1/21/26 at 2:52 p.m., Resident 63's unbagged nebulizer mouthpiece and tubing were observed on the seat of the chair next to the resident's bed. The medication chamber contained a clear liquid in it along with small bubbles on the inside of the chamber. On 1/22/26 at 9:48 a.m., Resident 63's unbagged nebulizer mouthpiece and tubing were observed on the seat of the chair next to the resident's bed. The medication chamber contained a clear liquid in it along with small bubbles on the inside of the chamber. Resident 63's record was reviewed on 1/21/26 at 3:18 p.m. The profile indicated the resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing related problems) and acute respiratory failure with hypoxia (critical condition where the lungs cannot adequately transfer oxygen to the blood, resulting in a sudden, dangerous drop in oxygen levels). A quarterly Minimum Data Set (MDS) assessment, dated 12/18/25, indicated the resident was cognitively intact and was not on oxygen therapy. A care plan, dated 6/23/25, indicated the resident had COPD with shortness of breath while lying flat. Interventions included but were not limited to, administer medication per medical provider's orders, monitor vitals, and observe for signs and symptoms of COPD. A physician order, dated 6/22/25, indicated albuterol sulfate inhalation nebulization solution (a medication that can help people with lung problems, like asthma or obstructive pulmonary disease, breathe easier); 2.5mg (milligrams)/3ml (milliliter) 0.083%. Administer one orally via nebulizer every 6 hours as needed for wheezing. Review of the January 2026 Medication Administration Record (MAR) indicated Resident 63 received a nebulizer treatment on January 20, 2026, at 7:52 p.m. During an interview, on 1/23/26 at 8:40 a.m., Licensed Practical Nurse (LPN) 9 indicated after the resident had completed their nebulizer treatment, the nurse was to rinse out the nebulizer equipment and then place it in a plastic bag for storage when not in use. During an interview, on 1/23/26 at 10:23 a.m., the Regional Director of Clinical Operations (RDCO) indicated the facility did not have a policy regarding the storage of nebulizer equipment while not in use but should be stored in a bag that was dated. On 1/23/26 at 10:23 a.m., the Regional Director of Clinical Operations (RDCO) provided an undated document titled, Nebulizer Treatments, and indicated it was the current policy being used by the facility. The policy indicated, .l. Rinse the nebulizer with sterile water and allow it to dry. Alternatively, discard it after therapy if applicable. 3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure a resident was provided routine dental services for 1 of 32 residents reviewed for dental services (Resident 9). Findings include:During an interview, on 1/21/26 at 9:31 a.m., Resident 9 indicated she wanted to see a dentist, but she did not think dental services had been offered to her since she was admitted to the facility. The resident indicated she had missing teeth and teeth that had fallen out that she wanted checked. Resident 9's record was reviewed on 1/22/26 at 1:33 p.m. Census information indicated the resident was admitted to the facility on [DATE]. A significant change Minimum Data Set (MDS) assessment, dated 12/19/25, indicated the resident was cognitively intact. A care plan, last revised on 5/21/25, indicated the resident had the potential for oral/dental problems due to carious (cavities or tooth decay) teeth. Interventions included, but were not limited to, dental consult as needed. The resident's electronic record lacked documentation the resident was offered, provided, or refused dental care. During an interview, on 1/23/26 at 2:40 p.m., Risk Management 15 indicated she was not able to find documentation the resident had been offered dental services since her admission to the facility. Dental services should have been offered to all residents at admission, but she was unable to find documentation this was completed. They planned to offer her dental services at this time. On 1/23/26 at 3:03 p.m., the Regional Director of Clinical Operations (RDCO) provided an undated document titled, Dental Services, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents.Dental and Oral health can impact the physical as well as the mental/emotional and psychological health of a resident. Poor dentition and/or poor oral health may impact nutritional and weight loss status. Procedure: I. The facility will assist the resident in: a. Obtaining routine Dental Services.c. Obtaining services to the resident to meet the needs of each resident. 3.1-24(a)(1)

Based on observation, record review, and interview, the facility failed to assess and initiate a care plan to support the use of elopement risk preventive measures for 1 of 23 residents reviewed for care plans (Resident 34). Findings include:On 1/21/26 at 10:33 a.m., during initial observation and interview, Resident 34 indicated he had an ankle bracelet alarm on his right ankle and did not understand why it was there. He indicated he had never been outside since he came to the facility and did not understand why he could not go outside. On 1/23/26 at 11:30 a.m., the medical record of Resident 34 was reviewed. The resident was admitted to the facility on [DATE]. Diagnosis included, but were not limited to, chronic obstructive pulmonary disease (COPD) (a group of diseases that cause airflow blockage and breathing-related problems), and bipolar disorder (formerly called manic-depressive illness or manic depression a mental illness that causes unusual shifts in a person's mood). A physician order, dated 10/3/24, indicated to place Wander Guard bracelet on the right ankle. Check wander guard placement every shift. A care plan, dated 10/3/24, indicated Resident 34 was an elopement risk. Intervention included but not limited to Wander Guard placement to right ankle. The care plan record lacked indication or documentation of resident exhibiting exit seeking behavior. Assessments titled Wandering and Elopement risk, dated 6/30/25, 10/6/25 and 1/8/26, indicated the resident was not an elopement risk. A quarterly Minimum Data Assessment (MDS), dated [DATE], indicated wandering and exit seeking behaviors was not exhibited and the resident was cognitively intact during the assessment period. A quarterly MDS, dated [DATE], indicated wandering and exit seeking behaviors was not exhibited and the resident had limited cognition during the assessment period. A quarterly MDS, dated [DATE], indicated wandering and exit seeking behaviors was not exhibited and the resident had limited cognition during the assessment period. An annual MDS, dated [DATE], indicated wandering was not exhibited and the resident had limited cognition during the assessment period. A quarterly MDS, dated [DATE], indicated wandering and exit seeking behaviors was not exhibited and indicated the resident was cognitively intact during the assessment period. A quarterly MDS, dated [DATE], indicated wandering and exit seeking behaviors was not exhibited and the resident had limited cognition during the assessment period. On 1/23/26 at 1:00 p.m., during an interview, LPN 7 indicated the resident had a wander guard because he had dementia and when he first came into the facility he got lost easily and would try to go outside. She did not recall if he had any issues with wandering since admission.The medical record lacked supporting diagnosis of dementia. On 1/23/26 at 1:44 p.m., during a phone interview, the resident's guardian indicated she was not sure why the resident still had a wander guard. She indicated when he first arrived at the facility he was wandering some, but she did not know if he still was. She indicated she would follow up with the facility to determine if he was still wandering to determine if he continued to require the wander guard. On1/23/26 at 3:07 p.m., the Regional Director of Clinical Operations (RDCO) provided an undated document titled, Clinical Documentation Standards, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure.b. The nurse is expected to; I. Document accurately and truthfully to the best of his/her knowledge, what is heard or seen during assessments or encounters that concern the resident.iv. Document the status of the resident including changes. 3.1-35(d)(2)(B)

Based on observation, record review, and interview, the facility failed to ensure call lights were kept within residents' reach for 3 of 32 residents reviewed for call lights (Resident 19, 55, and 10).Findings include:1. During an observation, on 1/21/26 at 9:17 a.m., Resident 19 was lying in bed with a touch pad call light at the foot of the bed, next to the resident's feet. The call light was out of the resident's reach. During an observation, on 1/21/26 at 2:56 p.m., Resident19 was lying in bed, and the bed was next to the wall. The call light was stuck between the bed and the wall, out of the resident's reach. During an observation, on 1/22/26 at 2:11 p.m., Resident19 was lying in bed, and the bed was next to the wall. The call light was stuck between the bed and the wall, out of the resident's reach. Resident 19's record was reviewed on 1/23/26 at 2:00 p.m. An annual Minimum Data Set (MDS) assessment, dated 11/25/25, indicated the resident had a severe cognitive impairment, required partial/moderate assistance from staff for transfers, and had two or more falls since the prior assessment. A care plan, last revised on 12/4/25, indicated the resident was at risk for falls and had a history of multiple falls. Interventions included, but were not limited to, place call light within reach and remind the resident to ask for assistance, remind the resident how to operate the call light, remind the resident to call for staff for assistance to the bathroom, and remind resident to call for staff before transferring into bed. A post fall evaluation indicated the resident fell on [DATE] at 7:00 p.m. The resident attempted to go to the bathroom without using the call light to ask for assistance. Interventions to prevent further falls included, but were not limited to, educating the resident to use call light for staff assistance prior to transfers. A post fall evaluation indicated the resident fell on [DATE] at 6:45 a.m. The root cause was the resident attempted to take himself to the bathroom without staff assistance. The intervention to prevent further falls was to educate the resident to use the call light for staff assistance. 2. During an observation, on 1/20/26 at 11:40 a.m., Resident 55 was lying in bed. The call light was clipped to something hanging on the wall behind the resident's head of the bed. At the same time, the resident indicated he used the call light to ask for staff assistance, but he did not know where it was. During an observation, on 1/20/26 at 11:43 a.m., Qualified Medication Aide (QMA) 17 entered Resident 55's room to provide care. During an observation, on 1/20/26 at 11:45 a.m., QMA 17 exited Resident 55's room. At the same time, the resident's call light remained clipped to something hanging on the wall behind the head of the bed, out of reach. During an observation, on 1/21/26 at 2:53 p.m., the resident was lying in bed. The call light remained clipped to something hanging on the wall behind the head of the bed, out of reach. At the same time, the resident indicated he was not able to find his call light. During an observation, on 1/22/26 at 10:35 a.m., the resident was lying in bed. The call light remained clipped to something hanging on the wall behind the head of the bed, out of reach. Resident 55's record was reviewed on 1/23/26 at 9:46 a.m. An annual Minimum Data Set (MDS) assessment, dated 11/12/25, indicated the resident had a moderate cognitive impairment. A care plan, last revised on 10/30/25, indicated the resident had an activities of daily living (ADL) self-care performance deficit and required the assistance of one staff member with transfers. A care plan, last revised on 12/15/25, indicated the resident was at risk for falls. Interventions included, but were not limited to, educate the resident to work the call light. During an interview, on 1/23/26 at 11:12 a.m., Certified Nurse Aide (CNA) 14 indicated Resident 55 used his call light to request assistance, and it should have been placed where he was able to reach it. 3. During an observation, on 1/20/26 at 11:20 a.m., Resident 10 was lying in bed. The touch pad call light was at the foot of the resident's bed and out of reach. At the same time, the resident indicated he did not know where the call light was located. During an observation, on 1/20/26 at 11:46 a.m., Resident 10 was sitting in a chair in his room. The resident's right hand was contracted (severe, chronic muscle stiffness which cause the hand to be fixed). The resident's call light was clipped to the chair behind, and to the right, of the resident's head. At the same time, the resident indicated he did not know where the call light was. Once the resident was made aware of where the call light was he attempted to reach across his body with his left arm to reach the call light, but he was unable to reach far enough. During an observation, on 1/21/26 at 2:51 p.m., Resident 10 was lying in bed, and the bed was next to the wall. The call light was placed on top of a box that holds gloves attached to the wall, above the resident's bed, and out of the resident's reach. During an observation, on 1/23/26 at 9:31 a.m., Resident 10 was up in a chair in his room. The call light was on the glove box, attached to the wall, above the resident's bed, and out of the resident's reach. Resident 10's record was reviewed on 1/23/26 at 2:26 p.m. The resident's profile included a diagnosis of hemiplegia (paralysis affecting one side of the body) affecting right dominant side. A care plan, last revised on 4/24/25, indicated the resident was at risk for falls and had a history of falls. A care plan, last revised on 8/21/25, indicated the resident had an activities of daily living (ADL) self-care performance deficit and was dependent on staff assistance for transfers. During an interview, on 1/27/26 at 10:19 a.m., Licensed Practical Nurse (LPN) 12 indicated all residents should have had their call lights within their reach. The CNAs and nurses should have made sure call lights were within the residents' reach prior to leaving a residents' room. On 1/27/26 at 10:32 a.m., the Regional Director of Clinical Operations (RDCO) provided an undated document titled, Resident Rights, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents.Procedure: 1. Residents will be treated with dignity and respect including but not limited to.c. To have a method to communicate needs to staff i. Call light or bell access will be within reach of the resident as one method to communicate needs to staff. 3.1-3(v)(1)

Based on observations, record review, and interview, the facility failed to ensure the resident was provided the necessary services to maintain grooming and daily care needs for 1 of 32 residents reviewed for daily care needs (Resident 12). Findings include:On 1/20/26 at 10:00 a.m., during an initial observation, observed Resident 12 lying in bed with excessive facial hair, dried pureed food on her shirt, oxygen tubing lying in the dried food, and hair was greasy and disheveled. On 1/21/26 at 10:15 a.m., the medical record of Resident 12 was reviewed. The resident was admitted to the facility on [DATE]. Diagnosis included, but were not limited to, diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), hypertension (high blood pressure), anxiety (a feeling of fear, dread, and uneasiness) and osteomyelitis (a painful bone infection that causes inflammation and swelling in the bone) of the left foot. The medical record lacked supporting documentation of respiratory diagnosis. The medical record lacked documentation of a care plan indicating the resident refused care. An annual Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident 12 was cognitively intact and required extensive to maximum assistance for daily care needs. The MDS did not indicate refusal of care or exhibited behaviors during the assessment period. On 1/21/26 at 2:54 p.m., during a routine observation Resident 12 was lying in bed with excessive facial hair observed. On 1/22/26 at 2:48 p.m., during a routine observation Resident 12 was lying in bed with excessive facial hair noted. On 1/23/26 at 9:15 a.m., during an interview, Licensed Practical Nurse (LPN) 7 indicated the resident refused to allow the staff to shave her. On 1/23/26 at 9:20 a.m., during an interview Certified Nurse Aide (CNA) 8 indicated the resident allowed her to shave her and to provide assistance with care needs. On 1/23/26 at 9:25 a.m., during an observation and an interview Resident 12 indicated she allowed the staff to shave her and did not refuse assistance with care needs. On 1/23/26 at 10:23 p.m., the Administrator provided an undated document titled, Routine Resident Care, and indicated it was the policy currently being used by the facility. The policy indicated, .2. Provide routine daily care by a certified nursing assistant.g. Assisting and teaching activities of daily living.k. Providing an environment that contributes to a positive self-image preserves dignity and promotes privacy.3. Unlicensed staff.b. Routine care by a nursing assistant includes but is not limited to the following: i. Assisting or provides personal care. 3.1-38(a)(3)

Based on record review and interview, the facility failed to provide family notification after a resident experienced a significant change in condition and subsequently received life-sustaining interventions to include a ventilator without notification to the emergency contact, for 1 of 3 residents reviewed for quality of care (Resident B). Findings include, A confidential interview during the survey indicated Resident B's emergency contact was not notified when the resident was transferred from the facility on [DATE]. Resident B's clinical record was reviewed on [DATE] at 10:47 a.m. Diagnoses on Resident B's profile included personal history of transient cerebral ischemic attack (TIA-stroke), and seizure disorder. A physician's order, dated [DATE], indicated send the resident to the hospital for evaluation and treatment. An eINTERACT SBAR Summary for Providers, dated [DATE] at 5:30 a.m., indicated the resident had a fall and was unresponsive. Resident B was found on floor in the bathroom, assessed, transferred to the bed unresponsive, 911 was called, and he transferred to a local hospital emergency room. A Transfer to Hospital form, dated [DATE] at 5:30 a.m., Section E Key Contacts, documented Resident B's sister's name with phone number as his emergency contact. The box was checked to indicate the representative was not aware of the transfer. On [DATE] at 5:45 a.m., Registered Nurse (RN) 8 documented she was coming on shift when she observed an ambulance at the facility to transport Resident B to the hospital for stroke symptoms. Staff reported that the resident had been observed by a Certified Nursing Assistant (CNA) at 5:00 a.m., and he was up and talking at that time. At about 5:35 a.m., Resident B's roommate put on his call light and reported Resident B was on the floor in the bathroom. Resident B had right sided facial dropping and was not able to raise his right arm. 911 was called and an ambulance picked the resident up. Resident B's clinical record lacked documentation the emergency contact was made aware of the resident's fall, acute change in condition, or transfer to the hospital on [DATE]. During an interview on [DATE] at 10:31 a.m., Resident B's family member indicated she was the resident's emergency contact, and they were in communication often. The resident's birthday was on [DATE]th, and the family had made plans to visit the resident on that day to celebrate. On [DATE] the family member had made 3 attempts to call the resident during the day, and each time the call was transferred to the nurse's station but never picked up. A 4th phone call that evening around 9:00 p.m. was finally picked up by a staff member. The unidentified staff member relayed the information that Resident B had been sent to a local hospital on the morning of [DATE], but later the same day transferred to Indianapolis where he remained hospitalized in the Intensive Care Unit (ICU) where he was receiving life-sustaining interventions to include a ventilator. The family member indicated, in her opinion, [Resident B] had suffered while laying alone in the hospital. If the facility had contacted her as they should have, she might have been able to be by his side in his last lucid moments, and he would have known she was sitting by his side, holding his hand, and offering comfort. Resident B subsequently died on [DATE], never having regained consciousness. On [DATE] at 4:30 p.m., the Divisional Director provided a Notification of Change in Condition policy, undated, and indicated the policy was the one currently being used by the facility. The policy indicated, The center must inform the resident, consult with the resident's medical practitioner and/or notify the resident's representative, authorized family member, or legal power of attorney/guardian when there is a change requiring such notification. Circumstances requiring notification including but not limited to. 2. Significant change in resident's physical, mental, or psychosocial condition such as deterioration in health.a. life-threatening conditions.4. A transfer or discharge of the resident from the center.Notifications.When a change in condition is noted, the nursing staff will contact the resident representative.Notifications that are for emergency situations require prompt notification as soon as time permits. Examples may include but are not limited to: transfer to hospital, severe change in physical or mental health. This citation relates to Intake 2707163. 3.1-5(a)(2)3.1-5(a)(4)

Based on interview and record review, the facility failed to protect the resident's right to be free from neglect, when the facility failed to ensure a resident was provided adequate monitoring and care during the night shift for 1 of 4 residents reviewed for neglect (Resident B). The immediate jeopardy began on [DATE] when staff failed to visualize a resident during the 8-hour night shift and the resident was found deceased on the floor between the bed and wheelchair the next morning at 7:15 a.m. The Administrator, Director of Nursing (DON), Regional Director of Clinical Operations (RDCO), and a RDCO in training were notified of the immediate jeopardy on [DATE] at 4:52 p.m. The immediate jeopardy was removed on [DATE], 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:Resident B's record was reviewed on [DATE] at 10:40 a.m. Census information indicated the resident was admitted to the facility on [DATE] and expired on [DATE]. Diagnoses on the resident's profile included, but were not limited to, chronic obstructive pulmonary disease (COPD) (a group of lung diseases that cause airflow obstruction and breathing problems), unspecified systolic congestive heart failure (a condition where the heart's left ventricle cannot pump blood effectively enough to meet the body's needs), type two diabetes mellitus without complications (a chronic condition where the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels), and atherosclerotic heart disease of native coronary artery (buildup of fats, cholesterol and other substances in and on the walls of the heart arteries) without angina pectoris (chest pain). A quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was cognitively intact, had not refused care, used a walker and wheelchair, required supervision or touching assistance with toileting hygiene, showering/bathing, upper/lower body dressing, personal hygiene, chair/bed transfers, toilet transfers, and tub/shower transfers. A Physician's Orders for Scope of Treatment (POST) form (a medical document that outlines a patient's end-of-life care preferences, designed for individuals who are seriously ill or frail and may have limited life expectancy), dated [DATE], was signed by the resident. The form indicated the resident wanted cardiopulmonary resuscitation (CPR) (an emergency lifesaving procedure performed when the heart stops beating) if the resident was found not breathing and with no pulse. A care plan, current at the resident's death and goal target dated [DATE], indicated the resident had an activities of daily living (ADL) performance deficit and required assistance with ADLs related to cognitive deficit, disease process, and functional deficit. Interventions included, but were not limited to, the resident preferred to go to bed by 9:30 p.m. to 10:00 p.m.; required the assistance of one staff member for transfers; staff were to place the resident's call light within reach and remind the resident to call for assistance if cognitively intact; and required supervision/touching assistance where the helper cued and touched/steadied the resident for toileting hygiene, upper body dressing, lower body dressing, putting on and taking off footwear, personal hygiene, rolling left and right in bed, sitting to lying, lying to sitting on the side of the bed, sit to stand movement, chair to bed and bed to chair transfers, and toilet transfers. A care plan, current at the resident's death and goal target dated [DATE], indicated the resident was incontinent of urine related to impaired mobility. Interventions included, but were not limited to, check the resident for incontinence, wash, rinse, and dry the perineum (layer of skin between genitals and anus), and change clothing as needed after incontinence episodes. A care plan, current at the resident's death and goal target dated [DATE], indicated the resident had impaired thought processes related to the resident being developmentally delayed with a long history of mental illness and mild intellectual disability. Interventions included, but were not limited to, provide the resident approaches that maximize her involvement in daily decision making and activities using cueing, task segmentation, and instructions. A care plan, current at the resident's death and goal target dated [DATE], indicated the resident was at risk for falls related to decreased mobility, anxiety, osteoarthritis (a common joint disease that causes pain, stiffness, and loss of function) to the right hip, type two diabetes mellitus, COPD, and systolic heart failure. The resident received psychotropic medication which increased the risk of falls and had a history of falls. Interventions included, but were not limited to, ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed and remind the resident and reinforce safety awareness including locked brakes on the bed and wheelchair before transfers, and sit on the side of the bed for a few minutes before transfers. A care plan, current at the resident's death and goal target dated [DATE], indicated the resident was able to make health care decisions and was a full code. Care plans lacked documentation the resident was independent with ADLs or refused for staff to enter the room. A Nurse Practitioner (NP) Progress Note, dated [DATE], indicated the resident was seen for a follow-up visit. The resident reported she fell a few days ago and did not tell any staff about it. The resident reported she experienced dizziness at times and right elbow and right hip pain. X-rays were ordered. A nurse's note, dated [DATE], indicated Resident B self-reported to Activities that she fell in her room around 4:30 a.m. The nurse spoke with the resident who stated she was in the bathroom, turned too fast, and fell. The resident stated her right upper arm was still sore from a fall last week. The resident was educated on turning her light and not rushing with ambulating and turning, she voiced that she understood. A nursing progress note, dated [DATE] at 7:15 a.m., indicated, Writer went into resident room to obtain [blood sugar] and pass morning medication. Resident was found on floor between wheelchair and bed, face down, resident unresponsive and cool to touch at this time. Writer called for other staff to help, resident had no pulse at this time, DON [Director of Nursing], MD [Medical Doctor], Admin [Administrator] were all called to report death. Progress notes from [DATE] until [DATE] were reviewed. There was only one unrelated progress note documented on [DATE] at 1:00 a.m. The next progress note documented was [DATE] at 7:15 a.m. when the resident was found deceased . Resident B's record lacked documentation the resident refused care, was independent with activities of daily living (ADLs), or refused staff to come into the resident's room at night. A Medication Administration Record (MAR), dated [DATE], indicated the resident had not refused any oral medications during the month. The resident refused Lantus (long-acting insulin) 10 times in the morning and 13 times during the month at bedtime. The resident refused insulin lispro (rapid-acting insulin) 9 times in the morning, 5 times in the afternoon, and 10 times in the evening. A MAR, dated [DATE], indicated the resident refused all medications, including insulin, at bedtime on [DATE]. A plan of care (POC) response history report, dated [DATE] to [DATE], indicated the amount of support provided for toilet use was to be documented and was to include, .how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad.adjusts clothes. For the 30 day report, the resident required no set up or physical help from staff twice during the look back period, set up help only 51 times during the look back period, and one person physical assistance twice during the look back period. The last recorded entry was on [DATE], and the report lacked documentation toilet assistance was provided after [DATE]. A POC response history report indicated the resident had no bowel movement on [DATE] at 11:37 p.m. The POC history report lacked further documentation after the entry on [DATE] at 11:37 p.m. A POC response history report indicated the resident was continent of bladder on [DATE] at 11:37 p.m. The POC history report lacked further documentation after the entry on [DATE] at 11:37 p.m. A POC response history report for toilet use indicated the number of times the resident used the toilet should be documented, between numbers one and ten. The last entry on the report was dated [DATE], and the report lacked documentation the resident used the toilet on [DATE] or [DATE]. On [DATE] at 1:39 p.m., the Regional Director of Clinical Operations (RDCO) provided an incident file regarding Resident B's death. The following documentation was included in the file. -A timeline of events indicated, on [DATE], at 7:15 a.m., Resident B was found by oncoming shift nurse Licensed Practical Nurse (LPN) 4 during morning rounds. The resident was located next to her bed with her wheelchair on her right side, was nonresponsive to verbal stimuli, and there was no pulse or respirations. LPN 4 identified Resident B had irreversible signs of death including rigor mortis (a post-death phenomenon where the muscles of the body become stiff and inflexible), and CPR was not initiated. At 7:16 a.m., LPN 4 called 911, the Administrator, and the DON. At 7:20 a.m., the resident's body was left untouched, and the door was closed. At 7:30 a.m., the first attempt to notify Resident B's family was made with multiple calls made until the resident's family was reached. At 7:30 a.m., the Administrator notified corporate management, and they instructed the Administrator to start an investigation. At 8:30 a.m., the Coroner arrived at the facility and requested the police be notified. At 9:10 a.m., the detective arrived at the facility. At 10:45 a.m., the body was released to the Coroner. -A typed statement from Licensed Practical Nurse (LPN) 7, dated [DATE], indicated, I did not physically go in to see her [Resident B], if she needs anything she typically comes out of her room and gets me. No change of condition was reported to me. -A typed statement from Certified Nurse Aide (CNA) 5, dated [DATE], indicated, I did not really interact with her all night, I knew she had refused her dinner and her bedtime meds. She had put her trash out and went to bed. She normally doesn't want us to come in, she comes out if she needs anything. -A typed statement from Qualified Medication Aide (QMA) 6, dated [DATE], indicated, I checked on her at the beginning of my shift, she was in bed sleeping, no change of condition was given to me at report, and no overnight medications were required. Normally she would come get me if she were to need anything. She doesn't really like it when people enter her room on overnights. -A typed statement from CNA 23, dated [DATE], indicated during the evening shift, [Resident B] seemed like her normal self, she refused dinner but that isn't out of the normal for her sometimes she chooses other things or eats things she has bought. She had been in activities but then went to her room, I offered her snacks and other drinks, but she refused. -A phone interview, performed by the Administrator on [DATE], with CNA 5 indicated the resident was fine but said she was not feeling well and refused bedtime medications. She was independent with ADLs, and the CNA did not provide much care to the resident. -A phone interview, performed by the Administrator on [DATE], with LPN 7 indicated LPN 7 never saw Resident B during the shift, and no changes in condition were reported. The resident was normally in bed during night shift and came out of the room if she needed something. She would have provided care, .very little if any at all, unless she comes out of her room and asks directly or a change of condition is reported. The interview did not indicate how LPN 7 would have become aware of a change in the resident's condition if she did not enter the resident's room for the duration of her shift. A preliminary autopsy report, dated [DATE], indicated the resident's date of death was [DATE]. The preliminary findings included, but were not limited to, atherosclerotic cardiovascular disease and no suspicious trauma. On [DATE] at 3:39 p.m., a police incident report was received. The incident report, dated [DATE], indicated the city police responded to the facility due to Resident B's death. The report narrative indicated the officer was made aware of the deceased resident and responded to the scene. The Coroner's deputy was outside the resident's room upon the officer's arrival. The officer observed Resident B lying on her back with a small amount of foam coming from her nose and mouth. Resident B's face was discolored more than the rest of her body. The officer spoke with LPN 4 who advised she arrived at the facility at 6:00 a.m., and went to check on the resident at approximately 7:15 a.m. LPN 4 observed the resident face down on the floor and called for help. LPN 4 advised the officer when she touched Resident B's arm, she knew Resident B was deceased . The Administrator was on the scene and provided staff information for the last 12 hours. The Administrator advised the officer LPN 7 was assigned to Resident B's unit on night shift and was assisted by CNA 5. The Administrator advised the officer residents should have been checked on every two hours. During an interview, on [DATE] at 10:30 am., the County Coroner indicated he received a call from his deputy regarding Resident B's death. Due to the circumstances, the death was investigated by the Coroner's office. The resident was found face down, on the floor, next to her wheelchair. It appeared as though she had possibly fallen out of the wheelchair. The autopsy was performed the morning of [DATE]. During an interview, on [DATE] at 10:52 a.m., LPN 4 indicated she was Resident B's nurse, on [DATE] at 7:15 a.m., when the resident was found deceased . LPN 4 went into the resident's room for morning medication pass and found the resident, on the floor, between the wheelchair and the bed. LPN 4 yelled for help and checked the resident for a pulse, but there was no pulse. LPN 9 responded and verified the resident had no pulse. LPN 4 called 911, the Administrator, DON, physician, and the coroner's office. The coroner's deputy came to the facility, and upon his arrival requested police assistance. LPN 4 believed the resident died in her wheelchair and fell out of the chair. The resident was stiff, cold, and unable to be moved to perform CPR due to full rigor mortis being set in. LPN 4 had not received any information the resident had been experiencing anything unusual during the shift-to-shift report. LPN 4 indicated all residents should have been checked on every two hours, and LPN 4 believed Resident B was dead longer than two hours before being found. LPN 4's shift started at 6:00 a.m. The previous night shift (10:00 p.m. to 6:30 a.m.), there was only one nurse on duty for the entire building, one QMA assigned to Resident B's unit and two other units (three units total on the assignment for one QMA), and one CNA assigned to Resident B's unit and one other unit (two units total on the assignment for one CNA). This was not an unusual number of staff for night shift, and there was often only one nurse for the shift. LPN 4 indicated she thought there was normally between 93 and 96 residents in the facility. The number of staff in the building had an effect on how often they were able to check on the residents. LPN 4 had worked night shift, and staffing on night shift was worse than day shift. LPN 4 normally worked day shift. LPN 4 thought she was able to get the residents taken care of on night shift, but it was hard. During an interview, on [DATE] at 11:09 a.m., CNA 5 indicated she worked a double shift, including evening shift on [DATE] and night shift on [DATE] into the morning of [DATE]. On [DATE], evening shift, CNA 5 was assigned to one on one observation of another resident on Resident B's unit. CNA 5 thought she saw Resident B for the last time around 9:00 p.m. or 10:00 p.m., on [DATE], while she was assigned to the other resident for one on one observation. CNA 5 indicated she was assigned to Resident B's unit and one other unit during the night shift, from [DATE] into the morning of [DATE]. There was one nurse for the entire building and a QMA also assigned to Resident B's unit and two other units. CNA 5 indicated she did not see Resident B during the night shift, after her last observation between 9:00 p.m. and 10:00 p.m., on [DATE]. CNA 5 indicated Resident B toileted herself and would turn on her call light if she needed something. CNA 5 had not worked a night shift in a while, and it was more difficult than what she had experienced before. Resident B slept with her door closed and the curtain pulled and did not have a roommate. CNA 5 indicated she normally did rounds every two hours, but she had taken care of the resident for a long time and was used to the resident's normal behavior. She normally would have went into the resident's room, said her name, and checked on her, but she had not done that on the night of [DATE] into the morning of [DATE]. She had not worked night shift in a long time and thought she would be able to get to everyone, but she was not. She left the facility right at 6:00 a.m. on the morning of [DATE]. During an interview, on [DATE] at 11:23 a.m., CNA 8 indicated she worked day shift, the morning of [DATE]. CNA 8 indicated she was assigned to Resident B's unit and received a written shift-to-shift report from CNA 5 at the beginning of her shift. CNA 8 indicated the written report indicated Resident B was fine, sleeping. It was not common for her to only receive a written report, but she thought the night shift CNA worked a double shift and was not at the facility when CNA 8 arrived at 7:00 a.m. Normally, at shift change the CNAs should have walked room to room observing the residents and giving an oral report from the off-going to the oncoming shift. If this had occurred as it should have, they would have found Resident B at least a little bit sooner. CNA 8 indicated she had not gone into Resident B's room yet when the nurse found Resident B deceased and CNA 8 had only been in the facility about 15 minutes. CNA 8 indicated she had not worked night shift, but she thought night shift staffing was an issue because she often came into her shift and found people excessively incontinent of urine, as though they had not been checked or provided incontinence care. Resident B was pretty independent and needed supplies provided and set-up assistance with ADLs. Staff should have been checking on all residents, even independent residents, at least every two hours. During an interview, on [DATE] at 11:29 a.m., LPN 9 indicated she was the second nurse to respond to Resident B's room after LPN 4 found Resident B deceased . LPN 9 indicated she worked day shift on [DATE]. When she arrived to Resident B's room, Resident B was lying in the fetal position, on the floor, on her right side, with the right arm straight back behind the shoulder. They knew the resident requested CPR if found with no pulse or respirations, however the resident was already mottled (purplish-red skin discoloration that occurs after death due to the pooling of blood in the lower parts of the body with stiff hands and feet). The nurses called the Administrator, and the Administrator instructed them to not touch anything and to leave the room. 911 was called. LPN 9 reviewed the schedule and indicated there was one nurse for the entire facility, one QMA assigned to Resident B's unit and two other units, and one CNA assigned to the resident's unit and one other unit, for the night shift on [DATE] into the morning of [DATE]. LPN 9 indicated that number of staff was pretty typical for the normal level of night shift staffing. LPN 9 indicated she had worked night shift previously, and that was not enough staff to get the residents checked on and provided care. LPN 7 had been the only nurse in the facility on night shift, and one nurse was just not enough. The staffing level contributed to this situation, and Resident B had been there quite a while before they found her. LPN 9 indicated Resident B put items on her bed during the day, and her bed was often covered with stuff. At night, when getting ready to go to bed, Resident B moved those items to her wheelchair. All the items were still on Resident B's bed, which led LPN 9 to believe Resident B never went to bed the night of [DATE]. Resident B normally went to bed around 9:00 p.m. or 10:00 p.m. and should have been checked on every two hours. Residents should have been checked on every two hours, regardless of how much ADL assistance they required. During an interview, on [DATE] at 11:43 a.m., the RDCO indicated it was their standard to check on residents every two hours, but she was not sure if there was a facility policy. During an interview, on [DATE] at 12:00 p.m., the County Coroner indicated Resident B's preliminary autopsy report was available. The resident likely died of natural cardiac related causes. There was no suspicious trauma. The Coroner estimated the length of time the resident was deceased before being found was between four and six hours. The Coroner indicated when the scene was observed, there was a lot of stuff on the resident's bed, so it was thought the resident was in the wheelchair at the time of the event. During an interview, on [DATE] at 12:52 p.m., LPN 7 indicated she was the nurse in the building for night shift, on the night of [DATE] into the morning of [DATE]. LPN 7 indicated she was the only nurse in the facility. There was a QMA assigned to Resident B's unit and two other units, a second QMA assigned to the other three units, and a CNA was assigned to Resident B's unit. The CNA assigned to Resident B's unit also had a second full unit and four rooms on another unit included on her assignment. LPN 7 indicated she did not see Resident B at all on her shift. Resident B did not require any care which led to LPN 7 entering her room. CNAs should have checked all residents every two hours, regardless of the level of assistance the residents required. Resident B normally came out of the room if she needed something or turned the call light on. There had only been one night shift nurse scheduled for a really long time. LPN 7 indicated if there were no issues on the night shift it might be OK, but if anything at all happened it was not enough staff. LPN 7 worried she would be unable to address more than one emergency at a time. LPN 7 indicated she was supposed to take a lunch break but was not able to because there were no other nurses available. There was not enough staff to get everything done. During an interview, on [DATE] at 1:30 p.m., QMA 6 indicated she worked night shift on [DATE] into the morning of [DATE]. QMA 6 was assigned to three units total and did not go into Resident B's room because she did not require medications. QMA 6 indicated she completed one round when her shift started and opened Resident B's door, sometime between 10:30 p.m. and midnight. She thought Resident B was in bed, but she did not actually see Resident B. QMA 6 indicated she observed Resident B's wheelchair next to her bed, with the curtain pulled, and assumed she was in bed, but QMA 6 did not fully enter the room to visualize Resident B. There was one nurse in the facility and one CNA assigned to Resident B's unit, one other unit, and part of a third unit. CNAs should have done bed checks every two hours. Resident B was independent, but she thought staff should have checked on the resident at least a couple of times a night. QMA 6 indicated she did not think there was enough staff on night shift to take care of the residents and check on them the way they need to. The staff was very spread out, and it was hard during emergencies. She would have to look for other staff for help. It was hard for the staff to take breaks, and the night shift nurse never took a break. Staffing was the worst on nights. CNA 5 assigned to Resident B had left the written report because the CNA had worked a double shift, evening shift on [DATE] and night shift from [DATE] into the morning of [DATE], and was assigned to work eight hours later, evening shift on [DATE]. CNA 5 had to leave the facility because she had to be back at work less than eight hours later. During an interview, on [DATE] at 2:52 p.m., the RDCO indicated Resident B had not wanted staff in her room at night. Resident B's preference should have been included on the care plan, but it was not. If a resident requested not to be checked on every two hours, resident education should have been provided, and the care plan should have been updated. On [DATE] at 1:39 p.m., the RDCO provided an undated document, titled, Nurse Aid Rounds, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: .CNA's.provide patient centered care by monitoring patient care needs and safety on a routine basis throughout the day.Procedure: 1. CNA's will routinely monitor residents.for routine care needs and safety.referred to as rounding.2. Rounding will be completed by CNA to safely transfer care between on-coming and off-going shifts.3. Nurses will monitor that rounding schedule is adequate and complete for meeting resident needs. On [DATE] at 10:50 a.m., the RDCO provided an undated document titled, Abuse & Neglect & Misappropriation of Property, and indicated it was the policy currently being used by the facility. The policy indicated, .Neglect: In Indiana, neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness (Deprivation of services). Examples: An action or lack of action that actually harms a resident such as.7) An action or lack of action that places one or more residents in a life-threatening situation, such as.c) Staff failing to identify, assess, monitor, and respond to residents suffering an acute condition.II. Training: 1. Provide education and training upon hire, annually and as needed for re-training to include but not limited to.e. Observations that may identify abuse or neglect.III. Prevention.3. Staffing is established based on census, acuity level, needs, and is posted daily in a conspicuous area for residents, family and visitors. The immediate jeopardy that began on [DATE] was removed on [DATE], when the facility ensured a systemic plan to include education and monitoring of staff to ensure staff provided supervision and required care to all residents residing at the facility. 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 Intakes 2635111 and 2635242. 3.1-27(a)(3)

Based on interview and record review, the facility failed to ensure sufficient staffing was provided to care for and supervise the residents that resided at the facility for 1 of 7 residents reviewed for sufficient staffing (Resident B). The immediate jeopardy began on [DATE] when the facility staff failed to provide care and supervision of residents residing at the facility during the eight hour night shift resulting in a resident not being checked on all night and was found deceased on [DATE] at 7:15 a.m. The Administrator, Director of Nursing (DON), Regional Director of Clinical Operations (RDCO), and a RDCO in training were notified of the immediate jeopardy on [DATE] at 4:52 p.m. The immediate jeopardy was removed on [DATE], 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:Resident B's record was reviewed on [DATE] at 10:40 a.m. Census information indicated the resident was admitted to the facility on [DATE] and expired on [DATE]. Diagnoses on the resident's profile included, but were not limited to, chronic obstructive pulmonary disease (COPD) (a group of lung diseases that cause airflow obstruction and breathing problems) unspecified, unspecified systolic congestive heart failure (a condition where the heart's left ventricle cannot pump blood effectively enough to meet the body's needs), type two diabetes mellitus without complications (a chronic condition where the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels), and atherosclerotic heart disease of native coronary artery (buildup of fats, cholesterol and other substances in and on the walls of the heart arteries) without angina pectoris (chest pain). A Physician's Orders for Scope of Treatment (POST) form (a medical document that outlines a patient's end-of-life care preferences, designed for individuals who are seriously ill or frail and may have limited life expectancy), dated [DATE], was signed by the resident. The form indicated the resident wanted cardiopulmonary resuscitation (CPR) (an emergency lifesaving procedure performed when the heart stops beating) if the resident was found not breathing and with no pulse. A nursing progress note, dated [DATE] at 7:15 a.m., indicated, Writer went into resident room to obtain [blood sugar] and pass morning medication. Resident was found on floor between wheelchair and bed, face down, resident unresponsive and cool to touch at this time. Writer called for other staff to help, resident had no pulse at this time, DON [Director of Nursing], MD [Medical Doctor], Admin [Administrator] were all called to report death. A plan of care (POC) response history report, dated [DATE] to [DATE], indicated the amount of support provided for toilet use was to be documented and included, .how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad.adjusts clothes. The last recorded entry was on [DATE], and the report lacked documentation toilet assistance was provided after [DATE]. A POC response history report indicated the resident had no bowel movement on [DATE] at 11:37 p.m. The POC history report lacked further documentation after the entry on [DATE] at 11:37 p.m. A POC response history report indicated the resident was continent of bladder on [DATE] at 11:37 p.m. The POC history report lacked further documentation after the entry on [DATE] at 11:37 p.m. A POC response history report for toilet use indicated the number of times the resident used the toilet should be documented, between numbers one and ten. The last entry on the report was dated [DATE], and the report lacked documentation the resident used the toilet on [DATE] or [DATE]. On [DATE] at 1:39 p.m., the Regional Director of Clinical Operations (RDCO) provided an incident file regarding Resident B's death. The following documentation was included in the file. -A timeline of events indicated, on [DATE], at 7:15 a.m., Resident B was found by oncoming shift nurse Licensed Practical Nurse (LPN) 4 during morning rounds. The resident was located next to her bed with her wheelchair on her right side, was nonresponsive to verbal stimuli, and there was no pulse or respirations. LPN 4 identified Resident B had irreversible signs of death including rigor mortis (a post-death phenomenon where the muscles of the body become stiff and inflexible), and CPR was not initiated. At 7:16 a.m., LPN 4 called 911, the Administrator, and the DON. At 7:20 a.m., the resident's body was left untouched, and the door was closed. At 7:30 a.m., the first attempt to notify Resident B's family was made with multiple calls made until the resident's family was reached. At 7:30 a.m., the Administrator notified corporate management, and they instructed the Administrator to start an investigation. At 8:30 a.m., the Coroner arrived at the facility and requested the police be notified. At 9:10 a.m., the detective arrived at the facility. At 10:45 a.m., the body was released to the Coroner. -A typed statement from Licensed Practical Nurse (LPN) 7, dated [DATE], indicated, I did not physically go in to see her [Resident B], if she needs anything she typically comes out of her room and gets me. No change of condition was reported to me. -A typed statement from Certified Nurse Aide (CNA) 5, dated [DATE], indicated, I did not really interact with her all night, I knew she had refused her dinner and her bedtime meds. She had put her trash out and went to bed. She normally doesn't want us to come in, she comes out if she needs anything. -A typed statement from Qualified Medication Aide (QMA) 6, dated [DATE], indicated, I checked on her at the beginning of my shift, she was in bed sleeping, no change of condition was given to me at report, and no overnight medications were required. Normally she would come get me if she were to need anything. She doesn't really like it when people enter her room on overnights. -A phone interview, performed by the Administrator on [DATE], with CNA 5 indicated the resident was fine but said she was not feeling well and refused bedtime medications. She was independent with ADLs, and the CNA did not provide much care to the resident. -A phone interview, performed by the Administrator on [DATE], with LPN 7 indicated LPN 7 never saw Resident B during the shift, and no changes in condition were reported. During an interview, on [DATE] at 10:52 a.m., LPN 4 indicated she was Resident B's nurse, on [DATE] at 7:15 a.m., when the resident was found deceased . LPN 4 went into the resident's room for morning medication pass and found the resident, on the floor, between the wheelchair and the bed. The resident was stiff, cold, and unable to be moved to perform CPR due to full rigor mortis being set in. LPN 4 had not received any information the resident had been experiencing anything unusual during the shift-to-shift report. LPN 4 indicated all residents should have been checked on every two hours, and LPN 4 believed Resident B was dead longer than two hours before being found. LPN 4's shift started at 6:00 a.m. The previous night shift (10:00 p.m. to 6:30 a.m.), there was only one nurse on duty for the entire building, one QMA assigned to Resident B's unit and two other units (three units total on the assignment for one QMA), and one CNA assigned to Resident B's unit and one other unit (two units total on the assignment for one CNA). This was not an unusual number of staff for night shift, and there was often only one nurse for the shift. LPN 4 indicated she thought there was normally between 93 and 96 residents in the facility. The number of staff in the building influenced how often they were able to check on the residents. LPN 4 had worked night shift, and staffing on night shift was worse than day shift. LPN 4 normally worked day shift. LPN 4 thought she was able to get the residents taken care of on night shift, but it was hard. During an interview, on [DATE] at 11:09 a.m., CNA 5 indicated she worked a double shift, including evening shift on [DATE] and night shift on [DATE] into the morning of [DATE]. On [DATE], evening shift, CNA 5 was assigned to one on one observation of another resident on Resident B's unit. CNA 5 thought she saw Resident B for the last time around 9:00 p.m. or 10:00 p.m., on [DATE], while she was assigned to the other resident for one on one observation. CNA 5 indicated she was assigned to Resident B's unit and one other unit during the night shift, from [DATE] into the morning of [DATE]. There was one nurse for the entire building and a QMA also assigned to Resident B's unit and two other units. CNA 5 indicated she did not see Resident B during the night shift, after her last observation between 9:00 p.m. and 10:00 p.m., on [DATE]. CNA 5 had not worked a night shift in a while, and it was more difficult than what she had experienced before. CNA 5 indicated she normally did rounds every two hours. She normally would have gone into the resident's room, said her name, and checked on her, but she had not done that on the night of [DATE] into the morning of [DATE]. She had not worked night shift in a long time and thought she would be able to get to everyone, but she was not. She left the facility right at 6:00 a.m. on the morning of [DATE]. During an interview, on [DATE] at 11:23 a.m., CNA 8 indicated she worked day shift, the morning of [DATE]. CNA 8 indicated she was assigned to Resident B's unit and received a written shift-to-shift report from CNA 5 at the beginning of her shift. CNA 8 indicated the written report indicated Resident B was fine, sleeping. It was not common for her to only receive a written report, but she thought the night shift CNA worked a double shift and was not at the facility when CNA 8 arrived at 7:00 a.m. Normally, at shift change the CNAs should have walked room to room observing the residents and giving an oral report from the off-going to the oncoming shift. If this had occurred as it should have, they would have found Resident B at least a little bit sooner. CNA 8 indicated she had not gone into Resident B's room yet when the nurse found Resident B deceased since she had only been in the facility about 15 minutes. CNA 8 indicated she had not worked night shift, but she thought night shift staffing was an issue because she often came into her shift and found people excessively incontinent of urine, as though they had not been checked or provided incontinence care. Resident B was pretty independent and needed supplies provided and set-up assistance with ADLs. Staff should have been checking on all residents, even independent residents, at least every two hours. During an interview, on [DATE] at 11:29 a.m., LPN 9 indicated she was the second nurse to respond to Resident B's room after LPN 4 found Resident B deceased . LPN 9 indicated she worked day shift on [DATE]. LPN 9 reviewed the schedule and indicated there was one nurse for the entire facility, one QMA assigned to Resident B's unit and two other units, and one CNA assigned to the resident's unit and one other unit, for the night shift on [DATE] into the morning of [DATE]. LPN 9 indicated that number of staff was pretty typical for the normal level of night shift staffing. LPN 9 indicated she had worked night shift, and that was not enough staff to get the residents checked on and provided care. LPN 7 had been the only nurse in the facility on night shift, and one nurse was just not enough. The staffing level contributed to this situation, and Resident B had been there quite a while before they found her. LPN 9 indicated Resident B put items on her bed during the day, and her bed was often covered with stuff. At night, when getting ready to go to bed, Resident B moved those items to her wheelchair. All the items were still on Resident B's bed, which led LPN 9 to believe Resident B never went to bed the night of [DATE]. Resident B normally went to bed around 9:00 p.m. or 10:00 p.m. and should have been checked on every two hours. Residents should have been checked on every two hours, regardless of how much ADL assistance they required. During an interview, on [DATE] at 12:00 p.m., the County Coroner indicated Resident B's preliminary autopsy report was available. The Coroner estimated the length of time the resident was deceased before being found was between four and six hours. The Coroner indicated when the scene was observed, there was a lot of stuff on the resident's bed, so it was thought the resident was in the wheelchair at the time of the event. During an interview, on [DATE] at 12:52 p.m., LPN 7 indicated she was the nurse in the building for night shift, on the night of [DATE] into the morning of [DATE]. LPN 7 indicated she was the only nurse in the facility. There was a QMA assigned to Resident B's unit and two other units, a second QMA assigned to the other three units, and a CNA was assigned to Resident B's unit. The CNA assigned to Resident B's unit also had a second full unit and four rooms on another unit included on her assignment. LPN 7 indicated she did not see Resident B at all on her shift. Resident B did not require any care which led to LPN 7 entering her room. CNAs should have checked all residents every two hours, regardless of the level of assistance the residents required. Resident B normally came out of the room if she needed something or turned the call light on. There had only been one night shift nurse scheduled for a really long time. LPN 7 indicated if there were no issues on the night shift it might be OK, but if anything at all happened it was not enough staff. LPN 7 worried she would be unable to address more than one emergency at a time. LPN 7 indicated she was supposed to take a lunch break but was not able to because there were no other nurses available. There was not enough staff to get everything done. During an interview, on [DATE] at 1:30 p.m., QMA 6 indicated she worked night shift on [DATE] into the morning of [DATE]. QMA 6 was assigned to three units total and did not go into Resident B's room because she did not require medications. QMA 6 indicated she completed one round when her shift started and opened Resident B's door, sometime between 10:30 p.m. and midnight. She thought Resident B was in bed, but she did not actually see Resident B. QMA 6 indicated she observed Resident B's wheelchair next to her bed, with the curtain pulled, and assumed she was in bed, but QMA 6 did not fully enter the room to visualize Resident B. There was one nurse in the facility and one CNA assigned to Resident B's unit, one other unit, and part of a third unit. CNAs should have done bed checks every two hours. QMA 6 indicated she did not think there was enough staff on night shift to take care of the residents and check on them the way they need to. The staff was very spread out, and it was hard during emergencies. She would have to look for other staff for help. It was hard for the staff to take breaks, and the night shift nurse never took a break. Staffing was the worst on nights. CNA 5 assigned to Resident B had left the written report because the CNA had worked a double shift, evening shift on [DATE] and night shift from [DATE] into the morning of [DATE], and was assigned to work eight hours later, evening shift on [DATE]. CNA 5 had to leave the facility because she had to be back at work less than eight hours later. During an interview, on [DATE] at 2:30 p.m., Resident F indicated he did not think there was enough staff to meet his needs, especially at night. The staff called in a lot, and they were short staffed. During an interview, on [DATE] at 2:55 p.m., Resident G indicated the facility was short staffed at night, and the facility assigned too many residents to one person. There was not enough staff to provide for her care needs, and she required assistance with daily care. She indicated there were times when she was very ill and had to wait some time for a nurse to check on her because the nurse was busy. During an interview, on [DATE] at 3:00 p.m., the Administrator indicated they normally scheduled two nurses and two QMAs or a nurse and three QMAs on night shift. During an interview, on [DATE] at 3:52 p.m., LPN 11 indicated there was not enough staff to provide resident care on evening and night shift. Facility management told them the facility corporation would not allow them to have an additional nurse on night shift because the facility's census was not high enough. The night shift was consistently staffed with one nurse to cover the entire building and a QMA on the secured unit. Midnight census reports indicated there were 97 residents in the facility on [DATE] and 96 residents on [DATE]. During an interview, on [DATE] at 11:43 a.m., the RDCO indicated it was their standard to check on residents every two hours, but she was not sure if there was a facility policy. At the same time, the Administrator indicated the corporation had to review the Facility Assessment and provide it to the facility. The Administrator indicated she would provide the Facility Assessment when she received it. On [DATE] at 2:52 p.m., the RDCO provided the Facility Assessment, and indicated it was the assessment being used by the facility. The assessment indicated, .The purpose of the assessment is to comply with CMS [Centers for Medicare and Medicaid Services] Survey and Certification requirements.[NAME] Healthcare Center has reviewed our patient/resident population served, identified their evidence-based information, and extracted it from the resident assessments. The information is used to determine resident needs and clarified what the assessments reported by counting residents with the various assessment defined data. To support this Facility Assessment, we are reviewing what we learn, what resources we have to meet needs and care plans and what resources we do not have to meet those needs. In this way, needs are examined so that the resources necessary to care for residents competently are available during both day-to-day operations and emergencies.Overview of the [NAME] Healthcare Center Facility-Wide Assessment: 1. Resident profile presenting summary numbers for the population, admissions, diseases/conditions, physical and cognitive disabilities, CMS Case Mix acuity, behavioral health needs, and ethnic/cultural/religious factors present among the persons served.3. Services and care offered based on resident needs defined by the Resident Assessment Instrument.that includes the types of care our historic population of individuals have required. The Facility Assessment included a review of residents' Minimum Data Set (MDS) ADL data for eating, toileting hygiene, sitting to lying, lying to sitting on bedside, sit to stand, chair/bed to chair transfer, toilet transfer, oral hygiene, walk 50 feet with 2 turns, and walk 150 feet. There were no residents documented as independent with any of the ADL categories. All residents required set-up or clean-up assistance, supervision or touching assistance, partial/moderate assistance, substantial/maximal assistance, dependent, or the activity was not attempted for medical or safety reasons. A review of special resident treatments or conditions on the Facility Assessment indicated 82 residents had active or current substance use disorders, 1 resident was on dialysis, 12 residents were on hospice care, 91 residents received injections, 2 residents were on isolation or quarantine for active infectious disease, 23 residents received intravenous (IV) medications, 16 residents received ostomy care, 4 residents had bilevel positive airway pressure (BIPAP) (non-invasive ventilation therapy that delivers two different levels of air pressure to help people with breathing problems) or continuous positive airway pressure (CPAP) (treatment for sleep apnea and other breathing disorders that involve airway collapse during sleep), 48 residents received oxygen therapy, 1 resident received suctioning, and 1 received tracheostomy care. During the MDS look-back period 12 residents exhibited physical behaviors directed towards others, 40 residents exhibited verbal behaviors directed towards others, 50 residents exhibited other behaviors not directed towards others, 19 residents rejected care, and 9 residents exhibited wandering behavior. The Facility Assessment included the following prompts that had not been reviewed or revised by the facility. - .Policies and procedures for provision of care: 3.5. Describe how you evaluate what policies and procedures may be required in the provision of care, and how you ensure those meet current professional standards of practice. Included, for example, your process to determine if new or updated policies are needed and how they are developed or updated. The assessment lacked documentation this prompt was evaluated. - .Working with medical practitioners.3.6. Describe your plan to recruit and retain enough medical practitioners (e.g., physicians, nurse practitioners) who are adequately trained and knowledgeable in the care of your residents/patients, including how you will collaborate with them to ensure that the facility has appropriate medical practices for the needs and scope of your population. 3.7. Describe how the management and staff familiarize themselves with what they should expect from medical practitioners and other healthcare professionals related to standards of care and competencies that are necessary to provide the level and types of support and care needed for your resident population. For example, do you share expectations for providers that see residents in your nursing Residence on the use of standards, protocols, or other information developed by your medical director? Do you have discussions on what providers and staff expect of each other in terms of the care delivery process and clinical reasoning essential to providing high quality care? The assessment lacked documentation this prompt was evaluated. The Facility Assessment indicated the following regarding the staffing model, .Staffing plan.Based on our facility resident population and their needs for care and support, our approach to staffing is to ensure that each of our Nursing Facility residents has the minimum direct care staff to meet the needs of the residents at any given time. An example for [facility name] that we strive to achieve is as shown below. Natural events, staff needs for illness, support of loved ones or family, and other unpredictable events do influence staff available. We work to assure necessary staff based on the model shown below. The staffing model referenced divided the facility up into six units, numbered one to six. The night shift licensed nurse range indicated 1-2 licensed nurses were required for units 1, 3, 4, and 5, for a total of 4 to 8 licensed nurses. The night shift nurse aide range indicated 1-2 nurse aides were required for units 1, 2, 3, 4, 5, and 6, for a total of 6 to 12 nurse aides. The staffing model did not include QMAs. Daily staffing schedules, dated [DATE] to [DATE], night shift included the following staffing and census. a. On [DATE], there was one licensed nurse, two QMAs, and five CNAs with a facility census of 97 residents. b. On [DATE], there was one licensed nurse, two QMAs, and six CNAs with a facility census of 93 residents. c. On [DATE], there was one licensed nurse, two QMAs, and five CNAs with a facility census of 93 residents. d. On [DATE], there were two licensed nurses with one not arriving until midnight, two QMAs, and five CNAs with a facility census of 97 residents. e. On [DATE], there was one licensed nurse, one QMAs, and four CNAs. The census was not included with this staffing schedule. The schedule indicated one QMA called in and lacked documentation a replacement was secured. f. On [DATE], there was one licensed nurse, two QMAs, and four CNAs with a facility census of 97 residents. g. On [DATE], there was one licensed nurse, two QMAs, and three CNAs with a facility census of 97 residents. A fourth CNA worked 10:00 p.m. until 2:00 a.m., and one CA called in, and the schedule lacked documentation a replacement was secured. h. On [DATE], there was one licensed nurse, two QMAs, and five CNAs with a facility census of 97 residents. i. On [DATE], there was one licensed nurse, two QMAs, and six CNAs with a facility census of 97 residents. j. On [DATE], there was one licensed nurse, two QMAs, and five CNAs with a facility census of 97 residents. k. On [DATE], there was one licensed nurse, two QMAs, and four CNAs with a facility census of 96 residents. One CNA called in, and the schedule lacked documentation a replacement was secured. l. On [DATE], there was one licensed nurse, two QMAs, and five CNAs with a facility census of 97 residents. m. On [DATE], there was one licensed nurse, two QMAs, and five CNAs with a facility census of 96 residents. n. On [DATE], there was one licensed nurse, two QMAs, and five CNAs with a facility census of 96 residents. One CNA called in, and the schedule lacked documentation a replacement was secured. o. On [DATE], there was one licensed nurse, two QMAs, and four CNAs with a facility census of 95 residents. p. On [DATE], there was one licensed nurse, two QMAs, and three CNAs with a facility census of 95 residents. One CNA called in, and the schedule lacked documentation a replacement was secured. q. On [DATE], there was one licensed nurse, two QMAs, and four CNAs with a facility census of 94 residents. r. On [DATE], there was one licensed nurse, two QMAs, and five CNAs with a facility census of 93 residents. s. On [DATE], there was one licensed nurse, two QMAs, and four CNAs with a facility census of 94 residents. t. On [DATE], there was one licensed nurse, two QMAs, and five CNAs with a facility census of 94 residents. u. On [DATE], there was one licensed nurse, two QMAs, and five CNAs with a facility census of 92 residents. One CNA called in, and the schedule lacked documentation a replacement was secured. v. On [DATE], there was one licensed nurse, two QMAs, and four CNAs with a facility census of 92 residents. w. On [DATE], there was one licensed nurse, two QMAs, and five CNAs with a facility census of 92 residents. x. On [DATE], there was one licensed nurse, two QMAs, and five CNAs with a facility census of 95 residents. y. On [DATE], there was one licensed nurse, two QMAs, and three CNAs with a facility census of 95 residents. Two CNAs called in, and the schedule lacked documentation replacements were secured. z. On [DATE], there was one licensed nurse, two QMAs, and four CNAs with a facility census of 95 residents. One CNA called in, and the schedule lacked documentation a replacement was secured. aa. On [DATE], there was one licensed nurse, two QMAs, and four CNAs with a facility census of 95 residents. bb. On [DATE], there was one licensed nurse, two QMAs, and five CNAs with a facility census of 95 residents. cc. On [DATE], there was one licensed nurse, two QMAs, and four CNAs with a facility census of 95 residents. dd. On [DATE], there was one licensed nurse, one QMA, and five CNAs with a facility census of 95 residents. One QMA called in, and the schedule lacked documentation a replacement was secured. ee. On [DATE], there was one licensed nurse, two QMAs, and five CNAs with a facility census of 95 residents. ff. On [DATE], there was one licensed nurse, one QMA, and four CNAs with a facility census of 96 residents. One QMA called in, and the schedule lacked documentation a replacement was secured. gg. On [DATE], there was one licensed nurse, two QMAs, and five CNAs with a facility census of 97 residents. hh. On [DATE], there was one licensed nurse, two QMAs, and five CNAs with a facility census of 98 residents. ii. On [DATE], there was one licensed nurse, two QMAs, and four CNAs with a facility census of 98 residents. Licensed Practical Nurse (LPN) 7 was noted to be scheduled every night shift from [DATE] to [DATE] without a day off. During an interview, on [DATE] at 2:52 p.m., the RDCO reviewed the Facility Assessment and confirmed it indicated one to two licensed nurses for four of the units and one to two nurse aides for all the units. She indicated the Facility Assessment did not really mean there were four to eight licensed nurses and six to twelve nurse aides required for night shift, but she was unable to say what the Facility Assessment meant if the numbers did not indicate the staffing model. They did not staff that many nurses or nurse aides on night shift. The RDCO indicated she thought they normally had two nurses on night shift. If there was one nurse, and more than one emergency occurred, there were CNAs that were CPR certified. They could use QMAs in place of licensed nurses in some cases. During an interview, [DATE] at 3:55 p.m., the Administrator indicated LPN 7 worked every night shift from [DATE] to [DATE]. The Administrator indicated they employed other night shift nurses, but she was unable to identify who the other night shift nurses were at the time of the interview. During an interview, on [DATE] at 10:35 p.m., LPN 13 indicated she had been employed by the facility for about a week. She worked as the only nurse last night, but she did have a nurse with her tonight. She was told by the administration that there would be 2 nurses on the night shift from now on. LPN 13 indicated there were 2 nurses, 1 QMA, 6 CNA's, and 2 sitters in the building for night shift. During an interview, on [DATE] at 10:44 p.m., QMA 15 indicated there was only one nurse on night shift. She worked 12 hour shifts from 6:00 p.m. to 6:00 a.m., routinely. She was assigned to the closed unit with a CNA, and the nurse covered the rest of the building. It was very hard to oversee and meet all the residents' needs. During an interview, on [DATE] at 10:54 p.m., CNA 12 indicated she had worked at the facility for about a month and there had only been one nurse on duty for the night shift for the entire month. She indicated it was always the same nurse who worked the night shift, and it was LPN 7. During an interview, [DATE] at 8:48 a.m., the RDCO indicated Quality Assurance Performance Improvement (QAPI) staffing audits were completed through [DATE], per the plan of correction (POC) for the staffing deficiency cited during the annual survey in [DATE]. In July they had an interim Administrator who felt that staffing was better and stopped all staffing audits except daily staffing calls. Then when the current Administrator started, they began to do staffing audits again. During an interview, on [DATE] at 8:55 a.m., the Administrator indicated the daily staffing calls were with their corporate office. They discuss the census and the staffing numbers. Corporate would suggest that they may require more staff, so they would advertise and offer different incentives. The QAPI had begun performing staffing audits after she started her position as the Administrator. During an interview, on [DATE] at 10:40 a.m., Resident N indicated the same nurse aide usually worked the unit on night shift. When Resident N requested Tylenol, the nurse aide had to let the nurse know so it could be administered. Resident N had to wait a long time sometimes to get the Tylenol after she requested it. She heard the staff say there was only one nurse covering three units, but she was not sure. She knew they did not have very many staff who worked the night shift, and it was not enough. Resident N indicated she turned her call light on this morning before 6:00 a.m. to request Tylenol, and it took the nurse aide approximately half an hour to answer the call light. The nurse aide told the resident she would let the nurse know she wanted Tylenol. The nurse gave her the Tylenol at 7:00 a.m. with her other morning medications. She thought this type of thing happened because they did not have enough staff and could not get to the residents more quickly. During an interview, on [DATE] at 10:55 a.m., Resident P indicated it took a long time for him to get his pain medication. He had to request medication and waited as long as nine hours after his request until he received it. There was no nurse specifically assigned to his unit, so he had to wait for one to come to the unit and give him the pain medication after he asked for it. During an interview, on 10/9/

Based on record review and interviews, the facility failed to accurately document wound description upon admission to the facility for 1 of 3 residents reviewed for wounds (Resident B), and failed to ensure medications were documented according to physician orders for administration of insulin for 1 of 3 residents reviewed for medication administration (Resident D). Findings include: 1. On 9/3/25 at 11:00 a.m., the medical record of Resident B was reviewed. The resident was admitted to the facility on [DATE]. admission diagnosis included but were not limited to paraplegia (paralysis that occurs in the lower half of the body), and type 2 diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high). A physician order, dated 8/11/25, indicated to administer Medi honey Wound/Burn Dressing External Gel to coccyx wound topically every dayshift for pressure ulcer care cover with ABD pad and secure. A physician order, dated 8/10/25, indicated administer Miconazole Nitrate 2 % Cream to perimeter of coccyx wound topically two times a day for fungal. A physician order, dated 8/13/25, indicated apply Santyl (a prescription ointment that removes dead tissue from wounds to help them heal) external ointment to coccyx wound daily for wound care. A physician order, dated 8/10/25, indicated to perform daily coccyx wound assessment and document abnormalities in progress notes every shift for Wound Management. A physician order, dated 8/10/25, indicated the resident was on a pressure reducing/relieving mattress every shift for pressure reducing/relieving. A care plan, dated 8/10/25, indicated the resident had impaired skin integrity and was at risk for further altered skin integrity related to dependent on staff for turning/repositioning, peri care after incontinent episodes, has an unstageable wound to coccyx. Interventions included but were not limited to complete skin at risk assessment upon admission/readmission, encourage resident to turn and reposition or assist as needed as resident allows, provide appropriate off-loading mattress and off-loading cushion if applicable, and treatments as ordered. An admission MDS assessment, dated 8/14/25, indicated the resident was cognitively intact and dependent upon the staff for personal care. On 9/4/25 at 9:05 a.m., during an interview the Minimum Data Set Assessment (MDS) coordinator indicated she would measure wounds and would stage the wounds at the time of admission. She indicated she entered the wound measurements in centimeters. She indicated when she measured Resident B's wound on admission she measured the wound in centimeters she acknowledged the measurement of 4 x 4 was in centimeters not in inches. She indicated the resident informed her when he was at the hospital he was left in one position for several hours and he developed a wound on his bottom. On 9/4/25 at 10:15 a.m., during phone interview with outside wound center facility (Nurse at wound center), indicated the resident was seen on 8/7/25. This was 3 days prior to the resident admission to the facility on 8/10/25. The wound center record indicated the sacral wound measured 6.1cm x 8.8 cm x 0.1 cm. The resident was seen by the wound center on 8/14/25, the day the resident was discharged from the facility. The wound center nurse indicated their record indicated the sacral wound measurements were 10.7 cm x 13.5 cm x 0.1 cm. The medical record indicated the wound had deteriorated prior to the resident's admission to the facility. On 9/4/25 at 10:31 a.m., during interview the DON indicated the initial measurements should be made by the RN or the MDS Coordinator. The wound nurse would follow up with the resident. She did not know if they were allowed to stage a wound. She indicated the nurse should measure wound in centimeters not in inches. On 9/4/25 at 10:50 a.m., the Director of Nursing (DON) provided a document, titled, “Measuring a Wound,” dated12/19/24, and indicated it was the policy currently being used by the facility. The policy indicated, “ .Dimensions 1. Measure length, width, depth, undermining and tunneling in centimeters….” 2. Resident D's record was reviewed on 9/3/25 at 1:15 p.m. The profile indicated the resident's diagnosis included, but were not limited to, type 2 diabetes mellitus with hyperglycemia (occurs when a person with diabetes has persistently high blood sugar levels due to insulin resistance and/or insufficient insulin production). A quarterly Minimum Data Set (MDS) assessment, dated 7/16/25, indicated the resident had moderate cognitive deficit and was on insulin injections. A care plan, dated 2/2/24, indicated the resident had diabetes and was at risk of complications. Interventions included but were not limited to, administer medication per provider's orders and observe for side effects and effectiveness. A physician order, dated 4/17/24, indicated to administer Lispro (insulin medication) subcutaneous (under the skin) solution pen injector 100 unit/ml (milliliter), inject 10 units subcutaneously before meals for type 2 diabetes mellitus at 7:30 a.m., 11:30 a.m., and 4:30 p.m. A physician order, dated 4/16/24, indicated to administer Glargine (insulin medication) subcutaneous pen injector 100 unit/ml, inject 30 units subcutaneously in the evening for dates at 9:00 p.m. Review of August 2025 MAR (medication administration record) indicated the Lispro insulin medication was documented as administered at the following times: a. On 8/3/25 the 7:30 a.m. dose was documented as administered at 11:47 a.m. b. On 8/4/25 the 7:30 a.m. dose was documented as administered at 8:50 a.m. c. On 8/5/25 the 4:30 p.m. dose was documented as administered at 10:08 p.m. d. On 8/6/25 the 7:30 a.m. dose was documented as administered at 8:47 a.m. e. On 8/6/25 the 4:30 p.m. dose was documented as administered at 6:47 p.m. f. On 8/10/25 the 4:30 p.m. dose was documented as administered at 6:03 p.m. g. On 8/11/25 the 11:30 a.m. dose was documented as administered at 3:17 p.m. h. On 8/10/25 the 4:30 p.m. dose was documented as administered at 6:07 p.m. i. On 8/12/25 the 7:30 a.m. dose was documented as administered at 8:40 a.m. j. On 8/12/25 the 4:30 p.m. dose was documented as administered at 11:32 p.m. k. On 8/13/25 the 11:30 a.m. dose was documented as administered at 1:25 p.m. l. On 8/15/25 the 7:30 a.m. dose was documented as administered at 9:30 a.m. m. On 8/15/25 the 11:30 a.m. dose was documented as administered at 1:34 p.m. n. On 8/15/25 the 4:30 p.m. dose was documented as administered at 10:10 p.m. o. On 8/18/25 the 7:30 a.m. dose was documented as administered at 8:39 a.m. p. On 8/18/25 the 4:30 p.m. dose was documented as administered at 7:56 p.m. q. On 8/21/25 the 7:30 a.m. dose was documented as administered at 8:39 a.m. r. On 8/26/25 the 7:30 a.m. dose was documented as administered at 9:49 a.m. s. On 8/28/25 the 7:30 a.m. dose was documented as administered at 8:39 a.m. t. On 8/31/25 the 4:30 p.m. dose was documented as administered at 5:42 p.m. Review of August 2025 MAR indicated the Glargine insulin medication was documented as administered at the following times: a. On 8/3/25 the 9:00 p.m. dose was documented as administered on 8/4/25 at 1:10 a.m. b. On 8/5/25 the 9:00 p.m. dose was documented as administered at 10:09 p.m. c. On 8/8/25 the 9:00 p.m. dose was documented as administered at 11:09 p.m. d. On 8/10/25 the 9:00 p.m. dose was documented as administered at 11:29 p.m. e. On 8/11/25 the 9:00 p.m. dose was documented as administered at 10:06 p.m. f. On 8/15/25 the 9:00 p.m. dose was documented as administered at 11:02 p.m. g. On 820/25 the 9:00 p.m. dose was documented as administered on 8/21/25 at 12:50 a.m. h. On 8/27/25 the 9:00 p.m. dose was documented as administered at 11:18 p.m. i. On 8/15/25 the 9:00 p.m. dose was documented as administered at 11:49 p.m. Review of September 2025 MAR indicated the Lispro insulin medication was documented as administered at the following times: a. On 9/1/25 the 7:30 a.m. dose was documented as administered at 9:02 a.m. b. On 9/2/25 the 4:30 p.m. dose was documented as administered at 6:10 p.m. During an interview, on 9/4/25 at 10:00 a.m., Licensed Practical Nurse (LPN) 5 indicated that the nurses would have to administer insulins to the residents on the halls that had a Qualified Medication Aide (QMA) working because QMAs were not allowed to give insulin injections. LPN 5 indicated it could be hard to administer the insulin medication on time if the nurse didn't prioritize her time management properly. During an interview, on 9/4/25 at 10:10 a.m., Registered Nurse (RN) 6 indicated that she would often get the insulin medications administered on time, but she would not always get the insulin documented at the time of administration; therefore, on the medication administration record it would appear as if the medication was administered late. During an interview, on 9/4/25 at 10:31 a.m., the Director of Nursing (DON) indicated staff should document the administration of medications when they were administered to the residents to ensure adequate documentation. On 9/4/25 at 10:48 a.m., the DON provided a document, dated 12/2/24, titled, Medication Administration, and indicated it was the currently policy being used by the facility. The policy indicated, .MAR: Medication Administration Record - the legal documentation for medication administration .f. Observe the five rights in giving each medication: .ii. the right time .dd. Medications will be charted when given .a. Documentation of medication will be current for medication administration b. Documentation of medications will follow accepted standards of nursing practice This citation relates to Intake 2602845. 3.1-50(a)(2) 3.1-50(f)

Based on record review and interview, the facility failed to ensure a thorough investigation of abuse allegations was conducted and a record of the investigation was maintained for 3 of 3 residents reviewed for abuse (Residents H, G, and F). Findings include:1. An Indiana Department of Health (IDOH) reportable incident investigation file was reviewed on 9/3/25 at 2:31 p.m. The file included an IDOH incident report dated 6/14/25. The report indicated Residents H and G had an altercation in the dining room. Resident H pushed Resident G's wheelchair across the dining room. There was no physical touch or harm. The staff immediately separated the residents, and an investigation was initiated. The report indicated the investigation would include resident statements. The incident file included two statements from staff members who witnessed the incident and three days of psychosocial follow-up for Residents H and G. The incident file lacked documentation of resident statements, including interviews to determine if other residents had experienced negative interactions with Resident H. Resident H's record was reviewed on 9/3/25 at 2:47 p.m. Diagnoses on the resident's profile included, but were not limited to, schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) unspecified. A quarterly Minimum Data Set (MDS) assessment, dated 7/9/25, indicated the resident had moderate cognitive impairment. The resident's electronic health record, including progress notes, lacked documentation of the incident on 6/14/25. 2. Resident G's record was reviewed on 9/4/25 at 10:28 a.m. Diagnoses on the resident's profile included, but were not limited to, unspecified dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) with behavioral disturbance. A quarterly Minimum Data Set (MDS) assessment, dated 7/14/25, indicated the resident had severe cognitive impairment. The resident's electronic health record, including progress notes, lacked documentation of the incident on 6/14/25. During an interview, on 9/4/25 at 10:50 a.m., the Executive Director (ED) indicated normally they interviewed other residents to determine if there were any other abuse concerns during investigations. She was not sure if this was done and would look for further information. During an interview, on 9/4/25 at 11:15 a.m., the ED indicated the information regarding the altercation should have been documented in the residents' electronic health record. During an interview, on 9/4/25 at 11:38 a.m., the ED indicated she was not able to find further documentation for the incident file, including interviews with other residents, at this time. 2. An Indiana Department of Health incident report document, dated 8/17/25 at 9:52 a.m., indicated staff had reported to the Executive Director (ED) that Certified Nurse Aide (CNA) 3 had made contact with Resident C on the facility's Memory Care unit resulting in Resident C sustaining a skin tear to his right forearm. The CNA had been suspended pending the investigation of the incident. Resident C's record was reviewed on, 9/3/25 at 10:33 a.m. The profile indicated the resident's diagnoses included, but were not limited to, unspecified dementia (a diagnosis given when a person experiences cognitive decline and symptoms of dementia, but the specific underlying cause or type of dementia cannot be identified through testing or observation). A quarterly Minimum Data Set (MDS) assessment, dated 7/28/25, indicated the resident had severe cognitive deficit and had no documented behaviors. A care plan, dated 7/20/23, indicated the resident had ADL (activities of daily living-the basic, routine tasks of self-care that most healthy individuals perform daily without assistance) deficit and required substantial to maximal assistance with ADLs. A care plan, dated 7/21/23, indicated the resident was at risk for altered skin integrity. A weekly skin check form, dated 8/15/25 at 5:38 a.m., indicated the resident had no new skin area issues. A weekly skin check forms, dated 8/22/25 at 5:38 a.m. and 8/22/25 at 6:25 a.m., indicated the resident had no new skin area issues. Weekly skin check form, dated 8/22/25 at 6:28 a.m., indicated the resident had a new skin area noted, but that area was not new since last skin check. The form lacked documentation of where the new skin area was located and what type of skin issue it was. The weekly skin check forms lacked documentation that any skin check was completed on 8/17/25, the date of the reported incident. Review of the nurse progress notes, dated 8/15/25 to 8/22/25, lacked documentation of any incident resulting in a skin tear to the resident's forearm. A Wound Nurse Practitioner progress note, dated 8/22/25, lacked documentation of a skin tear to the resident right forearm. A 30-day CNA Point of Care form, dated 8/5/25 through 9/3/25, lacked documentation of any observations of new skin area concerns. Review of the facility's incident investigation documentation, on 9/4/25 at 9:05 a.m., indicated the following: a. An undated statement from CNA 3. The statement lacked documentation of any situation where the resident was contacted by the CNA, any fall, or other reason where a skin tear would have been received by the resident. b. An interview of Resident C, dated 8/17/25, conducted by the ED and the Regional Director of Clinical Operations (RDCO). The interview document indicated the resident was not sure how he received the skin tear. He denied being afraid of any staff on the unit and that he felt safe on the unit. The document also included a statement which indicated that the ED and RDCO had interviewed the staff on the unit who had been working at the time of the incident. The statement lacked documentation of the names, titles, and individual statements by the staff who were interviewed. During an interview, with the ED and the RDCO, on 9/4/25 at 9:49 a.m., the ED indicated she and the RDCO were in the building when the incident happened, and the staff immediately notified her. She made the decision to suspend the CNA at that time. She indicated a skin assessment should have been done after the resident received the skin tear. She was unsure why there was not an assessment completed until 8/22/25. At the same time, the RDCO indicated they interviewed staff who had been working on the unit at the time of the incident. The staff indicated they could not determine that any type of abuse had been committed. He thought they had obtained individual statements from the staff who were interviewed but were not able to locate them. On 9/4/25 at 10:57 a.m., the ED provided a written statement from a housekeeper who indicated she was not on the unit during the time of the incident. No other statements were presented. During an interview, on 9/4/25 at 11:38 a.m., the ED indicated they had not been able to find any further documentation for this investigation. The nurse on the unit during the incident with the CNA had been interviewed and a statement was written. However, they could not find a copy of this statement. She had contacted the nurse, via telephone, and the nurse remembered writing a statement, but she did not have a copy of it. On 9/3/25 at 11:14 a.m., the ED provided an undated document, titled, “Indiana Abuse & Neglect & Misappropriation of Property,” and indicated it was the policy currently being used by the facility. The policy indicated, “…Investigation of Incidents…1…e. Statements will be obtained from the resident or from the reporter of the incident…g. Documentation of the facts and findings will be completed in each resident medical record…2. Suspected Abuse…d. Statements will be obtained from staff related to the incident, including victim, person reporting the incident, accused perpetrator and witnesses. This statement should be in writing, signed, and dated at the time written….” This citation relates to Intake 2591628. 3.1-28(d)

Based on observation, record review, and interview, the facility failed to ensure medications were administered and documented according to physician orders for administration of insulin for 4 of 4 residents reviewed for medication administration (Residents, D, F, B, and E). Findings include: 1. On 4/9/25 at 10:00 a.m., during an initial observation and interview of Residents D and E. The residents indicated they had received their insulin. They were not sure of times of administration and indicated it was administered at breakfast. On 4/9/25 at 1:40 p.m., observed Licensed Practical Nurse (LPN) 7, at the medication administration cart. The LPN indicated she was not usually late administering insulin. On 4/9/25 at 1:05 p.m. during interview with Resident D. She indicated she received her insulin around 12:30 p.m., She indicated she did not eat breakfast that a.m. but she did receive insulin. She did not know what time it was administered. She indicated she usually got her insulin before she ate but it did vary. On 4/9/25 at 2:10 p.m., during interview with Resident E, the resident indicated she thought her insulin was administered before meals, but she did not know the times it was administered. On 4/10/25 at 7:00 a.m., observed Registered Nurse (RN) 9, administering medications to residents. The employee indicated she had not administered insulin to residents and would administer insulins with their breakfast. On 4/10/25 at 10:40 a.m., the medical record of Resident D was reviewed. The resident was admitted to the facility on [DATE]. Admitting diagnosis included, but were not limited to, type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high), with diabetic neuropathy (a type of nerve damage that can occur if you have diabetes). A care plan, dated 10/7/20, indicated the resident had diabetes mellitus and was at risk for complications. Interventions included but were not limited to, diabetes medication as ordered by doctor. A Minimum Data Set (MDS) assessment, dated 3/31/25, indicated the resident was cognitively intact and received insulin injections during the look back period. A physician order, dated 3/3/25 and 3/19/25, indicated to administer insulin, Aspart Flex Pen 100 unit/ml solution pen-injector, inject 10 unit subcutaneously (under the skin) before meals for diabetes mellitus. Administration times were 7:30 a.m., 11:30 a.m., and 4:30 p.m. A physician order, dated 3/3/25, indicated to administer insulin glargine solostar subcutaneous solution pen-injector 100 unit/ml (Glargine), inject 30 unit subcutaneously one time a day for diabetes. Administration time was indicated as AM. A physician order, dated 3/19/25, indicated to administer Lantus SoloStar 100 unit/ml Solution pen-injector, inject 30 unit subcutaneously at bedtime for Diabetes Mellitus. Administration time was indicated as HS (hour of sleep). The medical record lacked documentation of administration Lantus insulin on 3/26/25. A physician order, dated 3/21/25 at 10:15 p.m., indicated to administer insulin lispro subcutaneous solution pen injector 100 unit/ml (Insulin Lispro), inject 15 unit subcutaneously STAT (immediately) for hyperglycemia (high blood sugar). The medical record lacked documentation of administration of insulin. A physician order, dated 3/22/25, indicated to administer insulin lispro, injection solution 100 unit/ml (Insulin Lispro) inject subcutaneously before meals and at bedtime for diabetes mellitus as per sliding scale. (Sliding scale insulin is units of insulin that is administered according to the range of the residents blood sugar reading): For blood sugar of 100 - 150 = 0 units; blood sugar of 151 - 200 = 2 units; blood sugar of 201 - 250 = 4 units; blood sugar of 251 - 300 = 6 units; blood sugar of 301 - 350 = 8 units; blood sugar of 351 - 400 = 10 units; and blood sugar of 401 - 999 = 12 units. Administration times were 7:00 a.m., 11:00 a.m., 4:00 p.m., and 9:00 p.m. From 3/3/25 to 3/11/25, Glargine insulin was scheduled to be administered at 7:00 a.m., the record indicated the insulin was administered at the following times: 3/3/25 - 9:32 a.m. 3/4/25 - 11:48 a.m. 3/6/25 - 9:40 a.m. 3/8/25 - 9:25 a.m. 3/9/25 - 9:38 a.m. 3/10/25 - 9:28 a.m. 3/11/25 - 11:01 a.m. From 3/1/25 to 3/31/25, Aspart insulin was to be administered at 7:30 a.m. the MAR indicated the insulin was administered at the following times. 3/4/25 - 11:47 a.m. 3/6/25 - 9:40 a.m. 3/7/25 - 11:13 a.m. 3/8/25 - 9:30 a.m. 3/9/25 - 9:42 a.m. 3/10/25 - 9:24 a.m. 3/11/25 - 10:48 a.m. 3/20/25 - 9:01 a.m. 3/21/25 - 9:32 a.m. 3/22/25 - 10:17 a.m. 3/24/25 - 10:32 a.m. 3/26/25 - 9:38 a.m. 3/29/25 - 11:32 a.m. 3:30/25 - 9:35 a.m. 3/31/25 - 9:39 a.m. From 3/1/25 to 3/31/25, Aspart insulin was to be administered at 11:30 a.m. the MAR indicated the insulin was administered at the following times. 3/8/25 - 2:03 p.m. 3/10/25- 1:50 p.m. 3/20/25 - 1:12 p.m. 3/23/25 - 1:26 p.m. 3/25/25 - 7:10 p.m. 3/26/25 - 2:08 p.m. From 3/1/25 to 3/31/25, Aspart insulin was to be administered at 4:30 p.m., the MAR indicated the insulin was administered at the following times. 3/3/25 - 8:48 p.m. 3/6/25 -10:25 p.m. 3/10/25 - 11:29 p.m. From 3/21/25 to 3/31/25, Aspart insulin was to be administered at 5:30 p.m., the MAR indicated the insulin was administered at the following times. 3/21/25 - 10:37 p.m. 3/23/25 - 10:21 p.m. 3/24/25 - 9:56 p.m. 3/30/25 - 8:00 p.m. 3/31/25 - 8:21 p.m. On 3/22/25, 3/23/25, 3/24/25, 3/25/25, 3/26/25, 3/27/25, 3/28/25, 3/29/25, 3/30/25, 3/32/25 and 4/1/25. Lispro insulin sliding scale, was not documented as administered. From 4/1/25 to 4/10/25, Aspart insulin was to be administered at 7:30 a.m., the MAR indicated the insulin was administered at the following times. 4/3/25 - 10:47 a.m. 4/4/25 - 3:23 p.m. 4/7/25 - 9:24 a.m. 4/9/25 - 9:56 a.m. From 4/1/25 to 4/10/25, Aspart insulin was to be administered at 11:30 a.m., the MAR indicated the insulin was administered at the following times. 4/4/25 - 3:24 p.m. 4/9/25 - 1:44 p.m. From 4/1/25 to 4/10/25, Aspart insulin was to be administered at 4:00 p.m., the MAR indicated the insulin was administered at the following times. 4/7/25 - 7:25 p.m. 4/8/25 - 6:49 p.m. From 4/1/25 to 4/10/25, Aspart insulin was to be administered at 5:30 p.m., the MAR indicated the insulin was administered at the following times. 4/1/25 - 9:53 p.m. 4/7/25 - 7:25 p.m. 4/9/25 - 7:12 p.m. From 4/1/25 to 4/10/25 Lispro insulin was to be administered at 7:00 a.m., the MAR indicated the insulin was administered at the following times. 4/2/25 - 8:42 a.m. 4/3/25 - 10:47 a.m. 4/4/25 - 9:22 a.m. 4/7/25 - 9:24 a.m. 4/9/25 - 9:51 a.m. From 4/1/25 to 4/10/25 Lispro insulin was to be administered at 11:30 a.m., the MAR indicated the insulin was administered at the following times. 4/4/25 - 3:24 p.m. From 4/1/25 to 4/10/25 Lispro insulin was to be administered at 4:00 p.m., the MAR indicated the insulin was administered at the following times. 4/7/25 - 7:25 p.m. 4/8/25 - 6:49 p.m. On 4/10/25 at 7:10 a.m., during an interview RN 8, indicated, if the medication was late being administered the Medication Administration Record (MAR) would indicate it was late. The MAR was green when it was ready to be administered, it turned yellow when it was close to the end of the administration time and red when it was past the administration time. She indicated she documented medications at the time she administered them. On 4/10/25 at 1:05 p.m., during interview the Nurse Consultant indicated the staff did not administer Lispro insulin according to the physician order, dated 3/22/25, from 3/22/25 to 4/1/25. She indicated the order had not been confirmed by the nurse in the medical record and was not entered into the EMAR (electronic medical record) until 4/2/25. She indicated the nurse did administer the STAT order on 3/21/25 however the nurse indicated she did not document the administration of the medication. 35317 2. Resident F's record was reviewed on 4/10/25 at 11:00 a.m. The profile indicated the resident's diagnosis included but were not limited to, type 2 diabetes mellitus with hyperglycemia (occurs when a person with diabetes has persistently high blood sugar levels [hyperglycemia] due to insulin resistance and/or insufficient insulin production). A quarterly Minimum Data Set (MDS) assessment, dated 1/24/25, indicated the resident had moderate cognitive deficit and was on insulin injections. A care plan, initiated on 2/2/24 and revised on 2/24/24, indicated the resident had diabetes and was at risk of complications. Interventions included but were not limited to, administer medication per provider's orders and observe for side effects and effectiveness. A physician order, dated 4/17/24, indicated to administer Lispro (insulin medication) subcutaneous (under the skin) solution pen injector 100 unit/ml (milliliter), inject 10 units subcutaneously before meals for type 2 diabetes mellitus at 7:30 a.m., 11:30 a.m., and 4:30 p.m. Review of March 2025 MAR indicated the Lispro insulin medication was documented as administered at the following times: a. On 3/1/25 the 7:30 am. dose was documented as administered at 6:37 p.m. b. On 3/1/25 the 11:30 a.m. dose was documented as administered at 3:11 p.m. c. On 3/1/25 the 4:30 p.m. dose was documented as administered at 9:48 p.m. d. On 3/2/25 the 7:30 a.m. dose was documented as administered at 2:07 p.m. e. On 3/2/25 the 11:30 a.m. dose was documented as administered at 2:07 p.m. f. On 3/3/25 the 4:30 p.m. dose was documented as administered at 8:36 p.m. g. On 3/6/25 the 7:30 a.m. dose was documented as administered at 9:23 a.m. h. On 3/6/25 the 4:30 p.m. dose was documented as administered at 9:30 p.m. i. On 3/7/25 the 7:30 a.m. dose was documented as administered at 10:24 a.m. j. On 3/7/25 the 11:30 a.m. dose was documented as administered at 1:18 p.m. k. On 3/8/25 the 11:30 a.m. dose was documented as administered at 1:08 p.m. l. On 3/9/25 the 7:30 a.m. dose was documented as administered at 11:39 a.m. m. On 3/10/25 the 7:30 a.m. dose was documented as administered at 11:29 a.m. n. On 3/10/25 the 4:30 p.m. dose was documented as administered at 11:15 p.m. o. On 3/11/25 the 7:30 a.m. dose was documented as administered at 9:42 a.m. p. On 3/11/25 the 4:30 p.m. dose was documented as administered at 5:58 p.m. q. On 3/12/25 the 7:30 a.m. dose was documented as administered at 9:01 a.m. r. On 3/13/25 the 11:30 a.m. dose was documented as administered at 1:39 p.m. s. On 3/14/25 the 11:30 a.m. dose was documented as administered at 1:16 p.m. t. On 3/14/25 the 4:30 p.m. dose was documented as administered at 7:47 p.m. u. On 3/25/25 the 11:30 a.m. dose was documented as administered on 3/17/25 at 5:20 p.m. v. On 3/15/25 the 4:30 p.m. dose was documented as administered at 9:10 p.m. w. On 3/16/25 the 7:30 a.m. dose was documented as administered at 9:14 a.m. x. On 3/16/25 the 4:30 p.m. dose was documented as administered at 7:20 p.m. y. On 3/17/25 the 4:30 p.m. dose was documented as administered at 7:08 p.m. z. On 3/18/25 the 4:30 p.m. dose was documented as administered at 9:33 a.m. aa. On 3/19/25 the 7:30 a.m. dose was documented as administered at 9:22 a.m. bb. On 3/21/25 the 7:30 a.m. dose was documented as administered at 9:15 a.m. cc. On 3/21/25 the 4:30 p.m. dose was documented as administered at 10:53 p.m. dd. On 3/23/25 the 11:30 a.m. dose was documented as administered at 1:23 p.m. ee. On 3/24/25 the 7:30 a.m. dose was documented as administered at 10:25 a.m. ff. On 3/24/25 the 11:30 a.m. dose was documented as administered at 12:50 p.m. gg. On 3/24/25 the 4:30 p.m. dose was documented as administered at 9:50 p.m. hh. On 3/25/25 the 11:30 a.m. dose was documented as administered at 4:41 p.m. ii. On 3/25/25 the 4:30 p.m. dose was documented as administered at 6:12 p.m. jj. On 3/26/25 the 7:30 a.m. dose was documented as administered at 3:42 p.m. kk. On 3/26/25 the 11:30 a.m. dose was documented as administered at 3:43 p.m. ll. On 3/26/25 the 4:30 p.m. dose was documented as administered on 3/27/25 at 9:49 a.m. mm. On 3/27/25 the 7:30 a.m. dose was documented as administered at 9:17 a.m. nn. On 3/28/25 the 11:30 a.m. dose was documented as administered at 1:04 p.m. oo. On 3/29/25 the 4:30 p.m. dose was documented as administered at 6:16 p.m. pp. On 3/30/25 the 7:30 a.m. dose was documented as administered at 9:26 a.m. qq. On 3/31/25 the 4:30 p.m. dose was documented as administered at 8:13 p.m. A physician order, dated 4/16/24, indicated to administer Glargine (insulin medication) solution pen injector 100unit/ml, inject 30 units subcutaneously in the evening for diabetes at 9:00 p.m. Review of March 2025 MAR indicated the Glargine insulin medication was documented as administered at the following times: a. On 3/2/25 the 9:00 p.m. dose was documented as administered on 3/12/25 at 2:05 p.m. b. On 3/10/25 the 9:00 p.m. dose was documented as administered at 11:15 p.m. c. On 3/16/25 the 9:00 p.m. dose was documented as administered on 3/17/25 at 7:21 p.m. d. On 3/17/25 the 9:00 p.m. dose was documented as administered on 3/18/25 at 10:16 a.m. e. On 3/21/25 the 9:00 p.m. dose was documented as administered at 10:53 p.m. Review of April 2025 MAR indicated the Lispro insulin medication was documented as administered at the following times: a. On 4/1/25 the 4:30 p.m. dose was documented as administered at 9:47 p.m. b. On 4/3/25 the 7:30 a.m. dose was documented as administered at 10:58 a.m. c. On 4/6/25 the 11:30 a.m. dose was documented as administered at 1:20 p.m. d. On 4/9/25 the 7:30 a.m. dose was documented as administered at 10:10 a.m. e. On 4/9/25 the 11:30 a.m. dose was documented as administered at 12:57 p.m. During an interview, on 4/10/25 at 11:41 a.m., Resident F indicated she sometimes received her insulin before meals and sometimes it was much later. She indicated the insulin administration times were all over the place. 34525 3. During an interview on 4/9/25 at 11:20 a.m., Resident B indicated it was always a 50/50 shot whether he received his insulin (a hormone produced by the pancreas that helps regulate blood sugar levels) injections on time. On this date he had just received his 8:00 a.m. injection just prior to the beginning of the interview. Resident B's record was reviewed on 4/9/25 at 10:51 a.m. The profile indicated the resident's diagnoses included, but were not limited to, type 2 diabetes mellitus with hyperglycemia (a chronic condition that happens when a person has persistently high blood sugar levels). An admission Minimum Data Set (MDS) assessment, dated 3/12/25, indicated the resident had no cognitive deficit, no documented behaviors for rejection of care, and received insulin injections. The resident's care plans lacked documentation of the resident having care plans related to his diagnosis of diabetes or that he received insulin injections. A physician's order, dated 3/6/25, indicated to administer insulin Lispro (a rapid-acting insulin used to lower blood sugar levels in people with diabetes) injection solution 100 units/milliliter (ml), subcutaneously (below the skin) before meals and at bedtime, (at 8:00 a.m., 11:00 a.m., 4:00 p.m., and 9:00 p.m.) for diabetes, per the following sliding scale: if blood sugar of 151 - 199 = 2 units; blood sugar of 200 - 249 = 4 units; blood sugar of 250 - 299 = 6 units; blood sugar of 300 - 349 = 8 units; blood sugar of 350 - 399 = 10 units; blood sugar of 400 - 449 = 12 units; blood sugar of 450 - 499 = 14 units; blood sugar of 500 - 549 = 16 units; blood sugar of 550 - 599 = 18 units. If blood sugar was greater than 599 call the physician. Review of the March 2025 Medication Administration Audit Report, the resident's Lispro administrations had been administered late on the following dates: a. The 8:00 a.m., dose was documented as administered late on, 3/7/25, 3/8/25, 3/9/25, 3/11/25, 3/14/25, 3/16/25, 3/18/25, 3/21/25, 3/22/25, 3/24/25, 3/26/25, 3/29/25, 3/30/25, and 3/31/25. b. The 11:00 a.m., dose was documented as administered late on, 3/7/25, 3/8/25, 3/9/25, 3/10/25, 3/12/25, 3/13/25, 3/14/25, 3/15/25, 3/17/25, 3/18/25. 3/19/25, 3/20/25, 3/21/25, 3/22/25, 3/23/25, 3/24/25, 3/25/25, 3/26/25, 3/28/25, 3/30/25, and 3/31/25. c. The 4:00 p.m., dose was documented as administered late on, 3/6/25, 3/7/25, 3/8/25, 3/10/25, 3/11/25, 3/12/25, 3/13/25, 3/15/25, 3/16/25, 3/17/25, 3/18/25, 3/19/25, 3/21/25, 3/22/25, 3/23/25, 3/24/25, 3/25/25, 3/28/25, 3/29/25, 3/30/25, and 3/31/25. d. The 9:00 p.m., dose was documented as administered late on, 3/6/25, 3/10/25, 3/16/25, 3/17/25, 3/20/25, 3/21/25, 3/23/25, and 3/2/5/25. Review of the April 2025 Medication Administration Audit Report, the resident's Lispro administrations had been administered late on the following dates: a. The 8:00 a.m., dose was documented as administered late on, 4/1/25, 4/4/25, 4/7/25, and 4/9/25. b. The 11:00 a.m., dose was documented as administered late on, 4/2/25, 4/4/25, 4/7/25, and 4/9/25. c. The 4:00 p.m., dose was documented as administered late on, 4/1/25, 4/2/25, 4/6/25, 4/7/25, 4/8/25, and 4/9/25. d. The 9:00 p.m., dose was documented as administered late on, 4/2/25, 4/4/25, 4/5/25, and 4/6/25. A physician's order, dated 3/6/25, indicated to administer 35 units of insulin Glargine (a synthetic version of human insulin) subcutaneous solution 100 units/ml, two times daily for diabetes, at 7:00 a.m., and 9:00 p.m. Review of the March 2025 Medication Administration Audit Report, the resident's Glargine administrations had been administered late on the following dates: a. The 9:00 p.m., dose was documented as administered late on, 3/10/25, 3/16/25, 3/17/25, and 3/20/25. Review of the April 2025 Medication Administration Audit Report, the resident's Glagine administrations had been administered late on the following dates: a. The 7:00 a.m., dose was documented as administered late on, 4/18/25, 4/26/25, and 4/29/25. b. The 9:00 p.m., dose was documented as administered late on, 4/10/25, 4/16/25, 4/17/25, and 4/20/25. 4. Resident E's record was reviewed on 4/10/25 at 8:53 a.m. The profile indicated the resident diagnoses included, but were not limited to, type 2 diabetes with diabetic chronic kidney disease (a chronic condition that happens when a persons high blood sugar levels damage the kidneys so that they cannot filter blood effectively). A quarterly Minimum Data Set (MDS) assessment, dated 3/28/25, indicated the resident had no cognitive deficit, no documented behaviors of refusals of medications, and the resident received insulin injections. A care plan, revised on 3/20/22, indicated the resident had a potential for complications related to her diagnoses of diabetes. Interventions included, but were not limited to, administer diabetes medication as ordered by the doctor. A physician's order, dated 11/4/24, indicated to administer 50 units of Lantus solution (a a long-acting man-made-insulin used to control high blood sugar in adults) 100 units/ml, subcutaneously two times a day for diabetes, at 8:00 a.m., and 8:00 p.m. Review of the March 2025 Medication Administration Audit Report, the resident's Lantus administrations had been administered late on the following dates: a. The 8:00 a.m., dose was documented as administered late on, 3/2/25, 3/3/25, 3/4/25, 3/6/25, 3/13/25, 3/14/25, 3/16/25, 3/18/25, 3/21/25. 3/22/25, 3/24/25, 3/26/25, 3/29/25, 3/30/25, and 3/31/25. b. The 8:00 p.m., dose was documented as administered late on, 3/1/25, 3/4/25, 3/5/25, 3/6/25, 3/8/25, 3/10/25, 3/12/25, 3/13/25, 3/16/25, 3/19/25, 3/20/25, 3/21/25, 3/23/25, 3/24/25, and 3/25/25. Review of the April 2025 Medication Administration Audit Report, the resident's Lantus administrations had been administered late on the following dates: a. The 8:00 a.m., dose was documented as administered late on, 4/3/25, 4/4/25, 4/7/25, 4/9/25, and 4/10/25. b. The 8:00 p.m., dose was documented as administered late on, 4/1/25 and 4/5/25. A physician's order, dated 11/21/24, indicated to administer insulin Lispro (a rapid-acting insulin used to lower blood sugar levels in people with diabetes) solution Pen-injector (an injection device used to deliver preloaded insulin into the subcutaneous [under the skin] tissue) 100 units/milliliter (ml). Inject 22 unit subcutaneously before meals for diabetes, at 7:30 a.m., 11:30 a.m., and 4:30 p.m. Review of the March 2025 Medication Administration Audit Report, the resident's Lispro administrations had been administered late on the following dates: a. The 7:30 a.m., dose was documented as administered late on, 3/1/25, 3/2/25, 3/3/25, 3/4/25, 3/5/25, 3/6/25, 3/9/25, 3/13/25, 3/14/25, 3/16/25, 3/17/25, 3/18/25, 3/19/25, 3/20/25, 3/21/25, 3/22/25, 3/24/25, 3/26/25, 3/27/25, 3/28/25, 3/29/25, 3/30/25, and 3/31/25. b. The 11:30 a.m., dose was documented as administered late on, 3/2/25, 3/6/25, 3/8/25, 3/9/25, 3/10/25, 3/12/25, 3/13/25, 3/14/25, 3/15/25, 3/19/25, 3/21/25, 3/22/25, 3/23/25, 3/24/25, 3/26/25, 3/30/25, and 3/31/25. c. The 4:30 p.m., dose was documented as administered late on, 3/1/25, 3/3/25, 3/4/25, 3/6/25, 3/8/25, 3/10/25, 3/11/25, 3/12/25, 3/13/25, 3/14/25, 3/15/25, 3/16/25, 3/18/25, 3/21/25, 3/22/25, 3/23/25, 3/24/25, 3/29/25, 3/30/25, and 3/31/25. Review of the April 2025 Medication Administration Audit Report, the resident's Lispro administrations had been administered late on the following dates: a. The 7:30 a.m., dose was documented as administered late on, 4/2/25, 4/3/25, 4/4/25, 4/7/25, 4/8/25, 4/9/25, and 4/10/25. b. The 11:30 a.m., dose was documented as administered late on, 4/3/25, 4/4/25, 4/7/25, and 4/9/25. c. The 4:30 p.m., dose was documented as administered late on, 4/1/25, 4/8/25, and 4/9/25. During an interview, on 4/9/25 at 1:40 p.m., Licensed Practical Nurse (LPN) 7 indicated she was late administering insulin to residents because she was administering insulin to residents on three different halls and was completely overwhelmed. During interview, on 4/10/25 at 7:10 a.m., Registered Nurse (RN) 8 indicated she would document medications at the time she administered them. If the medication was scheduled for morning or bedtime she would administer the medication within two hours. If a medication was scheduled for a specific time she would give it according to the scheduled administration time. During interview, on 4/10/25 at 7:30 a.m., LPN 7 indicated she administered medications according to the administration times. If she was late documenting the administration of a medication, she would change the administration time to the actual time she administered the medication. On 4/10/25 at 9:00 a.m., the Regional Nurse Consultant provide a document, dated 2013, titled, Medication Administration, and indicated it was the policy currently being used by the facility. The policy indicated , .Procedure: I. General Procedures: 1 a. Administer medications only as prescribed by the provider .f. Observe the five rights in giving medication: .ii. the right time .ff. Medications will be administered within the time frame of one hour before up to one hour after time ordered .IV. Documentation: a. Documentation of medication will be current for medication administration. b. Documentation of medication will follow accepted standards of nursing practice This citation relates to Complaint IN00456945. 3.1-48(c)(2)

Based on observation, interview, and record review, the facility failed to ensure enhanced barrier precautions were followed during a dressing change for 1 of 3 residents reviewed for pressure ulcers (Resident G). Findings include: During a continuous observation, on 4/10/25 from 9:56 a.m. to 10:16 a.m., the following was observed. Licensed Practical Nurse (LPN) 7 performed hand hygiene, donned gloves and a gown, and completed the dressing change to Resident G's sacrum (bone at the base of the spine). Near the end of the sacrum dressing change, Certified Nurse Aide (CNA) 11 entered the room to assist LPN 7. CNA 11 did not perform hand hygiene after entering the room. CNA 11 donned gloves but did not put on a gown. CNA 11 held up Resident G's left heel so LPN 7 could complete the dressing change to that area. CNA 11 removed the dressing from Resident G's left heel and continued to hold up the resident's leg. CNA 11 did not perform hand hygiene or change gloves after she removed the resident's dressing. On 4/10/25 at 10:16 a.m., the continuous observation was completed. At the same time, LPN 7 indicated CNA 11 should have performed hand hygiene before she put on her gloves. CNA 11 should have worn a gown and should not have removed the dressing from Resident G's heel. Resident G required enhanced barrier precautions (strategic use of gown and gloves during high-contact resident care activities) during his wound care. Resident G's record was reviewed on 4/9/25 at 2:33 p.m. Diagnoses on the resident's profile included, but were not limited to, stage four (deep wound that extends into all underlying tissues such as muscles, tendons, and bones) pressure ulcer (local injury to the skin and underlying tissues caused by prolonged pressure) of the sacral region. A quarterly Minimum Data Set (MDS) assessment, dated 3/10/25, indicated the resident was cognitively intact and required pressure ulcer care. A physician's order, dated 1/7/25, indicated the resident required enhanced barrier precautions related to wounds. A physician's order, dated 3/24/25, indicated to cleanse the resident's left heel wound with wound cleanser, pat dry with gauze, apply skin prep (skin barrier) around the wound, apply collagen (promotes wound healing) to the wound bed, and cover with bordered gauze daily. A physician's order, dated 4/7/25, indicated to cleanse the resident's sacrum wound with wound cleanser, pat dry with gauze apply skin prep around the wound, apply Hydrofera Blue (absorbent foam wound dressing) to wound bed, cover with an abdominal (ABD) pad (dressing that manages moderately draining wounds), and secure with tape daily. On 4/10/25 at 11:30 a.m., the Nurse Consultant provided an undated document titled, Skin Care & Wound Management Overview, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy .Skin care and wound management program includes, but is not limited to .Application of treatment protocols based on clinical 'best practice' standards for promoting wound healing On 4/10/25 at 11:30 a.m., the Nurse Consultant provided an undated document titled, Enhanced Barrier Precautions, and indicated it was the policy currently being used by the facility. The policy indicated, .Definitions .PPE [personal protective equipment] required-gowns and gloves .Policy: Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employs hand hygiene, targeted gown and glove use during high contact resident care activities that include .Wound care: any skin opening requiring a dressing .EBP are indicated for residents with any of the following .Wounds .even if the resident is not know to be infected or colonized with a MDRO [multi-drug resistant organisms] During an interview, on 4/10/25 at 11:38 a.m., the Nurse Consultant indicated there was no specific facility policy for dressing changes. She indicated she provided the applicable policies. This citation relates to Complaint IN00455170. 3.1-18(b)(1)

Based on interview and record review, the facility failed to ensure adequate nurse staffing for 5 of 6 units schedules reviewed (units 100, 200 A, 200 B, 400, and 500). Findings include: 1. During an interview, on 12/31/24 at 9:25 a.m., Resident K indicated there were sometimes when she had not been given her insulin. She understood that the nurses were human and were really busy, but she was a Registered Nurse in her career and knows that insulin needs to be given as ordered. She would never refuse any of her insulin, it was too important for her to have it. Resident K's record was reviewed on 12/31/24 at 8:29 a.m. The profile indicated the resident resided on the 400 unit of the facility. Her diagnoses included, but were not limited to, type 2 diabetes mellitus (a chronic disease that occurs when the body doesn't produce enough insulin [a hormone that regulates blood sugar levels] or doesn't use it properly, resulting in high blood sugar levels) with hyperglycemia (high blood sugar). A significant change Minimum Data Set (MDS) assessment, dated 10/28/24, indicated the resident had moderate cognitive deficit and required insulin injections (medication that is used to take the place of insulin that is normally produced by the body). A care plan, with a revised date of 2/14/24, indicated the resident was at risk for complications due to diabetes. Interventions included, but were not limited to, administer medications per medical provider's orders. A physician's order, dated 4/16/24, indicated to administer 30 units of Glargine insulin (used to control blood sugars in persons with diabetes) subcutaneous (SQ-under the skin) every evening at 9:00 p.m., for type 2 diabetes. A physician's order, dated 4/17/24, indicated to administer 10 units of Lispro insulin (used to control blood sugars in persons with diabetes) subcutaneous (SQ-under the skin) before meals on 7:30 a.m., 11:30 a.m., and 4:30 p.m., for type 2 diabetes. Review of the daily 400 unit nursing staff schedule, for 12/10/24 through 12/28/24, indicated the following: a. The 12/10/24 400 unit schedule lacked documentation of any nurse or Qualified Medication Aide (QMA) scheduled for the day shift (6:00 a.m., to 2:30 p.m.). Review of the December 2024 medication administration record (MAR) lacked documentation that Resident K's 7:30 a.m., and 11:30 a.m., doses of Lispro insulin had been administered on 12/10/24, and lacked documentation of any refusal by the resident. b. The 12/20/24 400 unit schedule lacked documentation of any nurse or QMA scheduled for the day shift and the evening shift. Review of the December 2024 MAR lacked documentation that Resident K's 4:30 p.m., dose of Lispro insulin and the 9:00 p.m., dose of Glargine insulin had been administered on 12/20/24, and lacked documentation of any refusal by the resident. c. The 12/25/24 400 unit schedule indicated LPN 14 was assigned to the 400 unit on the day shift. The 400 unit schedule lacked documentation that any nurse or QMA had been scheduled for the evening shift. Review of the December 2024 MAR lacked documentation that Resident K's 11:30 a.m., dose of Lispro insulin had been administered on 12/25/24, and lacked documentation of any refusal by the resident. d. The 12/27/24 400 unit schedule indicated that QMA 11 was assigned to the hall on the evening shift. LPN 8 was to cover the hall until 6:00 p.m. The schedule lacked documentation of any nurse assigned to cover the hall after 6:00 p.m. Review of the December 2024 MAR lacked documentation that Resident K's 4:30 p.m., dose of Lispro insulin and the 9:00 p.m., dose of Glargine insulin had been administered on 12/27/24, and lacked documentation of any refusal by the resident. e. The 12/28/24 400 unit schedule lacked documentation of any nurse or QMA scheduled for the evening shift. Review of the December 2024 MAR lacked documentation that Resident K's 4:30 p.m., 9:00 p.m., dose of Glargine insulin had been administered on 12/28/24, and lacked documentation of any refusal by the resident. During an interview, on 12/31/24 at 10:46 a.m., the Regional Director of Clinical Operations (RDCO) indicated she believed the nurses were administering the insulin medications but had failed to document on the MAR that they were given. 35317 2. During an interview, on 12/31/24 at 10:52 a.m., Resident F indicated there were times when she was not given her insulin medications, and she missed doses. The resident indicated she had noticed it had happened more often on the evening shift. Resident F's record was reviewed on 12/30/24 at 1:10 p.m. The profile indicated the resident's diagnosis included, but were not limited to, systemic lupus erythematosus (an illness that occurs when the immune system attacks healthy tissue and organs) and diabetes mellitus (a group of diseases that result in too much sugar in the blood). A quarterly Minimum Data Set (MDS) assessment, dated 11/8/24 indicated the resident was cognitively intact and was on insulin medication. A care plan, dated 10/7/20, indicated the resident had diabetes mellitus and had potential for complications. Interventions included, but were not limited to, diabetes medication as ordered by doctor and educate regarding medications and importance of compliance. Review of daily staffing sheets for December 10 through December 28, 2024, indicated the following: a. On 12/10/24 Qualified Medication Aide (QMA) 11 was assigned to work on the 2A unit from 2-10:30 p.m., which Resident F resided on. Licensed Practical Nurse (LPN) 8 was assigned to cover QMA until 6 p.m. Review of December Medication Administration Record (MAR) indicated the record lacked documentation of Fiasp (insulin medication) was administered to Resident F on 12/10/24 at 4:30 p.m. and Exenatide (insulin medication) at 4:00 p.m. The record also lacked documentation of the resident's refusal. b. On 12/13/24 a former QMA was assigned to work the 2A unit from 2-10:30 p.m., which Resident F resided on. The record lacked which nurse was covering the QMA for the evening shift. Review of December MAR indicated the record lacked documentation of Fiasp was administered to Resident F on 12/13/24 at 4:30 p.m., Exenatide at 4:00 p.m., and Basaglar (insulin medication) at 9:00 p.m. The record also lacked documentation of the resident's refusal. c. On 12/25/24 QMA 12 was assigned to work on the 2A unit from 6-10 p.m., which Resident F resided on. The record lacked which nurse was to cover the QMA from 6-10 p.m. Review of December MAR indicated the record lacked documentation of an accu check (used by people with diabetes to monitor their blood glucose (known as blood sugar) levels) was obtained on 12/25/24 at 9:00 p.m., or Basaglar was administered at 9:00 p.m. The record also lacked documentation of the resident's refusal. d. On 12/27/24 QMA 10 was assigned to work on the 2A unit from 2-6:30 p.m. LPN 8 covered QMA until 6:30 p.m. Review of December MAR indicated the record lacked documentation of Exenatide being administered at 4:00 p.m. and Fiasp on 12/27/24 at 9:00 p.m. The record also lacked documentation of the resident's refusal. e. On 12/28/24 QMA 12 was assigned to work on the 2A unit from 6-10:30 p.m. The record lacked which nurse was assigned to cover the QMA'a for the evening shift. Review of December MAR indicated the record lacked documentation of an accu check being obtained on 12/28/24 at 4:30 p.m., Exenatide being administered at 4:00 p.m., Fiasp at 4:30 p.m., and Basaglar at 9:00 p.m. The record also lacked documentation of the resident's refusal. During an interview, on 12/31/24 at 9:44 a.m., Registered Nurse (RN) 3 indicated staff had to look at the daily staffing schedule to see what hall they were working on and if they were covering QMA's. RN 3 indicated to a new employee the schedule can be a little confusing to understand, but she was used to it. During a confidential interview, on 12/31/24 at 10:00 a.m., the employee indicated there had been times when she would have to cover the whole building due to only QMA'a and her being scheduled. She indicated she was able to get her work completed but it could be difficult. During an interview, on 12/31/24 at 11:14 a.m., the Regional Director of Clinical Operations (RDCO) indicated she thought the nurses were administering the insulin medications but forgot to document on the MAR that they were given. She indicated the management team had been aware of the documentation issues and they were re-educating the nursing staff. The cooperation did employee QMA's and they could perform the accu checks but they were not able to administer the insulin medications, and they had to be administered by the nurse. 48226 3. On 12/28/24 at 5:22 p.m., during observation. The posted schedule indicated that Licensed Practical Nurse (LPN) 8 was working on the 100 unit. Qualified Medication Aide (QMA) 10 was working on 200-B hall from 2 p.m. to 6:30 p.m., QMA 12 was scheduled to work on 200 A hall and 200 B hall from 6:30 p.m. to 10:30 p.m., QMA 15 was working on 500 hall. LPN 8 was working on the 600 hall and 200 B Hall. The schedule lacked documentation of a nurse covering the 400 unit. On 12/28/24 at 5:25 p.m., LPN 8 indicated she was scheduled on 100 unit and overseeing the QMA's on all of the units except 600 unit. She indicated she was very overwhelmed because a resident had fallen on another hall, and she was trying to send the resident to the hospital and still oversee the QMA's. She indicated the facility often had QMA's scheduled, and one nurse oversaw them on all of the halls except 600 hall. She indicated a nurse was scheduled for the 600 hall. On 12/28/24 at 5:51 p.m., during a phone interview Resident B indicated at times there was only one nurse and two aides for the whole building. She indicated this was more prevalent on the weekends. On 12/30/24 at 2:49 p.m., during interview LPN 8 indicated she covers 400 and 500 hall and when she worked there was always a nurse on 600 hall. She indicated she covered 3 halls plus worked on 100 hall. On 12/31/24 at 10:00 a.m., during an interview Certified Nurse Aide (CNA) 9 indicated she found her assignment on the assignment board each day and it indicated what hall she was scheduled to work on. On 12/31/24 at 10:07 a.m., during an interview LPN 14 indicated she understood the daily schedule, but the new people did not understand it and she had to explain to them where they were working. On 12/31/24 at 10:00 a.m., a review of the daily nursing schedules the following was indicated. a. On 12/10/24 on 2:00 p.m., to 10:00 p.m., shift LPN 8 was scheduled to work on 100 hall and overseeing 400 hall, 500 hall and 200 A hall till 6:00 p.m. LPN 17 was assigned to work from 6:00 p.m. to 10:00 p.m. on 600 hall and 200 B hall. QMA 11 was scheduled to work on 500 hall and 200 A hall. The record lacked evidence of nurse coverage for 200 B hall before 6:00 p.m., or coverage for 200 A hall, 400 hall and 500 hall after 6:00 p.m. b. On 12/13/24 on 2:00 p.m., to 10:00 p.m., shift. LPN 8 was scheduled to work on 100 hall, 400 hall and 500 hall. LPN 16 was scheduled to work 600 hall, part of 200 B hall and oversee 200 A hall. QMA 12 was scheduled to work on 500 hall and part of 200 A hall. c. On 12/20/24 on 2:00 p.m., to 10:00 p.m., shift. LPN 14 was scheduled to work on 100 hall till 3:15 p.m., LPN 8 was scheduled to work on 100 hall from 8:30 p.m., to 10:30 p.m. LPN 17 was scheduled to work on 200 A hall and 200 B hall and oversee 600 hall. QMA 18 was scheduled to work on 200 B hall and 600 hall. QMA 11 was scheduled to work on 500 hall. The record lacked evidence of nurse coverage for 400 hall or nurse coverage for 100 hall from 3:15 p.m. to 8:30 p.m. d. On 12/27/24 on 2:00 p.m., to 10:00 p.m., shift. LPN 8 was scheduled to work 100 hall and oversee 200 A hall, 400 hall and 500 hall till 6:00 p.m. LPN 17 was scheduled to work at 6:00 p.m., on 200 A hall and 200 B hall. LPN 16 was scheduled to work 600 hall. QMA 11 was scheduled to work on 400 hall and 500 hall. The record lacked evidence of a nurse overseeing 400 hall and 500 hall after 6:00 p.m. e. On 12/27/24 on 2:00 p.m., to 10:00 p.m., shift. LPN 8 was scheduled to work 100 hall. LPN 16 was scheduled to work 200 B hall and 600 hall. QMA 15 was scheduled to work on 500 hall. The record lacked evidence of nurse coverage for 400 hall and lacked an LPN overseeing 200 A and 500 hall. On 12/31/24 at 2:00 p.m., the Regional Director of Clinical Operations indicated if a nurse was scheduled to work on 100 hall and had to oversee the QMA's. The nurse would not be assigned to work a cart so the nurse would be free to administer insulins and other medications for the QMA's. She indicated the facility did not have a policy for staffing. This citation relates to Complaint IN00449502. 3.1-17(a)

Based on interview and record review, the facility failed to ensure supervision of a moderately cognitively impaired resident with a history of diabetes, mental illness, illicit drug use, and new onset aphasia; and failed to follow the facility elopement policy resulting in a delay in contacting the police for approximately 20 hours after the resident had gone missing for 1 of 4 residents reviewed for quality of care (Resident B). The immediate jeopardy begun on [DATE] at 8:30 p.m., after Resident B was witnessed by her peers to be upset and tearful and left the facility without signing out as she usually did. Staff became aware Resident B was missing at approximately 8:30 p.m. when she was unable to be located for her evening medication administration. Although an initial search was conducted by nursing and administrative staff, the search was stopped at 11:45 p.m. without locating the resident. Law enforcement was not notified until [DATE] at 4:22 p.m., approximately 20 hours after Resident B went missing. Ultimately, a body presumed by law enforcement to be Resident B was later found on [DATE] less than half a mile from the facility. The [NAME] President of Risk Management and Performance Improvement (VP, RM-PI), Regional Director of Clinical Operations (RDCO), Administrator (ADM), and the Director of Nursing (DON), were notified of the immediate jeopardy on [DATE] at 5:01 p.m. The immediate jeopardy was removed, and the deficient practice corrected, on [DATE], prior to the start of the survey and was therefore Past Noncompliance. Findings include: During a confidential interview with one of Resident B's peers, it was indicated Resident B had been upset in the days leading up to her elopement. She had recently had a stroke and could no longer talk except for repeating the word, well, over and over. The peer indicated they were with her on the smoking patio the night of [DATE] when she left the facility. She had been very upset, inconsolable, and cried. The peer was unable to determine why she was upset because all she could say was, well, well, well, well. Resident B did not want to go back inside when the peer did, but the peer told a nurse that Resident B was still upset and outside crying. During a confidential interview with another of Resident B's peers, it was indicated Resident B was on the smoking patio the evening of [DATE] and was uncontrollably crying. The peer was not able to understand Resident B because she could only repeat the words, Well, well, well. When the peer was done smoking, they tried to get Resident B to come inside with them, but she was not done with her cigarette yet. It was getting dark, and it was cold. She was still crying. The peer was worried about Resident B so when they went back inside they told one of the nurses that Resident B was still outside in the smoking area, upset and crying. During a confidential interview with a third peer, it was indicated Resident B was very different after her stroke. She was mad and frustrated about everything that happened, and could only repeat, well, well, well, well. She got stuck on that word and it made her so mad she would start to cry. There was a rumor that her son had been in trouble with the law, and the peer thought maybe she was upset about that. The peer indicated, Resident B would go out LOA all the time, but was always back by midnight. During a confidential interview, a peer who had been one of Resident B's roommates indicated it was obvious that Resident B was different after her stroke, she could not talk anymore which made her angry and upset, she screamed and cried a lot more after the stroke. During a confidential interview, one of Resident B's peers indicated, they were in their room which had a window that overlooked the smoking patio. They observed Resident B outside with two peers on the evening of [DATE], and Resident B was clearly upset. When the two other peers came back inside, they decided to go outside and smoke one more time before night. In a span of 15 seconds, with their back turned to get an E-cigarette, Resident B was there, and then gone. She had a red walker. During a confidential interview with a family member, it was indicated, Resident B was trying to get better so she could leave the facility and live on her own again. Before she had the stroke, she complained that she did not receive her insulin, but after her stroke all she could say was, well, well, well. The family member worried about how the resident would communicate and staff would understand if the resident needed something or missed more of her insulin. After Resident B's body was found, the family was told she left the facility because she wanted to leave. But she did not take her identification (ID), phone, wallet, bus pass, or other items she would need or that she would always take with her when she went on Leave of Absence (LOA). The family member indicated Resident B had a history of mental illness which included bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and was impulsive. Along with her mental illness she had used illicit drugs in the past to cope, and because of her history and behaviors she needed additional supervision and help with her medical management. This was why she was in a nursing home in the first place. During a confidential interview with a family member, it was indicated, they got a call around 9:00 p.m., on the evening of [DATE]. It was a nurse from the facility asking the family member if they had heard from or knew where Resident B was. The family member indicated, no, they had not, and asked what was wrong. The family member was told Resident B had left the facility and not returned yet. They told the family member not to worry and they would call back with an update, but never did. The family member never knew Resident B was missing or potentially in danger until a detective called them on [DATE]. The detective told her they found a body with similar characteristics as Resident B. Until DNA could confirm the identity of the deceased , it was assumed to be Resident B due to identification makers of surgically amputated toes, and a unique tattoo on her back. The family member indicated they were shocked and angry because the family was never called back with an update from the facility when she did not return to the facility the next day. If they had been notified, the family member would have come to help with the search. During a confidential interview, a staff member indicated Resident B had been at the facility for close to a year. She had been pleasant and engaged with other residents before her stroke. After her stroke she kept more to herself and was unable to talk with her friends anymore which made her upset. Resident B was a bad diabetic, her sugar would drop all the time. Half the time she would eat, but other times she would not. Although Resident B had a bit of a past, and had used Meth and other drugs, since being at the facility she was clean and worked hard to get better so she could leave. Resident B was a resident that smoked, she knew the code to the smoking patio, which was the same as the front door code, so she could leave anytime she wanted. She would occasionally forget to sign out, but most of the time she did use the LOA book and signed herself in and out. After her stroke, maybe she had more difficulty remembering to do that. It was indicated the staff member knew Resident B very well, and she never heard her make statements that she was going to leave. She did go out of the facility a lot, but she always came back by midnight. During an interview on [DATE] at 1:00 p.m., Unit Manager (UM) 16 indicated Resident B was friendly and outgoing. She liked to socialize with the other residents, mostly the other smokers, and she would go to the smoking patio a lot. Since Resident B was an independent smoker, she was able to take herself in and out for smoke breaks, but the policy of the facility was no smoking between the hours of 10:00 p.m. and 6:00 a.m., for resident safety. After her stroke she remained independent with her smoking and was compliant with the smoking policies. On the night of [DATE] UM 16 got a call from the DON around 10:00 p.m., who asked her to come to the facility and help find Resident B. UM 16 arrived to the facility around 10:15 p.m., and begun to assist in a search for Resident B. A resident count was completed, and the entire facility was searched. Additionally, UM 16 and the Scheduler got in their vehicles and drove through some surrounding neighborhoods. They were unable to locate Resident B. Around 11:45 p.m., the search concluded, and staff were dismissed to go home. During an interview on [DATE] at 2:16 p.m., the Scheduler indicated Resident B enjoyed being outside with her friends and smoked quite a bit. In the days leading up to [DATE], she had been her normal self until the day before or the day of when she had been upset over some news regarding her son. On the evening of the 30th, she got a call from the DON to come assist with the search, but they were unable to find Resident B. Around 11:30 to 11:45 p.m., they stopped searching and were told to go home. During an interview on [DATE] at 2:20 p.m., the DON indicated she was hands on with the residents of the facility and knew Resident B well. Resident B was an independent smoker and compliant with the facility's policy. Resident B did have the code to the smoking patio, which was the same as the front door, and it was common for her to leave LOA for hours and sometimes days at a time. Resident B also utilized the LOA book to sign herself out, but sometimes she forgot. During an interview on [DATE] at 2:39 p.m., Registered Nurse (RN) 21 indicated she was the nurse working on the evening of [DATE]. She did not notice Resident B was gone until she went to her room to give her evening medication between 8:00 and 9:00 p.m. She looked around but could not find Resident B, so she asked some other staff to help her. When they were unable to locate Resident B she called the DON. RN 21 indicated Resident B sometimes forgot to sign herself out LOA, so they thought that was what happened that night. During an interview on [DATE] at 3:30 p.m., the ADM indicated she received a call around 9:30 p.m. on [DATE]. She was notified that staff were unable to locate Resident B. She rushed to the facility. During the drive in the ADM made a call to her supervisor and the RDCO and VP-RM/IP. When she got to the building, all staff conducted what she called a Fire Watch, wherein every door in the facility was opened. A resident count and search of the grounds was conducted. Some staff members even went in their own cars to look for her in the surrounding neighborhoods. The ADM tried to call Resident B since she was her own representative, but Resident B did not answer. When the ADM looked in Resident B's room, they did not find her phone, but did find her wallet with her ID. The search was concluded around 11:30 or 11:45 p.m. as the staff assumed she must have gone LOA and forgot to sign out. She probably walked to a friend's house. The ADM returned early the next morning and learned Resident B still had not returned, which was when they decided to contact the police. The ADM indicated the police came and took a statement, but they did not search her room of the facility/grounds, they did not ask for specific medical conditions, or request a recent photo of Resident B. The ADM printed off Resident B's face sheet and provided a copy to the officer. During an interview on [DATE] at 12:01 p.m., the facility's attending Psychiatrist indicated, He knew of Resident B from a previous stay in another nursing home and found her to be unreceptive to psychiatric care, she was not very open. After Resident B admitted to the current facility, he saw her twice before she left. An initial face-to-face visit and assessment was conducted on [DATE] and he determined psychiatric services were needed due to her bipolar disorder and polysubstance abuse. In his opinion and professional judgement, Resident B needed a mood-stabilizing medication, in the worst way, but Resident B was unaccepting of his recommendation. When asked if Resident B exhibited behaviors related to her bipolar disorder he indicated, Constantly! She had no impulse control; her mood swings were erratic. She was going to do something stupid. When asked if her behaviors were problematic enough to require increased supervision and medical management, he indicated, of course she needs more supervision that's why she's there, she's a mess. When asked if Resident B would be considered cognitively impaired, he indicated, it was difficult to determine as a comprehensive cognitive exam of her baseline status due to her refusal to answer questions and non-compliance with a medication regimen. He indicated the notes he documented for her were rather short and general due to the fact she was unreceptive to the service. During an interview on [DATE] at 1:40 p.m., Occupational Therapist (OT) 23 indicated she had conducted Resident B's initial OT assessment when she returned after her stroke on [DATE]. At that point, in the first several days after her return, she was very impulsive and could only say, well, well, well. She would forget to lock her wheelchair breaks when she stood up, forget to use her walker, and needed a lot of reminders to slow down. During an interview on [DATE] at 1:55 p.m., Physical Therapist (PT) 24 indicate Resident B had a distinct and significant decline in her physical and cognitive function after her stroke. Before she had been nearly independent with all her ADLs (activities of daily living) but after her stoke she needed a lot more assistance and could only repeat the word, well. She had poor safety awareness and was impulsive which increased her risk for accidents. She would get very frustrated when she could not communicate, I could see it on her face, and she would cry. During an interview on [DATE] at 2:35 p.m. the Detective assigned to Resident B's case, indicated the investigation was ongoing and although they were waiting for DNA conformation, the body found near the facility was very similar to the missing person reported from the facility. The detective indicated a walker was located approximately 1600 feet away from the facility, and the body was located approximately 1000 feet from the walker. It was assumed that she had been wearing shoes, but only one tennis shoe was found, and she only wore a t-shirt with a pair of black sweatpants type pants. The detective indicated the missing person report was filed on [DATE] at 4:22 p.m. During an interview on [DATE] at 2:52 p.m., the ADM indicated the facility's elopement procedure was to first determine if the resident had eloped or was gone LOA. An elopement was any resident that was not cognitively intact, or confused, and left without signing LOA. At the time, the ADM and her supporting staff, did not consider Resident B as eloped because she often left LOA without signing out. The only reason they had decided to do a search for her was because of her history of drug abuse. They did not consider her a missing person until she had not returned the next day. On [DATE] at 11:25 a.m., Resident B's medical record was reviewed. She had diagnoses which included, but were not limited to, type II diabetes (a blood sugar disorder) with neuropathy (numbness, tingling and/or pain in the extremities and hyperglycemia (high blood sugar), other stimulant abuse, severe and reoccurring major depressive disorder. A quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident B was moderately cognitively impaired with a BIMS score of 12. She was admitted on [DATE] after an acute hospital stay in which she was treated for severe burns to her toes. They became infected and required amputation. She readmitted to the facility on [DATE]. A Pre-Admission Screen and Resident Review (PASRR), dated [DATE], indicated Resident B was considered mentally ill and met PASRR criteria with the diagnoses of bipolar disorder and schizophrenia. A nursing progress note, dated [DATE] at 2:14 p.m., indicated Resident B called a cab to be picked up and was going to stay with her daughter. She had signed the LOA book. The corresponding pages from Resident B's LOA book indicated she had signed herself out on [DATE] at 12:13 p.m. The time planned to return was after a few hours, but the return date and time were left blank. The record lacked documentation of when Resident B returned. The next nursing progress note in Resident B's file was not until [DATE] at 3:00 p.m., which was a change of condition notification due to the resident's unusual behavior. A corresponding Nurse Practitioner, (NP) note, dated [DATE] at 4:29 p.m., indicated the NP had been in to see Resident B for a follow up to her toe amputation but was found sitting on the floor of her room wearing only a bra. She was observed to have uncontrolled gross motor clonic-type (repeated/violent muscle spasms) movements of arms and legs. She had a drug pipe in between her breasts that fell out of the bra when she rolled over. She was observed to have uncontrolled tongue thrusting, erratic speech and behaviors. She was resistive to staff care and admitted to using Meth. The NP gave an order to send the resident to the hospital due to stimulant intoxication for detox. Resident B's sign-out log was reviewed between the dates of [DATE]-[DATE]. The log indicated Resident B's compliance with the LOA policy as it was evident, she consistently signed herself out, at least several times a month, even after her stroke. The record lacked however, any documentation of her inability and/or refusals to follow LOA policy. Resident B's comprehensive care plan was reviewed and although Resident B's history of illicit drug use was well known, and stimulant abuse was one of her admitting diagnoses in [DATE], care plans for substance abuse were not initiated until [DATE]. A care plan, initiated [DATE] indicated Resident B had a substance use disorder disease process related to use of Meth and was at risk for complications. An intervention added to the plan of care after she returned on [DATE] was a referral to a substance abuse treatment facility to which Resident B was willing to do. The Social Service Director (SSD) placed a referral to a local facility who would have a bed available on [DATE], however on [DATE] the treatment center called the SSD back and indicated at that time Resident B was too medically complex for their program. A second care plan initiated [DATE] indicated Resident B had substance abuse behavior. Interventions for the plan of care included 1:1 supervision. An Interdisciplinary Team (IDT) progress note, dated [DATE] at 9:49 a.m., indicated Resident B was removed from one on one (1:1) supervision, however the care plan was not revised to remove the 1:1 supervision and a new intervention in its place was not added. A change of condition nursing progress note, dated [DATE] at 3:38 p.m., indicated Resident B had experienced an acute change of condition as evident by .Resident observed with slurred speech et mumbling, drooping right side of face, weak right arm/hand A nursing progress note, dated [DATE] at 6:13 a.m., indicated Resident B was admitted to the hospital after a stroke and new diagnosis of expressive aphasia. An admission nursing assessment was completed on [DATE] at 7:16 p.m. and indicated Resident B's cognitive status was not assessed due to aphasia. A brief smoking and elopement sections were included as a part of the overall admission assessment and had not changed since her last assessment. Further, a PTSD (post-traumatic stress disorder) screening asked if the resident had a history of drug use which was selected yes, but the type of drug used and dated of last use were not recorded, (admitted Meth use and transfer to the hospital on [DATE] for detox). The admission assessment's psychological assessment was detailed, depressed of her situation. A full hospital discharge summary note, dated [DATE] at 2:39 p.m., indicated Resident B had been admitted to the hospital and diagnosed with an acute CVA, expressive aphasia, receptive aphasia and a new diagnosis of PFO (patent foramen ovale- a hole between the left and right atria (upper chambers) of the heart, which increased the risk of stroke). Upon her readmission, Resident B was assessed and placed on Speech Therapy (ST), Occupational Therapy (OT), and Physical Therapy (PT). The corresponding notes were reviewed and revealed the following: Speech Therapy treatment notes as follows: On [DATE] at 12:20 p.m., .patient remains aphasic and only answers with well. Patient was able to follow basic commands of sit up and squeeze fingers. Attempted yes/no and picture identification for communication board, patient responses are 50% . do not feel patient has the receptive ability to use communication board at this time On [DATE] at 11:22 a.m., .patient remains aphasic . patient more frustrated today and was able to say, oh man. Patient completed yes/no questions with 20% accuracy today On [DATE] at 3:10 p.m., .patient declined sitting on the edge of the bed. Patient was able to sequence task of brushing hair and washing face with no cues. Cardiology entered room and patient was able to follow the commands given from the Dr with no cues. Patient then became very tearful and covered her face The ST evaluation and additional analysis, dated [DATE], indicated, patient returned from hospital with diagnoses of acute CVA, receptive and expressive aphasia. Attempted to administer BIMS [a test to determine cognitive status] and portions of the SLUMS [another test to determine cognitive status] however patients expressive language disorder impeded participation. Informal assessment of receptive/expressive language abilities indicated that patient responds to yes/no questions with 80% accuracy, follows 1-step directions with 25% accuracy, identifies basic nouns in pictures given a verbal prompt with 60% accuracy, identified numbers with 100% accuracy and identified 1 letter out of 5 prompts . When prompted to write her own name, she wrote number ,d+[DATE]. Patient attempted to name pictures and engage in conversation; however, the majority of speech output was, well repeated over and over with conversational intonation and gestures. Patient demonstrates limited awareness of this phenomena during conversation; however, she was aware of difficulty with structured tasks as evidence by increased frustration, teary eyes, and refusals A ST daily note, dated, [DATE] indicated, .patient was able to identify numbers five a field of 10, however was unable to identify pictures of functional needs . she was able to repeat nouns when given verbal models and picture stimulus cars with less than 25% accuracy. Words observed include, well, no, mmhmm, okay, three and four. A ST daily note, dated, [DATE] indicated, .patient observed with lunch tray for 10 minutes. Patient demonstrated an increase in mastication [chewing food enough to be able to swallow]. Patient requires cues to swallow before and after a liquid wash . SLP [speech language pathologist] recommends diet order for mechanical soft with thin liquids and discussed with staff . patient attempts to participate in simple conversation but responds with well well, or oh my. SLP provided simple one step directions. Patient unable to independently complete at this time A ST daily note, dated, [DATE] indicated, .SLP educated patient about communication board. SLP provides visual models for three images that are going to be targeted. SLP prompts patient to identify pictures. Patient demonstrates difficulty with comprehension, so SLP attempts to provide hand over hand assistance. Patient is resistant. Patient has difficulty following one-step directions A ST daily note, dated, [DATE] indicated, .SLP educates patient about using picture communication board to increase communication skills with staff. Patient demonstrates difficulty with comprehension . Patient demonstrated severe receptive language deficits at this time. Patient becomes emotional because she is unable to communicate with others . A ST daily note, dated, [DATE] indicated, .patient is education about picture communication board. Patient is not able to identify any images when prompted . SLP provides visual models and verbal cues. Patient demonstrated decreased activity participation . patient demonstrated difficulty following simple one step directions on the tablet The OT initial assessment and evaluation, dated [DATE], indicated, .patient is easily distracted, requires consistent instruction, requires consistent supervision and impulsive. Patient was walking around her room naked upon entering the room to complete the evaluation. Patient answers all questions and speech consists of well well well only . patient presents with a significant change in status from her prior level of functioning due to recent CVA with subsequent weakness and expressive/receptive aphasia . she was highly impulsive during ADL and transfers completion and was attempting to walk around her room without and clothing . risk factors: due to the documented impairments and associated functional deficits, the patient is at risk for compromised general health, decreased ability to return to prior level of supervision, decreased level of mobility, decreased leisure task participation, decreased participation with functional tasks, falls, further decline in function, increased dependency upon caregivers and muscle atrophy An OT daily note, dated, [DATE] indicated, .patient safety awareness is fair, but she is impulsive and needs almost constant reminders to perform tasks without rushing The PT initial assessment and current referral narrative, dated [DATE], indicated .patient referred to PT due to new onset of decrease in strength decrease in functional mobility, decrease in transfers, reduced ability to safely ambulate, reduced balance, reduced functional activity tolerance, decreased coordination, decreased motor control, cognitive deficits and an increased need for assistance from others placing patient at risk for contractures, decreased ability to return to prior level of assistance depression and falls . at this time of evaluation, patient presents with cognitive decline, aphasia, right facial droop right sided weakness and pain but is unable to rate and locate pain (due to aphasia). Patient also exhibits weakness deficits in right lower extremity coordination, reduced work tolerance and decreased safety awareness resulting in an increased risk for falls and increased dependence from others for functional gait and mobility A PT daily note, dated, [DATE] indicated, . patient demonstrates decreased safety awareness at this time . A PT daily note, dated, [DATE] indicated, . patient able to follow [cuing] but struggles with impulsivity which limits her safety ' A PT daily note, dated, [DATE] indicated, .patient has cognitive deficit (aphasia), is impulsive and had decreased safety awareness at this time. Patient's cognitive deficit is a big barrier to progress in therapy When Resident B was noted missing on [DATE] she was unable to receive the following medications which increased the risk of accidents putting her in immediate danger. a. Glargine Insulin, pen-injector 100 unit/mL Inject 55 units subcutaneously (under the skin) at bedtime for Type 2 diabetes mellitus (adult-onset blood sugar disorder) to stabilize her blood sugar and prevent complications of hyper/hypoglycemia. b. Buspirone (anti-anxiety) oral tablet, 15 mg. Give 1 tablet by mouth three times a day for to stabilize and maintain her mental/mood status. c. Quetiapine fumarate (anti-psychotic), oral tablet 25 mg. Give 0.5 tablet by mouth at bedtime to stabilize and maintain her mental/mood status. d. Clonidine (anti-hypertensive) oral tablet 0.1 mg. Give 1 tablet by mouth and at bedtime for hypertension (high blood pressure) to help stabilize her blood pressure. e. Apixaban (to prevent strokes or blood clots), oral tablet 5 mg. Give 1 tablet by mouth and at bedtime for circulation issues. f. FreeStyle Libre Reader Device (continuous blood glucose system receiver). Apply 1 application transdermal (through the skin) at bedtime for diabetes, to stabilize her blood sugar. Additional medications she missed the morning on [DATE] included: a. Lispro Insulin, injection solution 100 unit/mL Inject 20 unit subcutaneously with meals for diabetes mellitus. b. Buspirone oral tablet, 15 mg. Give 1 tablet by mouth three times a day for mental/mood status. c. Quetiapine fumarate, oral tablet 25 mg. Give 0.5 tablet by mouth every morning for mental/mood status. d. Clonidine, oral tablet 0.1 mg. Give 1 tablet by mouth every morning for hypertension (high blood pressure). e. Apixaban, oral tablet 5 mg. Give 1 tablet by mouth every morning for circulation issues. f. Paroxetine (treats depression, anxiety, obsessive-compulsive (OCD), oral tablet 20 mg. Give 1 tablet by mouth in the morning for depression. According to the National Weather Service, on [DATE], the day after the resident went missing, the local surrounding area experienced severe weather.thunderstorms developed along and ahead of a strong cold front on the evening of [DATE]. These storms produced 10 tornadoes along with widespread wind damage. Some fatalities were reported along with multiple injuries. This was part of a larger outbreak that produced a total of 23 tornadoes in Indiana alone. This makes the event the fifth largest tornado outbreak in Indiana history Additionally, weather archives for the night of the [DATE], and into [DATE] detailed dropping temperatures into the 50's, increased cloud coverage, wind and rain as severe weather moved into the area. By 9:00 p.m., on the [DATE] wind gusts as high at 52 miles per hour were recorded. On [DATE] at 2:04 p.m., the RDCO provided a copy of current, but undated, facility policy titled, Resident Leave of Absence. The policy indicated, .definition: Leave of Absence/LOA: leaving the facility with the appropriate authorization and notification to do so. Policy: . a resident/patient who is cognitively intact with independent decision making with a physician's order may sign themselves out for a LOA. In the event the resident/patient exits the facility without signing out on the log, the facility will initiate an investigation in an attempt to locate the resident. Upon the resident/patient return to the facility, appropriate re-education for the leave of absence will be completed On [DATE] at 2:04 p.m., the RDCO provided a copy of current, but undated, facility policy titled, Elopement Prevention and Management Overview. The policy indicated, .definition: Elopement is defined as when a resident/patient leaves the premises or safe area without authorization and/or any necessary supervision and places the resident/patient at harm or injury . Procedure: . 2. Determine elopement risk factors which may include, but are not limited to: a. Acute or chronic confusion/disorientation, b. Anxiety . e. new admission with adjustment difficulties, or a desire to return to previous living situation On [DATE] at 2:04 p.m., the RDCO provided a copy of current, but undated, facility policy titled, Elopement Prevention The policy indicated, .The facility strives to prevent resident/patient elopement, while promoting and supporting resident/patient independence and mobility. The focus is to enable the resident/patient to attain and maintain their highest practicable physical, mental and psychosocial wellbeing while maintaining safety . any resident/patient admitted who is cognitively impaired and can self-ambulate is consi[TRUNCATED]

Based on interview and record review, the facility failed to protect a resident (Resident G) from receiving another resident's medication (Resident F) occurred resulting in harm when the resident received an overdose of an opioid (narcotic pain medication) causing difficulty to arouse, shallow breathing pattern which resulted in [MEDICATION(S)] (used to treat narcotic overdose in emergency situation) being administered and the resident was admitted to the hospital for 1 of 3 residents reviewed for medication errors (Resident G). Findings include: Resident G's record was reviewed on 9/9/21 at 2:30 p.m. A facility census indicated the resident admitted to the facility on [DATE]. A nurse's progress note, dated 8/12/21 at 11:47 p.m., indicated the writer was notified of a medication error. The resident was resting peacefully, breathing even and non-labored, and was easy to arouse. Would continue to monitor at bedside one to one (1:1). The resident's family and physician were notified. A handwritten note by Licensed Practical Nurse (LPN) 12, dated 8/12/21 and untimed, indicated at approximately 8:00 p.m. Resident F had asked for pain medication. LPN 12 opened the narcotic book and signed out Resident F's pain medication. The phone was ringing, and not having a receptionist, LPN 12 answered the phone. When finished with the phone call LPN 12 asked staff working on the hall what room the new resident was in, and the staff responded with the room number to Resident G's room. LPN 12 took the medication to Resident G's room and asked the resident if she had asked for her medication and Resident G responded with yes. LPN administered the medication at that time and due to not verifying the resident name she gave the wrong medication to Resident G. A convergence narrative progress note, dated 8/13/21 at 4:40 a.m., indicated Resident G was given 60 milligrams (mg) of [MEDICATION(S)] by mouth (PO) and did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Plan indicated to continue current monitoring every 30 minutes and treatment included supplemental oxygen. [MEDICATION(S)] was at the resident's bedside, facility provider was to review all medications. Follow up in 3 hours or sooner if condition warrants. Hold all medications except for inhales and [CONDITION(S)] medication until resident was awake, alert, eating, and drinking, as needed. [MEDICATION(S)] dose ordered once if the respirations drop to less than 12. Staff were to wake resident every 30 minutes to 1 hour to monitor neurological status. A nurse's progress note, dated 8/13/21 at 8:05 a.m., indicated the resident's breath pattern was shallow, respirations were 11-12, oxygen saturation was 92% with 3 liters of supplemental oxygen, and the resident was difficult to arouse. The physician was notified, and a new order was received to administer [MEDICATION(S)] and transfer the resident to the emergency department. A nurse's progress note, dated 8/13/21 at 8:21 a.m., indicated the resident was administered 2 doses of [MEDICATION(S)]. Resident was awake and alert answering questions appropriately. Emergency Medical Services (EMS) notified and in route. Physician and family of transfer to the emergency department. The resident's vitals indicated oxygen saturation was 92% with 3 liters of supplemental oxygen. An acute hospital history and physical- general illness note, dated 8/13/21, indicated the patient was sent to the hospital from a long-term care facility after the patient reportedly received 60 milligrams (mg) of [MEDICATION(S)] the night prior. The patient was found to be unresponsive and unconscious this morning. Patient was given 4 mg of [MEDICATION(S)], and the patient awakened but continued to be somnolent and therefore was sent to the emergency room for evaluation. A physician note, dated 8/13/21 and untimed, indicated the patient had increased somnolence after opiate overdose last night. The patient had improved with [MEDICATION(S)] at nursing home and would be given an additional [MEDICATION(S)] 0.4 mg intravenously. Patient was also wheezing and having mild increased respiratory drive, would start nebulizer treatments. Patient [CONDITION(S)] to 120s with [CONDITION(S)] (a-fib). At the 11:04 hour (lacked a.m. or p.m.) the patient responded to intravenous (IV) [MEDICATION(S)] 0.4 mg briefly and became somnolent again. A repeat dose of IV 2 mg [MEDICATION(S)] was given and patient much more awake and alert at that time. A discharge hospital course note, dated 8/18/21 and untimed, indicated the patient unfortunately had suffered effects from a severe medication error and was administered 60 mg of [MEDICATION(S)] Sulfate at a long-term care facility that had been intended for another patient as a chronic maintenance dose for pain. This patient grew increasingly somnolent and poorly responsive and required to be sent to the emergency room for evaluation. The patient received several doses of [MEDICATION(S)] and eventually was able to regain her usual baseline level of function. A care plan, initiated 8/12/21, indicated the resident had chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) with shortness of breath while lying flat. Interventions included, but were not limited to, administer medications per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A record review was completed for Resident F on 9/9/21 at 11:00 a.m. A census indicated the resident admitted to the facility on [DATE]. Resident F's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A controlled drug administration record, dated 8/12/21, indicated two tablets had been signed out at 8:00 p.m., and two tablets had been signed out at 8:20 p.m. During an interview, on 9/10/21 at 11:10 a.m., the Regional Director of Clinical Operations indicated Licensed Practical Nurse (LPN) 12 had went to administer Resident F's [MEDICATION(S)] Sulfate (opioid) medication. She asked other staff on the unit where the new resident's room was and was told Resident G's room number. LPN 12 went to Resident G's room and failed to use the 5 rights for medication administration and administered Resident F's medication to Resident G. This was a medication error, and the nurse was provided with education. Resident G received the medication during the 8:00 p.m. medication pass on 8/12/21 and the error was discovered shortly after the administration. The resident was monitored through the night into the morning of 8/13/21 where the resident became difficult to arouse and the resident's breathing pattern was shallow. Resident G was administered two doses of [MEDICATION(S)] and sent the emergency room and was admitted to the hospital. The resident was discharged from the hospital to another long-term care facility. On 9/10/21 at 1:10 p.m. the Regional Director of Clinical Operations provided a document, undated, and titled, Highlights of Prescribing Information for [MEDICATION(S)] Sulfate Tablets, and indicated the indications and usage would be followed by the facility. The document indicated, .Clinical Pharmacology. Mechanism of Action: [MEDICATION(S)] Sulfate, an opioid agonist . in addition to [MEDICATION(S)], the widely diverse effects of [MEDICATION(S)] Sulfate include drowsiness, changes in mood, respiratory depression .and alterations of the endocrine and autonomic nervous system .5. Warnings and precautions: Use [MEDICATION(S)] Sulfate with extreme caution in patients with chronic obstructive pulmonary disease .In such patients, even usual therapeutic doses of [MEDICATION(S)] Sulfate may increase airway resistance and decrease respiratory drive to the point of apnea On 9/9/21 at 2:01 p.m., the Regional Director of Clinical Operations provided a document, revised 12/14/17, and titled, Medication Administration, and indicated it was the policy currently being used by the facility. The policy indicated, .Scope: This policy is applicable to all adult living centers .Policy: It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Safety of residents .is a top priority of care .Procedure: .a. Administer medication only as prescribed by the provider. b. A resident-centered, individualized approach to medication administration will be used for administering medications as possible. l Safety and avoiding adverse effects is considered a high priority for medication administration and may preclude some preferences .f. Observe the 'five rights' in giving each medication. i. the right resident. ii. the right time. iii. the right medicine. iv. the right dose. v. the right route .j. Full attention should be given during preparation of medications. i. Avoiding distractions is important for infection prevention and reducing errors .Narcotics will be signed out when given On 9/10/21 at 10:33 a.m., the Regional Director of Clinical Operations provided a document, effective 5/1/17, and titled, Medication Incident, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the resident .I. Medication Safety: .c. Medications will be administered to the resident for whom it was prescribed This Federal tag relates to Complaints IN 208 and IN 587. 3.1-48(c)(2)

Based on observation, record review, and interview, the facility failed to ensure physician's orders were followed for a gastrostomy tube, physician and family notification, obtain weights, and address significant weight loss for 1 of 4 residents reviewed for nutrition resulting in harm when the resident had a significant weight loss of 10% in 3 months (Resident D), and failed to ensure physician and family notification, obtain weights, and address significant weight loss for 1 of 4 residents reviewed for nutrition resulting in harm when the resident had a significant weight loss of 29% in 7 months (Resident J). Findings include: 1. During an observation, on 4/28/21 at 11:27 a.m., Resident D was observed up in his chair. His gastrostomy tube, ([G-tube] a tube inserted through the stomach that provides nutrition) machine was not observed to be on at this time and the G-tube tubing appeared to be clear. During an observation, on 4/28/21 at 12:05 p.m., Resident D was observed up in his chair. His G-tube machine was not observed to be on at this time and the g-tube tubing appeared to be clear. During an observation, on 4/28/21 at 1:09 p.m., Resident D was observed up in his chair. His G-tube machine was on at this time and feed rate indicated 79 milliliters (ml)/hour (hr) was being administered. The g-tube tubing had Vital 1.2 (supplemental nutrition) being administered through the tubing. Resident D's record was reviewed on 4/28/21 at 3:29 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 3/3/21, lacked documentation of a weight. A review of weights, dated 1/1/21, indicated the resident weighed 182 pounds (lbs). A dietary progress note, dated 1/14/21, indicated the resident's weight continued to be stable with current enteral feeding (EF) Vital AF 1.2 at 79ml/hr. with 40 ml flushed which provided the resident with 100% of his nutrition needs. The resident had a G-tube replacement noted due to pin hole and resident returned to the facility on [DATE]. No changes or recommendations at that time. Continue current plan of care and Registered Dietician (RD) to monitor weight changes. A dietary progress note, dated 1/28/21, indicated there had been no changes since the prior week. Resident continued to be stable with current EF Vital AF 1.2 79 ml/hr with 40 ml flushed which provided the resident with 100% of his nutrition needs. No changes or recommendations at that time. Continue current plan of care and RD to monitor weight changes. A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of weights lacked documentation a weight was obtained the month of February 2021. A dietary progress note, dated 2/12/21, indicated the resident readmitted from the hospital due to blood coming out of G-tube and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . No changes or recommendations at that time. Continue current plan of care and RD to monitor weight changes. A dietary progress note, dated 2/26/21, indicated the resident continued to be stable with current EF Vital AF 1.2 79 ml/hr with 40 ml flushed which provided the resident with 100% of his nutrition needs. RD requested current body weight for February. No changes or recommendations at that time. Continue current plan of care and RD to monitor weight changes. A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of weights, dated 3/1/21, indicated the resident weighed 163 lbs. On 3/5/21 the RD indicated the 3/1/21 was incorrect documentation and requested a re-weight. A review of weights, from 3/2/21 through 3/14/21, lacked documentation the resident had been weighed. A review of weights, dated 3/15/21, indicated the resident weighed 163 lbs. A dietary progress note, dated 3/23/21, indicated the resident triggered for a significant weight loss. The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Current order: EF Vital 1.2 79 cc/hr with 40 ml/hr flushes providing 100% of needs when given as ordered. RD recommended to change EF to run over 22 hours and continue with same rate and flush to allow stomach some rest. Resident would still receive 100% of estimated needs. RD notified the interdisciplinary to inform the physician and family of weight loss and EF recommendations. RD requested weekly weights. RD to follow up with enteral feeding tolerance, weight changes, RD recommendations as needed. A review of progress notes, dated 3/1/21 through 3/29/21, lacked documentation the physician or family had been notified of weight loss and EF recommendations. A MAR, dated March 2021 and discontinued on 3/29/21, indicated the resident received EF Vital AF 1.2 at 79 ml/hr (total amount 632 ml/shift). The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's order, dated 3/29/21, indicated EF Vital 1.2 at 45 ml/hr. A dietary progress note, dated 3/31/21, indicated the resident currently received EF Vital 1.2 45 ml/hr with 40 ml/hr flushes x 24 hours. RD recommended to change EF to Vital 1.2 to be ran over 22 hours at 79 ml/hr with 40 ml/hr flushes to allow stomach some rest. Resident would still receive 100% of estimated needs. A review of progress notes, dated 3/31/21 through 4/22/21, lacked documentation the physician had been notified of the RD's EF recommendation on 3/31/21. A review of weights, dated 4/12/21, indicated the resident weighed 160 lbs. A physician's order, dated 4/23/21, indicated EF Vital 1.2 at 79 ml/hr to be ran over 22 hours, off at 8:00 a.m. and on at 10:00 a.m. A dietary progress note, dated 4/27/21, indicated the RD reviewed the residents feeding change and current needs. Resident weight remained stable since initial loss. RD recommended to continue with current plan and would follow closely. Weight loss likely to be unavoidable due to history of pulling out G-tube. A review of the resident's medical record, dated 1/1/21 through 4/28/21, lacked documentation the resident had pulled out his G-tube. The resident's feeding was documented one time as refused on 1/30/21 evening shift. No other documentation of refusal was observed at this time. During an interview, on 4/29/21 at 12:02 p.m., the Registered Dietician (RD) 15 indicated he had reviewed the resident on 3/5/21 and requested the resident to be re-weighed. The resident was known to refuse weights and be combative and pull out his G-tube. The resident had been stable with weights and had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The residents body mass index (BMI) as of 4/26/21 was 21.1 which was considered within normal limits. The resident received 1738 ml which provided 2086 calories, 130 grams (gm) of protein per every 24 hours. The resident also had an auto flush that provided 880 ml of water in a 24-hour period. The current EF and flush order met/exceeded the estimated nutritional needs for the resident. During an interview, on 4/29/21 at 12:32 p.m., Licensed Practical Nurse 13 indicated on 4/28/21 she had turned the residents G-tube feeding off around 9:30 a.m. instead of the scheduled time of 8:00 a.m. She had been attending to a resident who had behaviors and a [CONDITION(S)] and was unable to get the G-tube on time. She was unable to tell what time she had turned the feeding back on and indicated she should have documented the time she turned if off and so she could have turned it back on two hours later as ordered. When she had worked the unit, the resident had not refused his feedings or weights. On 4/30/21 at 12:06 p.m., Corporate Consultant 4 provided a document, reviewed 5/29/19, and titled, Resident Weight, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: .It is the policy of this facility that a resident's weight will be accurately obtained within 24 hours of admission if resident is able, with changes in condition or as ordered by physician or practitioner .c) Compare weight to previous weight obtained. If a variance of 5 pounds or more is noted, reweight resident to verify weight .3 .d) Unstable residents will be reviewed by IDT team to determine weekly or other .6. Reweight Parameters: a) Recommend that residents with tube feedings be weighed weekly, unless otherwise indicated in care plan or by physician order. i) Reweight within 24 hrs. 1) Validation with nurse for accurate weight. 2) Notify IDT team/doctor/family if indicated .8. Reporting weights. a) Weight loss concerns will be discussed at the weekly clinical meetings On 4/30/21 at 12:06 p.m., Corporate Consultant 4 provided a document, reviewed 5/29/19, and titled, General Enteral Feeding Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, Policy: It is the policy of this facility to provide resident centered care by providing enteral feeding and hydration for residents unable to tolerate oral feedings or oral medication delivery and those who have stable (not new) enteral tube in place .A physician/provider order is required to include solution, amount, frequency, rate, intermittent stop times and flushing procedures. A licensed nurse will administer nutritional feeding and care for the enteral tube 2. Resident H's record was reviewed on 4/29/21 at 12:14 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 4/9/21, indicated the resident had a moderate cognitive impairment, had not rejected care during the assessment period, required total assistance from one staff member for eating, had a significant weight loss while not on a physician prescribed weight loss program and had pressure ulcers (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin). diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's order, dated 6/16/20, indicated regular diet with pureed (foods blended to a smooth consistency) texture. A physician's order, dated 9/1/20, indicated [MEDICATION(S)] (a diuretic) 20 milligrams (mg) by mouth daily for CHF. Current physician's orders lacked documentation of any nutritional supplements. A weight, dated 7/10/20, indicated the resident weighed 136.8 pounds. A weight, dated 8/18/20, indicated the resident weighed 139.6 pounds. A weight, dated 9/10/20, indicated the resident weighed 132.4 pounds. The record lacked documentation the resident was re-weighed after this weight was obtained. A Registered Dietitian (RD) note, dated 9/14/20, indicated the resident had a significant weight loss over the past month, seven pounds, 5.2 percent weight loss. Average intakes below 50 percent. The resident received Mighty Shakes with lunch and dinner. The resident's weight remained in her usual body weight range. No recommendations were made. The note lacked documentation of how much of the Mighty Shakes the resident consumed. A dietary nutritional review, dated 9/14/20, indicated the resident received Mighty Shakes (nutritional supplement) with lunch and dinner and weighed 132 pounds with a significant weight loss of 7 pounds over the past month. RD summary included, but was not limited to, resident has had a significant weight loss over the past month, average intake poor and less than 50 percent, no changes or recommendations made, and RD to monitor weight changes. The review lacked documentation of how much of the Mighty Shakes the resident consumed. A skin grid pressure, dated 9/22/20, indicated the resident had a facility acquired stage two (skin broken open, and can look like a scrape, blister, or shallow crater) pressure ulcer to the left heel, which measured 4.5 centimeters (cm) in length, 6 cm in width, and 0 cm in depth. The area was first observed on 9/17/20. A skin grid pressure, dated 9/29/20, indicated the resident had a facility acquired unstageable (full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar) pressure ulcer to the right heel, which measured 4 cm in length, 6 cm in width, depth was not measured. A care plan, initiated 10/7/20, indicated the resident was at risk for skin breakdown and had pressure ulcers to the left and right heels. A dietary nutritional assessment, dated 10/8/20, indicated the resident received Mighty Shakes with lunch and dinner, had a stage two pressure ulcer to the left heel, and an unstageable pressure ulcer to the right heel. The resident was totally dependent for dining and weighed 132 pounds, a weight loss of 7 pounds in 30 days. RD comments included, but were not limited to, resident had a significant weight loss over the past month, average intakes below 50 percent, received Mighty Shakes with lunch and dinner, no changes or recommendations, RD to monitor weight changes, and weight remained within usual body weight range. The note lacked documentation of how much of the Mighty Shakes the resident consumed and any further weights since 9/10/20. A specialty physician wound evaluation and management summary, dated 11/5/20, indicated the stage three pressure ulcer to the left heel deteriorated due to a generalized decline of the resident. A specialty physician wound evaluation and management summary, dated 11/19/20, indicated the stage three (the sore extends into the tissue below the skin and forms a small crater) pressure ulcer to the left heel deteriorated due to a generalized decline of the resident. A specialty physician wound evaluation and management summary, dated 12/3/20, indicated the stage three pressure ulcer to the left heel deteriorated due to a generalized decline of the resident and nutritional compromise. A dietary nutritional review, dated 12/14/20, indicated the resident received a regular pureed diet and Mighty Shakes with lunch and dinner. The resident had pressure ulcers to the right and left heel and required total assistance for dining. The most recent weight was 132 pounds. Average food intake was 26-75 percent. The RD requested the current body weight related to the last weight was 9/10/20. The resident continued on [MEDICATION(S)] and [MEDICATION(S)] (an antidepressant that can stimulate the appetite). The current care plan was continued, no new recommendations. The review lacked documentation of how much of the Mighty Shakes the resident consumed. A paper weight log, dated January 2021, indicated the resident refused to be weighed. The record lacked documentation of any re-attempts to weigh the resident and resident representative notification of the refusal. A specialty physician wound evaluation and management summary, dated 1/22/21, indicated the resident had a stage three pressure ulcer to the left heel deteriorated due to generalized decline of the resident, and an unstageable deep tissue injury to the right heel deteriorated due to generalized decline of the resident. A paper weight log, dated February 2021, indicated the resident refused to be weighed. The record lacked documentation of any re-attempts to weigh the resident and resident representative notification of the refusal. A weight, dated 2/9/21, was removed related to incorrect documentation. The weight previously indicated the resident weighed 145 pounds. The record lacked documentation the resident was re-weighed after this weight was determined to be incorrect. A paper weight log, dated March 2021, indicated the resident refused to be weighed. The record lacked documentation of any re-attempts to weigh the resident and resident representative notification of the refusal. A specialty physician wound evaluation and management summary, dated 3/4/21, indicated the resident had stage three pressure ulcers to the left and right heel deteriorated due to generalized decline of the resident. A specialty physician wound evaluation and management summary, dated 3/11/21, indicated the resident had a stage three pressure ulcer to the right heel deteriorated due to generalized decline of the resident. An RD note, dated 3/16/21, indicated the resident had a stage two pressure ulcer to the right heel, noted as deteriorated, and a stage two pressure ulcer to the left heel, noted as improved, per the Registered Nurse (RN) note. The resident continued with a pureed diet, and 26-75 percent average intake. The RD would review the March weight. Weight gain noted last month, beneficial for the resident. The note lacked documentation the referenced weight gain was found to be due to an incorrect weight, any nutritional supplements received, and how much of the nutritional supplements were consumed. A care plan, initiated 3/16/21, indicated the resident was at risk of nutritional decline, had skin breakdown, history of refusal of weights, and significant weight loss. Interventions included but were not limited to Mighty shakes with lunch and dinner and notify medical provider and resident representative of unplanned weight changes. A specialty physician wound evaluation and management summary, dated 3/18/21, indicated the resident had a stage three pressure ulcer to the right heel deteriorated due to generalized decline of the resident. An RD note, dated 3/30/21, indicated the resident had a stage three pressure ulcer to the right heel, noted as deteriorated, and a stage three pressure ulcer to the left heel noted as improved per the skin report. The resident continued with a pureed diet, and 26-75 percent average intake. Weight gain was noted last month, beneficial for the resident. The note lacked documentation the referenced weight gain was found to be due to an incorrect weight, any nutritional supplements received, and how much of the nutritional supplements were consumed. A nurse practitioner (NP) progress note, dated 4/1/21, indicated the resident weighed 145 pounds. The note lacked documentation the NP was aware this weight was determined to be inaccurate. An RD note, dated 4/9/21, indicated the resident had a stage three pressure ulcer to the right and left heel. The resident continued with a pureed diet and 26-75 percent average intake. The RD requested a current body weight related to the last weight was 2/9/21. The note lacked documentation the referenced weight, dated 2/9/21, was marked out as incorrect, any nutritional supplements received, and how much of the nutritional supplements were consumed. A weight, dated 4/16/21, indicated the resident weighed 94.3 pounds. The record lacked documentation the resident was re-weighed after this weight was obtained, weighed between 9/10/20 and 4/16/21, or the physician and resident representative were notified of the weight loss. On 4/29/21 at 2:00 p.m., Corporate Consultant 17 provided documentation of the resident's body mass index (BMI) (a measure of body fat based on height and weight). The document indicated the resident's BMI was 24.7 (normal weight) in August 2020, 23.4 (normal weight) in September 2020, and 16.6 (underweight) in April 2021. On 4/30/21 at 1:37 p.m., the RD provided a copy of the resident's tray card and identified it as current. The tray card indicated the resident received Mighty Shakes with lunch and dinner. The tray card lacked documentation of how much of the Mighty Shakes the resident consumed. During an interview, on 4/30/21 at 10:30 a.m., Corporate Consultant 17 indicated the paper weight logs showed weight refusals for January, February, and March 2021. She was not sure if they would have done an arm circumference or tried other ways to monitor a resident's nutritional status if weights were refused. There was no additional documentation of what was done when the resident refused weights. During an interview, on 4/30/21 at 11:24 a.m., Corporate Consultant 17 indicated the amount of nutritional supplements consumed was not documented anywhere. The resident had not triggered as a weight loss because it had been so long since a weight was put in the system. She was not sure if the resident had been physically assessed or if they would have been able to tell she had lost weight. During an interview, on 4/30/21 at 11:28 a.m., the RD indicated when weights were entered into the computer system he was notified of significant weight changes. This resident had not been weighed and had not triggered as a significant weight loss. The amount of nutritional supplements consumed was not documented so he would not know this information when assessing the residents and making new recommendations. During an interview, on 4/30/21 at 1:14 p.m., the RD indicated the resident had not triggered on the weight report as a significant weight loss since 9/14/20. At that time, she was within her usual body weight range, and no new recommendations were made. She continued to receive Mighty Shakes with lunch and dinner. He noticed the weight loss in April 2021 and requested a re-weight. It took at least two weeks for the re-weight to be obtained. There was greater than six months between the weights that triggered the significant weight loss, so it was not triggered on his report. He was reviewing her chart related to her having pressure ulcers, so he was aware of the weight change that way. He had not considered her to be a high risk for weight loss in September 2020, so she was not added for weekly weights or extra monitoring. During an interview, on 4/30/21 at 2:22 p.m., Corporate Consultant 4 indicated with a significant weight loss and pressure ulcer development, the resident was considered to be high risk. A high risk resident should have been weighed weekly and reviewed. A high risk designation was based off of the RD recommendations. The resident refused weights at times, but other attempts should have been made and documented. On 4/29/21 at 11:40 a.m., Corporate Consultant 17 provided a document titled, Medical Nutrition Therapy: Assessment and Care Planning, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedures: .2. The RDN or other clinically qualified nutrition professional will be responsible for the completion of a comprehensive assessment .as indicated by the clinical condition of the resident .7. The RDN or other clinically qualified nutrition professional will be responsible for ensuring follow up and appropriate documentation of recommended changes in the plan of care. 8. The RDN or other clinically qualified nutrition professional will be responsible for ensuring that all assessments meet current standards of practice On 4/29/21 at 12:06 p.m., Corporate Consultant 4 provided a document titled, Resident Weight, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure: .6) Reweight Parameters: a) A plus/minus of 5 pounds of weight in one week will result in: i) Reweight within 24 hours (1) Validation with nurse for accurate weight (2) Notify IDT team/doctor/family, if indicated 7) Monthly Weights: a) Obtain monthly weights by the 7th of the month in order to effect changes if indicated. 8) Reporting Weights (a) Weight loss concerns will be discussed at the weekly clinical meetings On 4/29/21 at 12:06 p.m., Corporate Consultant 17 provided a document, reviewed 5/30/19, and titled, Notification for Changes in Condition, and indicated it was the policy currently being used the facility. The policy indicated, Policy: .Changes may include but are not limited to accidents, incidents, transfers, changes in overall health status, significant medical changes .hospitalization s .II. Notifications: a. When a change in condition is noted, the nursing staff will contact the resident representative .III. Timing and Documentation of notifications: a. Notifications will be prioritized when competing changes occur. b. The attending practitioner must immediately notified of significant changes in condition, and the medical record must reflect the notification, response and interventions implemented to address the resident's condition. c. The nurse will record in the progress notes, the name of person called, the time of each attempt to contact, and the telephone number(s) attempted . On 5/3/21 at 9:56 a.m., Corporate Consultant 17 provided a document titled, Refusal of Care and Treatment, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the resident .Procedure: I. Overview: .c. The facility will make considerations for residents to the extent possible who are cognitively impaired and attempt to determine the reason for the refusal and provide potential solutions .III. Low Risk (non-emergency) refusal of care: .b. The staff will contact the family and/or resident representative for non-emergency refusals to assist with potential reasons and assistance with refusals. i. For on-going refusals, a care conference will be used to address on-going concerns for care and treatments, and possible solutions. c. Notify the ordering physician after three (3) refusals of care for treatment .d. Document refusal and reasons if known, in progress note. IV. Document: a. Education provided to the resident/family/representative regarding risks and benefits of the care or treatment. b. Attempts made to resolve the refusal including but not limited to other routes, other times, other methods that the resident is in agreement with. c. Contact attempts to the provider/ordering physician for all high-risk refusals of care. d. Contact attempts to the Medical Direct if applicable This Federal tag relates to Complaint IN 569. 3.1-46(a)(1)

Based on observation, record review, and interview, the facility failed to ensure interventions and treatments for pressure ulcers (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) were implemented for 1 of 9 residents reviewed for pressure ulcers resulting in harm when a resident developed an avoidable unstageable (full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar) pressure ulcer on the left heel that worsened to a stage four (a sore that extends below the subcutaneous fat into deep tissues like muscle, tendons, and ligaments; in more severe cases, they can extend as far down as the cartilage or bone), and developed an avoidable unstageable pressure ulcer to the right heel (Resident J). The facility failed to ensure documented interventions for refusal of wound care not resulting in harm but potential for harm for 1 of 9 residents reviewed for pressure ulcers (Resident F). Findings include: 1. During an initial pool observation, on 4/27/21 at 9:50 a.m., Resident J was observed lying in bed with dressings to bilateral (both) heels. The resident's heels were resting on the bed, no boots or off-loading of pressure was observed. The resident was observed on a standard mattress. On 4/29/21 at 9:50 a.m., the resident was observed up in his wheelchair in therapy, with dressings in place to bilateral heels. No sponge boots were in place. On 4/29/21 at 12:30 p.m., the resident was observed up in his wheelchair, in his room. No sponge boots were in place. The resident had a standard mattress in place to the bed. On 4/29/21 at 2:54 p.m., the resident was observed with Registered Nurse (RN) 7, sitting up in his wheelchair, no sponge boots were in place. At the same time, RN 7 indicated she was the wound nurse for the facility. She was not sure what type of mattress the resident had. The resident did not wear sponge boots, and staff should have off loaded his heels when he was in bed. On 5/4/21 at 10:55 a.m., the resident was observed sitting up on the edge of his bed. The resident's right heel was bare, with no dressing in place, and resting directly on the floor. One sponge boot was noted on the floor next to the bed. At the same time, when queried regarding if he wore the boots, the resident indicated, Wear it? I just got it. Resident J's record was reviewed on 4/30/21 at 2:43 p.m. A significant change Minimum Data Set (MDS) assessment, dated 4/16/21, indicated the resident had a moderate cognitive impairment, required extensive assistance of two staff members for bed mobility, extensive assistance of one staff member for transfers, had one stage four (a sore that extends below the subcutaneous fat into deep tissues like muscle, tendons, and ligaments; in more severe cases, they can extend as far down as the cartilage or bone) pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin), and received [CONDITION(S)] while a resident. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A re-admission assessment, dated 8/17/20, indicated the resident did not have any open areas to his skin. A specialty physician wound evaluation and management summary, dated 12/18/20, indicated the resident had an unstageable (full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar) due to necrosis pressure ulcer to the left heel, which measured 2.8 centimeters (cm) in length, 4 cm in width, and 0.1 cm in depth. The resident had an unstageable due to necrosis pressure ulcer of the right heel, which measured 1.9 cm in length, 1.7 cm in width, and 0.1 cm in depth. The dressing treatment plan indicated [MEDICATION(S)] (an antiseptic) covered with a sterile pad, applied once daily, to bilateral heels. Plan of care recommendations included float heels in bed, off load wounds, and sponge boots. A specialty physician wound evaluation and management summary, dated 12/23/20, indicated the resident had an unstageable due to necrosis pressure ulcer to the left heel which measured, 2.8 cm in length, 3.2 cm in width, and 0.1 cm in depth. The resident had an unstageable due to necrosis pressure ulcer to the right heel which measured, 1.5 cm in length, 2 cm in width, and 0.1 cm in depth. The dressing treatment plan indicated [MEDICATION(S)] covered with a sterile pad, applied once daily, to bilateral heels. Plan of care recommendations included float heels in bed, off load wounds, and sponge boots. A specialty physician wound evaluation and management summary, dated 12/30/20, indicated the resident had an unstageable due to necrosis pressure ulcer to the left heel which measured, 2.7 cm in length, 3.2 cm in width, and 0.1 cm in depth. The resident had an unstageable due to necrosis pressure ulcer to the right heel which measured, 2.5 cm in length, 1.8 cm in width, and 0.1 cm in depth. The dressing treatment plan indicated [MEDICATION(S)] covered with a sterile pad, applied once daily, to bilateral heels. Plan of care recommendations included float heels in bed, off load wounds, and sponge boots. A care plan, initiated 12/30/20, indicated the resident had impaired skin integrity to bilateral heels. Interventions included, but were not limited to, administer treatments as ordered by the medical provider and sponge boots on bilateral lower extremities. A Treatment Administration Record (TAR), dated December 2020, indicated Santyl (an enzyme used to help the healing of [CONDITION(S)], skin wounds, and skin ulcers) ointment to left heel every day and cover with non-adherent gauze and Kerlix (gauze), initiated 12/18/20. The TAR lacked documentation of why [MEDICATION(S)] was not applied to the left heel as ordered by the wound doctor. The TAR lacked documentation the Santyl treatment was offered, refused, or provided on 12/19/2020 and 12/22/20. The TAR indicated [MEDICATION(S)] was applied and covered with Kerlix to the right heel daily, initiated 12/18/20. The TAR lacked documentation the [MEDICATION(S)] treatment was offered, refused, or provided on 12/19/20 and 12/22/20. The TAR lacked documentation heels were floated while in bed, wounds were off loaded, and sponge boots were provided. A specialty physician wound evaluation and management summary, dated 1/22/21, indicated the resident had an unstageable due to necrosis pressure ulcer to the left heel which measured, 2.5 cm in length, 3.8 cm in width, and 0.1 cm in depth. The resident had an unstageable due to necrosis pressure ulcer to the right heel which measured, 3.2 cm in length, 2.2 cm in width, and 0.1 cm in depth. The dressing treatment plan indicated [MEDICATION(S)] covered with a sterile pad, applied once daily, to bilateral heels. Plan of care recommendations included float heels in bed, off load wounds, and sponge boots. A TAR, dated January 2021, indicated Santyl ointment to left heel every day and cover with Kerlix. The TAR lacked documentation of why [MEDICATION(S)] was not applied to the left heel as ordered by the wound doctor. The TAR lacked documentation the Santyl treatment was offered, refused, or provided on 1/8/21, 1/13/21, 1/21/21, and 1/30/21. The TAR indicated apply collagen (encourages the deposition and organization of newly formed collagen fibers and granulation tissue in the wound bed) to left heel wound bed and cover with gauze on 1/28/21 only. The TAR indicated [MEDICATION(S)] was applied to the right heel and covered with Kerlix daily. The TAR lacked documentation the [MEDICATION(S)] treatment was offered, refused, or provided on 1/8/21, 1/13/21, 1/21/21 and 1/30/21. The TAR lacked documentation heels were floated while in bed, wounds were off loaded, and sponge boots were provided. A specialty physician wound evaluation and management summary, dated 2/4/21, indicated the resident wound to the left heel had deteriorated due to a recent hospitalization . The resident had an unstageable due to necrosis pressure ulcer to the left heel which measured, 3.4 cm in length, 4.9 cm in width, and 0.1 cm in depth. The dressing treatment plan indicated [MEDICATION(S)] once daily for the left heel. The resident had a stage three (extends into the tissue beneath the skin, forming a small crater; fat may show in the sore, but not muscle, tendon, or bone) pressure ulcer to the right heel which measured, 2.2 cm in length, 3.1 cm in width, and 0.1 cm in depth. The dressing treatment plan indicated Santyl covered with a sterile pad daily for the right heel. Plan of care recommendations for bilateral heels included float heels in bed, off load wounds, and sponge boots. A specialty physician wound evaluation and management summary, dated 2/12/21, indicated the resident had an unstageable due to necrosis pressure ulcer to the left heel which measured, 3.8 cm in length, 4 cm in width, and 0.1 cm in depth. The dressing treatment plan indicated [MEDICATION(S)] once daily for the left heel. The resident had a stage three pressure ulcer to the right heel which measured, 2 cm in length, 3 cm in width, and 0.1 cm in depth. The dressing treatment plan indicated Santyl covered with a sterile gauze daily for the right heel. Plan of care recommendations for bilateral heels included float heels in bed, off load wounds, and sponge boots. A TAR, dated February 2021, indicated Santyl was applied to the left heel and covered with gauze daily from 2/1/21 to 2/15/21, and the wound to the left heel was cleansed with normal saline and a wet to dry dressing was applied daily from 2/16/21 to 2/28/21. The TAR lacked documentation of why the [MEDICATION(S)] treatment was not applied to the left heel as ordered by the wound doctor. The TAR lacked documentation treatments to the left heel were offered, refused, or provided on 2/5/21, 2/11/21, 2/14/21, 2/16/21, 2/17/21, 2/18/21, and 2/21/21. The TAR indicated [MEDICATION(S)] was applied to the right heel daily and covered with Kerlix. The TAR lacked documentation of why the Santyl treatment was not applied to the right heel as ordered by the wound doctor. The TAR lacked documentation the treatment to the right heel was offered, refused, or provided on 2/5/21, 2/11/21, and 2/18/21. The TAR lacked documentation heels were floated while in bed, wounds were off loaded, and sponge boots were provided. A specialty wound evaluation and management summary, dated 3/4/21, indicated the resident had a stage three pressure ulcer to the left heel, deteriorated due to generalized decline of the patient, which measured, 3.2 cm in length, 4.8 cm in width, and 0.1 cm in depth. The dressing treatment plan indicated Santyl covered with a sterile pad daily for the left heel. The resident had an unstageable due to necrosis pressure ulcer to the right heel which measured, 2.8 cm in length, 1.8 cm in width, and 0.1 cm in depth. The dressing treatment plan indicated [MEDICATION(S)] covered with a sterile pad daily for the right heel. Plan of care recommendations for bilateral heels included float heels in bed, off load wounds, and sponge boots. A specialty wound evaluation and management summary, dated 3/11/21, indicated the resident had an unstageable due to necrosis pressure ulcer to the left heel which measured, 3.4 cm in length, 4.4 cm in width, and 0.1 cm in depth. The dressing treatment plan indicated Santyl covered with a sterile pad once daily for the left heel. The resident had an unstageable pressure ulcer due to necrosis of the right heel which measured 2.8 cm in length, 1.8 cm in width, and 0.1 cm in depth. The dressing treatment plan was [MEDICATION(S)] covered with Kerlix daily for the right heel. Plan of care recommendations for bilateral heels included float heels in bed, off load wounds, and sponge boots. A specialty wound evaluation and management summary, dated 3/18/21, indicated the pressure ulcer to the left heel deteriorated due to the treatment was not applied. The area was a stage four pressure ulcer which measured, 3.5 cm in length, 3.8 cm in width, and 0.5 cm in depth. The dressing treatment plan indicated Santyl with a sterile pad once daily for the left heel. Surgical excisional debridement (cutting away of devitalized tissue, necrosis, or slough) was completed on the left heel. The pressure ulcer to the right heel deteriorated due to dressing not applied correctly. The resident had an unstageable pressure ulcer to the right heel which measured, 3.1 cm in length, 1.8 cm in width, and 0.1 cm in depth. The dressing treatment plan indicated [MEDICATION(S)] and cover with a sterile pad once daily for the right heel. Plan of care recommendations for bilateral heels included float heels in bed, off load wounds, and sponge boots. A specialty wound evaluation and management summary, dated 3/25/21, indicated the resident had a stage four pressure ulcer to the left heel which measured, 2.8 cm in length, 4.1 cm in width, and 0.5 cm in depth. The dressing treatment plan indicated Santyl covered with sterile pad daily for the left heel. The resident had an unstageable due to necrosis pressure ulcer to the right heel which measured, 2.8 cm in length, 2.1 cm in width, and 0.1 cm in depth. The dressing treatment plan indicated [MEDICATION(S)] and cover with Kerlix daily for the right heel. Plan of care recommendations for bilateral heels included float heels in bed, off load wounds, and sponge boots. A TAR, dated March 2021, indicated a wet to dry dressing was applied to the left heel daily. The TAR lacked documentation of why the Santyl treatment was not applied as ordered by the wound doctor. The TAR lacked documentation the treatment to the left heel was offered, refused, or provided on 3/10/21, 3/11/21, and 3/30/21. The TAR indicated [MEDICATION(S)] and Kerlix were applied to the right heel daily. The TAR lacked documentation a treatment to the right heel was offered, refused, or provided on 3/10/21, 3/11/21, and 3/30/21. The TAR lacked documentation heels were floated while in bed, wounds were off loaded, and sponge boots were provided. A specialty physician wound evaluation and management summary, dated 4/1/21, indicated the resident had a stage four pressure ulcer to the left heel which measured, 3.7 cm in length, 3.5 cm in width, and 0.5 cm in depth. The dressing treatment plan indicated Santyl covered with a sterile pad daily for the left heel. The resident had an unstageable due to necrosis pressure ulcer to the right heel which measured, 3 cm in length, 1.8 cm in width, and 0.1 cm in depth. The dressing treatment plan indicated [MEDICATION(S)] and cover with Kerlix for the right heel. Plan of care recommendations for bilateral heels included float heels in bed, off load wounds, and sponge boots. A TAR, dated April 2021, indicated a wet to dry dressing was applied daily to the left heel, but was discontinued on 4/5/21. The TAR lacked documentation of why the Santyl treatment was not applied as ordered by the wound doctor. The TAR lacked documentation the treatment to the left heel was offered, refused, or provided on 4/1/21. The TAR lacked documentation of any treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR lacked documentation heels were floated while in bed, wounds were off loaded, and sponge boots were provided. A paper TAR, not in the facility's computer system, indicated cleanse left and right heel with normal saline, apply Santyl to wound beds, and cover with pad, wrap with gauze, change daily and as needed. The paper TAR lacked documentation heels were floated while in bed, wounds were of loaded, and sponge boots were provided. Census information indicated the resident was hospitalized from 4/3/21 to 4/14/21. During an interview, on 5/3/21 at 11:21 a.m., RN 7 indicated she completed the dressing changes, but documented them on paper instead of the facility's computer system. She thought the resident only wore a sponge boot when he was in bed but was not sure. The resident's heels should have been off loaded when he was in bed. During an interview, on 5/3/21, at 12:25 p.m., the Administrator indicated she was unable to get any information from the mattress company to verify what stage pressure ulcers for which the standard mattress was rated. The mattress was considered to be a pressure redistribution mattress. During an interview, on 5/3/21 at 1:42 p.m., Corporate Consultant 17 indicated the resident developed wounds to his heels on 12/18/20 and was seen by the wound doctor. The wound doctor ordered [MEDICATION(S)] to bilateral heels at the visit. During an interview, on 5/3/21 at 2:24 p.m., Corporate Consultant 17 indicated when the wound doctor visited a resident, the staff should have reviewed the documentation and noted any orders for treatments or offloading recommendations. The staff should have ensured they were on the TAR. During an interview, on 5/3/21 at 3:00 p.m., Licensed Practical Nurse (LPN) 22 indicated the resident would usually wear pressure relief boots when he was in bed, but not in his wheelchair. The boots were not sent with the resident to [CONDITION(S)]. During an interview, on 5/4/21 at 10:30 a.m., Corporate Consultant 17 indicated she was not sure why the treatment orders on the TAR did not match recommendations made by the wound doctor. She was unable to find any additional documentation regarding the treatment orders. On 5/3/21 at 2:22 p.m., Corporate Consultant 17 provided a document titled, Skin Care and Wound Management Overview, and indicated it was the policy currently being used by the facility. The policy indicated, .Definition: A pressure ulcer is defined as a localized injury to skin and/or underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction. Policy: The facility staff strives to prevent resident/patient skin impairment and to promote the healing of existing wounds .Skin care and wound management program includes, but is not limited to: .Application of treatment protocols based on clinical 'best practice' standards for promoting wound healing .Implementation of prevention strategies to decrease the potential for developing pressure ulcers .Procedure: Prevention: .5. Communicate risk factors and interventions to the care giving team. 6. Evaluate for consistent implementation of interventions and effectiveness at clinical meeting .Treatment: .2. Review and select the appropriate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Communicate interventions to the caregiving team. 5. Document on the Treatment Administration Record (TAR). 6. Monitor and document progress. 7. Evaluate effectiveness of interventions during the clinical meeting 2. During an observation, on 5/4/21 at 12:01 p.m., Resident F was observed in her wheelchair in the common sitting area. Resident F's record was reviewed on 5/4/21 at 10:30 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 2/11/21, indicated the resident had a moderate cognitive impairment, required extensive assistance of two staff members for bed mobility, total dependence of two staff members for transfers, had three stage four (a sore that extends below the subcutaneous fat into deep tissues like muscle, tendons, and ligaments. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A handwritten Treatment Administration Record (TAR), dated April 2021, indicated to clean coccyx and bilateral buttocks with normal saline. Apply collagen to wound beds and cover with foam dressing. Change daily and as needed. No time was indicated for the treatment. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Non-pharmacological interventions. 1. Encourage resident to express feelings. 2. Explain risk and consequences of refusals. 3. Offer reassurance every shift for behaviors. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A skin grid pressure assessment, dated 4/1/21, indicated the resident had refused wound care on that day. The areas were first observed was 1/1/20 and noted to be house acquired. The risk factors included, but were not limited to, paralysis, noncompliance with dressing changes and wound care. Treatment order indicated collagen to wound bed and cover with foam dressing and change daily and as needed. A skin grid pressure assessment, dated 4/9/21, indicated the resident had refused wound care on that day. The risk factors included, but were not limited to, resident continued to refuse dressing changes, wound care, and to go to bed. Physician and family made aware. No new orders received. Resident educated on signs and symptoms of infection, wound care and turning schedule. A skin grid pressure assessment, dated 4/15/21, indicated the resident had refused wound care on that day. The risk factors included, but were not limited to, resident continued to refuse wound care and dressing changes. Resident was sitting up in common area and refused to go to bed at night. Physician and family notified. Resident educated on risk of infection. A skin grid pressure assessment, dated 4/16/21, indicated the resident had a wounds to the left buttock that measured 10.1 centimeter (cm) x 5.1 cm x 2.1 cm, coccyx that measured 7.8 cm x 4.2 cm x 2.1 cm, and right buttock that measured 7.7 cm x 4.1 cm x 2.0 cm. The assessment indicated the wound had deteriorated from the last assessment. The assessment lacked documentation for staging of the pressure ulcer. Physician aware of the resident's noncompliance issues. A skin grid pressure assessment, dated 4/23/21, indicated the resident had a wound to the left coccyx/buttock that measured 18.2 cm x 8.7 cm x 3.4 cm. The assessment indicated the wound had deteriorated from the last assessment. The assessment lacked documentation for staging of the pressure ulcer. Continue current treatment orders. The facility was unable to provide any other skin grid pressure assessments for April of 2021. A care plan revised on 10/7/20, indicated the resident had impaired skin integrity and was at risk for pressure ulcers. Resident continued to sit up in wheelchair and refused to lie down in bed. Interventions included, but were not limited to, continue to attempt to encourage resident to comply with treatments, change of positions, and staying up for only 2 hours at a time, administer medications as ordered and monitor for side effects and effectiveness, and administer treatments as ordered by medical provider. During an interview, on 5/4/21 at 2:39 p.m., Corporate Consultant 17 indicated the resident currently had 2 stage IV pressure ulcers, one to the left buttock and one to the right buttock. The resident had refused wound care on several occasions and had been educated regarding the risk factors or the wound worsening and had responded understanding but had not cared. The wound physician had discharged the resident from care due to the resident continuing to refuse wound care. Continue current treatment orders. She indicated the facility was in the wound nurse was not very familiar with the charting system and had completed handwritten skin assessments and wound treatments that had not been put in the computer. On 4/29/21 at 12:06 p.m., Corporate Consultant 17 provided a document, reviewed 5/30/19, and titled, Notification for Changes in Condition, and indicated it was the policy currently being used the facility. The policy indicated, Policy: .Changes may include but are not limited to accidents, incidents, transfers, changes in overall health status, significant medical changes .hospitalization s .II. Notifications: a. When a change in condition is noted, the nursing staff will contact the resident representative .III. Timing and Documentation of notifications: a. Notifications will be prioritized when competing changes occur. b. The attending practitioner must immediately notified of significant changes in condition, and the medical record must reflect the notification, response and interventions implemented to address the resident's condition. c. The nurse will record in the progress notes, the name of person called, the time of each attempt to contact, and the telephone number(s) attempted . On 5/3/21 at 9:55 a.m., Corporate Consultant 17 provided a document, reviewed 5/30/19, and titled, Physician Orders, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: .The purpose of this policy is to provide guidance for licensed nurses .to accurately document physician and provider orders as determined by the licensee's Scope of Practice .Procedure: .Taking the order .f. place orders in electronic Medical Record .Execution of Order and Notifications .ii. Update MAR/TAR with changes or new orders. iii. Notify internal staff of changes/updates as appropriate This Federal tag relates to Complaint IN 569. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to ensure issues were identified in which quality assessment and assurance activities were necessary as evidenced by the severity and number of deficiencies cited and to ensure active quality assessment and performance improvement (QAPI) plans were implemented to prevent deficiencies from re-occurring. This had the potential to affect 107 of 107 residents residing in the facility. Findings include: On 4/27/21 at 11:00 a.m., the Administrator provided an untitled document, and indicated it was the quality assessment and performance improvement (QAPI) plan currently being used by the facility. The plan indicated, .Mission: Identifies needs to organize Performance Improvement Teams with a specific goal of finding the root cause of the problem. Focus on identifying and undertaking systemic change to eliminate problems after the root cause is determined. While developing a feedback and monitoring system to sustain continuous improvement. Guiding Principles: QAPI is a proactive approach to improving quality of life, care, and services. The activities of QAPI involve members at all levels of the organization to: identify opportunities for improvement, address gaps in systems or processes; develop and implement an improvement or corrective plan; and continuously monitor effectiveness of interventions During this recertification and complaint survey, dated 4/26/21 to 5/5/21, two deficiencies were cited at harm level - F686 and F692. The facility also received eleven additional deficiencies - F622, F641, F657, F677, F684, F689, F757, F758, F760, F761, and F880. The facility's Quality Assurance Committee did not identify, develop, and implement appropriate measures to prevent deficiencies as follows: 1. Pressure ulcers: The facility failed to ensure interventions and treatments for pressure ulcers (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) were implemented for 1 of 9 residents reviewed for pressure ulcers resulting in harm when a resident developed an avoidable unstageable (full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar) pressure ulcer on the left heel that worsened to a stage four (a sore that extends below the subcutaneous fat into deep tissues like muscle, tendons, and ligaments; in more severe cases, they can extend as far down as the cartilage or bone), and developed an avoidable unstageable pressure ulcer to the right heel (Resident J). The facility failed to ensure documented interventions for refusal of wound care not resulting in harm but potential for harm for 1 of 9 residents reviewed for pressure ulcers (Resident F). One resident developed avoidable unstageable pressure ulcers to the bilateral (both) heels, which worsened to stage three and four pressure ulcers after the facility failed to provide treatments and pressure relief as ordered by the wound doctor. An action plan, dated 4/19/21, indicated a QAPI plan was in place for pressure ulcers. There was no evidence this plan was implemented or monitored to prevent the occurrence and worsening of pressure ulcers. A review of deficiencies cited from the complaint survey, dated 3/4/21, indicated F686 was cited when the facility failed to ensure measures to prevent pressure ulcers were implemented and treatments were completed correctly. Cross reference F686. 2. Nutrition: The facility failed to ensure physician's orders were followed for a gastrostomy tube, physician and family notification, obtain weights, and address significant weight loss for 1 of 4 residents reviewed for nutrition resulting in harm when the resident had a significant weight loss of 10% in 3 months (Resident D), and failed to ensure physician and family notification, obtain weights, and address significant weight loss for 1 of 4 residents reviewed for nutrition resulting in harm when the resident had a significant weight loss of 29% in 7 months (Resident J). Physician's orders were not followed for one resident who received enteral feeding, resulting in a significant weight loss. One resident was not weighed for an extended period of time, then found to have a significant weight loss. The physician and resident representative were not notified, interventions were not implemented, and the resident developed pressure ulcers. There was no evidence the facility had identified, developed, or implemented an action plan to ensure physician's orders for enteral feedings were followed, weights were obtained, and physician and resident representatives were notified of weight changes. Cross reference F692. A review of deficiencies cited from the Recertification and State Licensure survey, dated 5/3/19, indicated F692 was cited when the facility failed to implement interventions related to weight loss, notify the physician of weight loss, and obtain weekly weights. 3. Smoking: Two residents, assessed as independent smokers, were found to have their smoking materials unsecured in their rooms. Thirty of thirty residents, assessed as independent smokers, stored their smoking materials in their rooms. A facility smoking policy addendum, dated May 2021, indicated, .The Addendum follows: a. Independent smokers will secure their own smoking materials in locked bag when not in use There was no evidence the policy addendum was reviewed by the QAPI committee or an action plan was developed or implemented to ensure the new policy was put into place to prevent smoking accidents. Cross reference F689 4. QAPI: A review of deficiencies cited from the Recertification and State Licensure survey, dated 5/3/19, indicated F867, was cited when the facility failed to identify issues to which quality assessment and assurance activities are necessary, or develop and implement plans of actions to correct identified qualified deficiencies. During an interview, on 5/5/21 at 9:45 a.m., the Administrator indicated pressure ulcers and weights should have been reviewed prior to each QAPI meeting. There was a QAPI plan written for pressure ulcers, but it needed more training for staff and follow up. The QAPI committee was not aware nutrition and weights were an issue. The RD probably should have been aware of this and brought it to the QAPI meeting. The change of smoking policy was not done through the QAPI committee and had not been entirely implemented yet. 3.1-52(b)(2)

Based on observation, record review, and interview, the facility failed to follow Centers for Disease Control (CDC) guidance during a pandemic and ensure infection control practices for COVID-19 were implemented when a resident (Resident B) was not placed in transmission based precautions (TBP) after exposure to their roommate (Resident X) who was diagnosed with [REDACTED]. residents (Resident F, Resident G, Resident H, Resident J, Resident K, Resident T, Resident U, Resident V, and Resident W) without social distancing, and residents were observed out of their COVID-19 transmission based precaution rooms without masks covering their faces (Resident N, Resident P) for 12 of 21 residents reviewed for infection control. The facility has had 47 confirmed COVID-19 positive residents during their outbreak, with 6 confirmed COVID-19 residents currently residing in the facility. The immediate jeopardy began on [DATE] when Resident X was diagnosed with [REDACTED]. Resident E refused facility outbreak testing of COVID-19 on [DATE] and was not closely monitored for symptoms or social distanced from other residents. Resident M was observed without a mask walking through the facility and not social distanced from other residents. Resident E and Resident M were observed smoking, on [DATE], with COVID-19 negative residents without social distancing. Resident N and Resident P were on TBP and observed outside of their rooms without masks covering their faces and without social distancing. A systemic failure in inflection control practices was identified. The Executive Director and Interim Director of Nursing (DON) were notified of the immediate jeopardy on [DATE] at 4:24 p.m. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. Resident X's record was reviewed on [DATE] at 9:45 a.m. A lab diagnostic report, dated [DATE], indicated Resident X was tested for COVID-19 on [DATE]. The detected results indicated the presence of [DIAGNOSES REDACTED]-CoV-2 RNA (COVID-19) and was reported on [DATE]. A census sheet indicated the resident resided in a room with Resident B and had a room change to the Red Zone (COVID-19 positive unit) on [DATE]. Resident B's record was reviewed on [DATE] at 10:00 a.m. The record lacked documentation the resident had been placed on contact droplet isolation on [DATE] when her roommate, Resident X, tested positive for COVID-19. The record lacked documentation the resident was on contact droplet isolation from [DATE] to [DATE]. A lab diagnostic report, dated [DATE], indicated Resident B was tested for COVID-19 on [DATE]. The detected results indicated the presence of [DIAGNOSES REDACTED]-CoV-2 RNA (COVID-19) and was reported on [DATE]. A physician's order, dated [DATE], indicated the resident was in strict isolation with droplet precautions for positive COVID-19 test. A progress note, dated [DATE], indicated the resident had received a positive result for COVID-19 test and had been moved into the red zone. A Medication Administration Record [REDACTED]. Monitor every shift for COVID-19. The MAR indicated [REDACTED]. During an interview, on [DATE] at 2:00 p.m., Licensed Practical Nurse 11 indicated Resident B was currently on the COVID-19 unit for a positive COVID-19 test, and the resident had not been on contact droplet precautions prior to testing positive for COVID-19. During an interview, on [DATE] at 2:11 p.m., Certified Nursing Assistant (CNA) 16 indicated Resident B was not on contact droplet precautions prior to testing positive for COVID-19. During an interview, on [DATE] at 2:15 p.m., Licensed Practical Nurse (LPN) 17 indicated she did not believe Resident B was on contact droplet precautions prior to testing positive for COVID-19. During an interview, on [DATE] at 1:51 p.m., the Interim Director of Nursing (DON) indicated she thought Resident B had been placed on contact droplet precautions on [DATE] when her roommate, Resident X, tested positive for COVID-19. She was unable to find any documentation in Resident B's medical record that indicated the resident had been on contact droplet precautions prior to [DATE]. On [DATE] at 9:32 a.m., the ED provided a document, revised [DATE], and titled, Criteria for COVID-19 Isolation, and indicated it was the policy currently being used by the facility. The policy indicated, Policy: This policy is to assist with guidance on how to manage a COVID-19 Isolation Unit, the types of isolation units .1. A 'positive' isolation unit (red) 2. An 'at risk' unit (yellow) 3. Routine/normal nursing facility area (green) .At Risk for COVID-19 Unit: This unit will be used for residents who may be at risk for developing COVID-19, such as new admits, residents who have been exposed, but not showing signs and symptoms, etc .Process for 'At Risk' unit: .Admission criteria: .2. Any resident who may have been exposed .2. Full PPE will be used while working on the unit. Full PPE consist of N95 mask, gloves, gown and eye covers. 3. N95 masks will be used per the N95 policy. 6. Face shield/goggles will be changed out after providing resident care and exiting the resident room. 7. Hands will be washed and or sanitized prior to entering a resident's room and upon exiting the room .11. Each resident will have the COVID Symptom Evaluation completed each day. 12. Temperature, O2 sat and a respiratory evaluation will be completed every shift . 2. On [DATE] at 11:23 a.m., Resident E was observed in the smoking pavilion without a mask covering his face with Resident H. Resident H was also observed without a mask covering his face. At 11:26 a.m. Resident F was assisted by Resident G to the smoking pavilion. Resident F was observed without a mask covering her face. At 11:32 a.m., Resident J was observed to enter the smoking pavilion and sat next to Resident F and Resident G, without social distancing and without a mask covering their faces. At 11:45 a.m. Resident K was observed next to Resident E having a conversation, without social distancing and without a mask covering their faces. During an observation, on [DATE] at 3:07 p.m., Resident T and Resident U were observed in the smoking pavilion without social distancing and without a mask covering their faces. No staff were observed to redirect residents to social distance at this time. During an observation, on [DATE] from 3:29 p.m. to 3:37 p.m., Resident W, Resident V and Resident J were observed in the smoking pavilion, without social distancing and without a mask covering their faces. No staff were observed in the area to redirect residents to social distance at this time. During an interview, on [DATE] at 3:44 p.m., Resident J indicated residents were supposed to social distance when they were outside in the smoking pavilion, but the residents never did that. During a random observation, on [DATE] at 12:51 p.m., three residents were observed in the smoking pavilion without social distancing and without a mask covering their faces. No staff were observed in the area to redirect residents to social distance at this time. During a random observation, on [DATE] at 1:13 p.m., five residents were observed in the smoking pavilion without social distancing and without a mask covering their faces. No staff were observed in the area to redirect residents to social distance at this time. During a random observation, on [DATE] at 1:28 p.m., three residents were observed in the smoking pavilion without social distancing and without a mask covering their faces. No staff were observed in the area to redirect residents to social distance at this time. During a random observation, on [DATE] at 3:52 p.m., 11 residents were observed in the smoking pavilion without social distancing and without a mask covering their faces. No staff were observed in the area to redirect residents to social distance at this time. Resident E's record was reviewed on [DATE] at 11:40 a.m. A nurse's note, dated [DATE], indicated the resident refused weekly COVID-19 testing and the provider was made aware. A Medication Administration Record [REDACTED]. Monitor every shift for COVID-19. The MAR indicated [REDACTED]. A COVID-19 assessment, dated [DATE], indicated the resident had possible exposure to COVID-19. A care plan, dated [DATE], indicated Resident E refused to be tested for COVID-19. Interventions included, but were not limited to, educate resident on proper hand washing, social distancing, and encourage resident to cover mouth and nose when coughing. During an interview, on [DATE] at 11:10 a.m., the Executive Director (ED) indicated when a resident refused a COVID-19 test they would be placed on contact droplet precautions. The facility had the first outbreak for COVID-19 on [DATE] and had continued weekly testing of residents and staff since that date. A progress note, dated [DATE] at 1:32 p.m., indicated that while reviewing documentation, a COVID assessment had been completed on [DATE] and was incorrect. The resident had no direct exposure to a positive case of COVID-19. Resident E went from room to outside smoking area and returned. Resident E did not speak with other residents or visit other residents' rooms. During an interview, on [DATE] at 11:10 a.m., the Executive Director (ED) indicated residents from the green zone and yellow zone smoked in the pavilion outside of the facility. All smokers were independent and staff did not assist the residents when they went out to smoke. Residents were to social distance when outside smoking. She was unaware of Resident E's COVID-19 assessment that indicated the resident had possible exposure to COVID-19. During an interview, on [DATE] at 10:04 a.m., Unit Manager 14 indicated she had only been employed by the facility for a couple of weeks. She had been informed on [DATE] that when a resident refused COVID-19 testing they should be placed in contact droplet isolation. Resident E had refused a COVID-19 test and was not placed in contact droplet precautions at that time. She indicated there were no indoor/outdoor visits for family or residents due to the facility outbreak of COVID-19, and last week sometime she had observed two family members of a resident, without social distancing and without masks covering their faces, outside in the smoking pavilion. She was unsure how the family members got into the area, but advised them they could not be there. There were at least seven residents out in the smoking pavilion at the time the family members were also in the smoking pavilion. The Centers for Medicare & Medicaid Services (CMS) Center for Clinical Standards and Quality/Survey & Certification Group guidance, dated [DATE], with the subject, Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements and Revised COVID19 Focused Survey Tool, indicated, .Upon identification of a single new case of COVID-19 infection in any staff or residents, all staff and residents should be tested , and all staff and residents that tested negative should be retested every 3 days to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result .Refusal of Testing: .Residents may exercise their right to decline COVID-19 testing .In discussing testing with residents, staff should use person-centered approaches when explaining the importance of testing for COVID-19. Facilities must have procedures in place to address residents who refuse testing .If outbreak testing has been triggered and an asymptomatic resident refuses testing, the facility should be extremely vigilant, such as through additional monitoring, to ensure the resident maintains appropriate distance from other residents, wears a face covering, and practices effective hand hygiene until the procedures for outbreak testing have been completed 3. On [DATE] at 10:05 a.m., Resident M was observed exiting the building at the end of the 200 hallway into the outside smoking area. The resident was not wearing a mask. LPN 7 indicated Resident M resided on the 500 hallway, and he should have had on a face mask as all residents were supposed to wear masks when out of their rooms. The hallways were considered green zones, except for the end of the 200 hallway, which was the designated red zone. On [DATE] at 10:07 a.m., Resident M was observed sitting on top of a picnic table smoking in a fenced courtyard posted as the smoking area. The courtyard was littered with a large amount of trash, including surgical masks and gloves, in the bushes, on the ground, along the fence line, and on the picnic tables under the wooden pavilion. LPN 7 indicated, maintenance was responsible for keeping the trash picked up. Residents were given cloth masks to wear, and blue surgical masks only if they needed it. A trash can with a red bag was observed inside the pavilion, LPN 7 indicated the trash can was for all types of trash. A second observation of the smoking area at 11:20 a.m., indicated the area continued to be littered with trash, including used masks and gloves. On [DATE] at 11:41 a.m., Resident M was observed sitting in a common area within three feet of Resident J, separated by a small table with a radio on it between them. Both residents were wearing masks over their mouths; Resident M's was below his nose. Two rumpled cloth masks were laying on the table beside Resident J's elbow, and the resident indicated she did not know who they belonged to. At 12:45 p.m., one mask was observed on the table near another unidentified resident. At 2:08 p.m., the face mask remained on the table. Resident M was observed on each day of the survey outside smoking among his peers, walking up and down the hallways, and sitting in the common area of the facility. Resident M's record was reviewed on [DATE] at 3:16 p.m. [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, completed on [DATE], assessed Resident M as having the ability to make himself understood and to understand others. A BIMS (Brief Interview for Mental Status) score of 10 indicated moderately impaired cognition. Resident M required supervision and set up help only for transfers, walking in the room and corridor, and locomotion on and off the unit. A COVID-19 Symptom Evaluation Complete Assessment for Resident M, dated [DATE], indicated possible exposure. Lab results for [DIAGNOSES REDACTED]-CoV-2 RT-PCR (COVID-19) for Resident M, dated [DATE], [DATE], and [DATE], indicated not detected. There was no documentation to indicate the resident had been tested after documentation of possible exposure on [DATE]. Review of Progress Notes for Resident M, indicated there was no documentation for September or [DATE]. On [DATE] at 11:15 a.m., the DON indicated, progress notes should have reflected new and existing residents had been assessed. If a resident was newly admitted or had been exposed to COVID-19, they were to be in isolation, the resident should have had a physician's order for isolation, and staff should have been redirecting residents to maintain isolation precautions. On [DATE] at 1:50 p.m., LPN 7 indicated Resident M had no documentation in the EMR (electronic medical record) to indicate the physician had been notified of a potential COVID-19 exposure, no physician's order for isolation, no care plan for isolation, no progress notes by any department to indicate the resident had been in isolation, no documentation of a COVID-19 test after the potential exposure, and the daily COVID symptom tool had not been completed. On [DATE] at 12:36 p.m., the ED indicated staff and residents were not always good about using the trash cans for disposal in the outside designated smoking area, but there was no reason there should have been soiled masks and gloves out in the area as the staff were not supposed to be out there smoking. On [DATE] at 12:52 p.m., the Regional Nurse Consultant provided a statement, dated [DATE], signed by the ED that indicated an investigation had been conducted. The COVID-19 assessment was inaccurate and Resident M had not been exposed to COVID-19. The nurse had .misunderstood the concept behind contact tracing, and did not understand the verbiage that was to be indicated in the assessment to accurately identify why the assessment was being completed . 4. On [DATE] at 10:25 a.m., Resident N was observed in the middle of the 200 hallway, beside a nurse at a medication cart, her wheelchair against a mechanical lift, with a blue surgical mask under her chin. The resident indicated she lived on the hallway, but was not sure if she was supposed to be in isolation. Resident N's door was observed with a yellow infection PPE holder on the doorway, and a sign that indicated, Stop Droplet Precautions. The resident was not observed to be prompted by staff to return to her room or to properly position her face mask. On [DATE] at 10:53 a.m., CNA 12 was observed donning PPE to include an isolation gown that was not tied in the back, N95 mask, and face shield to enter Resident N's room. At 10:57 a.m., CNA 12 was observed exiting the room without her PPE, except for a blue surgical face mask and face shield, and an N95 mask was observed in her pocket. CNA 12 was not observed washing her hands or using hand sanitizer, or to clean her face shield after leaving the room. CNA 12 indicated staff were required to don PPE to enter all isolation rooms. Each resident requiring isolation was supposed to have PPE hanging on the outside of their door, and a trash can on the inside of the room for disposal when doffing PPE. There were no hand sanitizers inside resident rooms. On [DATE] at 11:22 a.m., Resident N and Resident P were observed in the hallway in wheelchairs, facing each other, and neither with a face mask covering their mouth and nose. The residents were observed to roll their wheelchairs backward and forwards within 2 feet of each other, as they asked staff who passed them about going out to smoke. The residents were not observed to be prompted by staff to return to their rooms, social distance from one another, or to properly position their face masks. Resident N's record was reviewed on [DATE] at 1:55 p.m. The resident was admitted on [DATE]. [DIAGNOSES REDACTED]. Physician's orders for Resident N, dated [DATE], indicated to test for COVID-19 as needed, and monitor for COVID-19 every shift. COVID-19 Symptoms Evaluation. Temperature, oxygen saturations %, respiratory signs or symptoms noted. A review of Resident N's Progress Notes, dated [DATE] - [DATE], indicated there had been no nursing documentation since admission. Review of vital signs for Resident N, indicated there was no documentation of vital signs to include a temperature or oxygen saturation on the day of admission, and one time only on [DATE]. Review of Resident N's EMR, dated [DATE] - [DATE], indicated there were no progress notes, assessments, 48 hour care plans, or subsequent documentation to indicated the resident had been assessed or monitored since admission. On [DATE] at 1:50 p.m., LPN 7 provided a handwritten Admission Assessment, with no resident name, undated, and indicated the assessment had been found on a desk and she thought it belonged to Resident N. The assessment indicated, the resident had a history of [REDACTED]. On [DATE] at 1:52 p.m., LPN 7 indicated, Resident N's record had no physician's order for isolation, no documentation that she had been in isolation, no COVID test since admission, no progress notes per any department, and the daily COVID symptom tool had not been completed. 5. On [DATE] 10:26 a.m., Resident P's door was observed with a yellow infection PPE holder on the doorway, and a sign that indicated, Stop Droplet Precautions. On [DATE] at 10:35 a.m., LPN 11 was observed setting up medications at the medication cart near the nurse's station. She wore a blue surgical mask, face shield, blue isolation gown, and indicated she was getting ready to go in to Resident P's isolation room. There were multiple used blue isolation gowns observed in the open trash container on the medication cart where LPN 11 was preparing medications. On [DATE] at 10:49 a.m., LPN 10 and LPN 11 were observed to don PPE, to include gloves, goggles, N95 masks and face shields, then entering Resident P's room with cups of medications and wound dressings. At 11:02 a.m., LPN 10 and LPN 11 were observed leaving the resident's room while still wearing full PPE. LPN 10 was observed to walk up the hallway past the nurse's station, and entered a storage room. LPN 11 walked down the hallway in the opposite direction, past 2 resident doorways, doffed her PPE, and placed it in a trash can in the hallway. Both nurses then walked to the nurse's station and used hand sanitizer, neither nurse was observed changing or cleaning her face shield. LPN 11 indicated, Resident P did not have a trash can to place soiled or used PPE inside of her resident room. On [DATE] at 11:06 a.m., CNA 12 was observed entering Resident P's room after donning PPE. CNA 12 was observed exiting the room without her PPE, except for a blue surgical face mask and face shield, an N95 mask was observed in her pocket. CNA 12 was not observed washing her hands or using hand sanitizer, or to clean her face shield after leaving the room. On [DATE] at 11:12 a.m., CNA 12 was observed entering Resident P's room with a mechanical lift, after donning PPE. At 11:20 a.m., CNA 12 was observed exiting the room without her PPE, except for a blue surgical face mask and face shield, an N95 mask was observed in her pocket. CNA 12 was not observed washing her hands or using hand sanitizer, or to clean her face shield after leaving the room. CNA 12 was observed to bring the mechanical lift from Resident P's room and place it beside the nurse's station without cleaning the lift, she then left to enter another resident room. On [DATE] at 11:22 a.m., Resident P was observed to exit her room in a wheelchair with a lift pad under her, and she was not wearing a mask. The resident propelled herself up the hallway, past the nurse's station, and past Resident N before she was asked by LPN 8 to don a mask. The nurse was overheard telling Resident P she could not go outside to smoke until other residents came in from the smoking area. Resident P and Resident N were observed in the hallway in wheelchairs, facing each other, and neither with a face mask covering their mouth and nose. The residents were observed to roll their wheelchairs backward and forwards within 2 feet of each other, as they asked staff who passed them about going out to smoke. The residents were not observed to be prompted by staff to return to their rooms, social distance from one another, or to properly position their face masks. Resident P then propelled herself down the hallway past her room, and sat beside the mechanical lift, where multiple staff and residents passed her in the hallway, including Resident J and Resident T. On [DATE] at 11:27 a.m., LPN 8 indicated, to her knowledge, there were currently 3 residents using the mechanical lift on the 200 hallway. Staff were supposed to clean the lifts with bleach after use with each resident. On [DATE] at 11:31 a.m., CNA 12 indicated the mechanical lifts were supposed to be cleaned after every resident use with bleach wipes that were kept at the nurse's station. On [DATE] at 2:00 p.m., the mechanical lift was observed beside the clean linen cart, between rooms [ROOM NUMBERS]. CNA 12 indicated it was the responsibility of whoever used the mechanical lift to clean it. It should not have been parked beside the clean linens. On [DATE] at 3:52 p.m., Resident P was observed outside in the smoking pavilion among 10 other residents, masks off as they smoked, and with no social distancing. Resident P's record was reviewed on [DATE] at 2:46 p.m. [DIAGNOSES REDACTED]. A document titled Positive Residents, undated, indicated Resident P had tested positive for COVID-19 on [DATE], and was recovered. A Physician's order for Resident P, dated [DATE], indicated, monitor every shift for COVID-19. COVID-19 Symptoms Evaluation. Temperature, oxygen saturation %, and respiratory signs and symptoms. A Physician's order for Resident P, dated [DATE], indicated test for COVID-19 as needed for preventative measure. A Lab Results Report for Resident P, dated [DATE], indicated COVID-19 RT-PCR positive. A Lab Results Report for Resident P, dated [DATE], indicated COVID-19 RT-PCR positive. A significant change MDS, completed on [DATE], assessed Resident P as having the ability to make herself understood and to understand others. A BIMS score of 11 indicated, moderately impaired cognition. Resident P required extensive assistance of 1 staff for bed mobility and dressing, total dependence of 2 staff for transfers, and supervision after set up help only for locomotion on and off the unit. A Physician's order for Resident P, dated [DATE], indicated resident in strict isolation with droplet precautions. A late entry Progress Notes from Social Service for Resident P, dated [DATE], indicated resident and family notified of room change. A review of care plans in the EMR for Resident P indicated, all care plans had been canceled. There were no current care plans to include isolation, COVID-19 status, or smoking. On [DATE] at 11:15 a.m., the DON indicated, PPE should be doffed and disposed of in a designated PPE garbage can in each resident's room. The ED was ultimately responsible for making sure the staff were trained on infection control, and the residents and staff were following guidelines. On [DATE] at 1:50 p.m., LPN 7 indicated, Resident P had been placed in isolation after moving in with her current roommate, who had been placed on isolation after losing a prior roommate in the past 2 weeks who had COVID type symptoms and died . LPN 7 thought Resident P might have been put into isolation by mistake. LPN 7 indicated, Resident P's EMR had no documentation of the possible COVID exposure, no physician's order for isolation, no documentation she had been in isolation, no care plan for isolation, no recent COVID test results, no progress notes per any department in the month of October, and the daily COVID symptom tool had not been completed. A list titled, Mechanical Lifts, undated, indicated there were currently 24 residents in the facility requiring a mechanical lift for transfers, included 5 residents on 100 hallway, 7 residents on 200 hallway, 4 residents on 400 hallway, 2 on the 500 hallway, and 6 residents on the red zone located on the end of the 200 hallway. All hallways were considered green zones, except the red zone at the end of the 200 hallway, with individual rooms considered yellow zone throughout the building. The facility had six mechanical lifts. On [DATE] at 10:05 a.m., RN 14 indicated, her primary job in the past 2 weeks has been to COVID test residents and staff. Residents were tested for COVID-19 every week, and results should be found in the EMR. Newly admitted residents were tested at the hospital before admission, were placed in isolation for the first 20 days, and then tested weekly. Residents who admitted from home or another facility were isolated for the first 20 days, and tested weekly. Residents who refused to be COVID tested were to be placed in isolation, but that process had just started the current week. There had been 6 or more residents refuse to be COVID tested in the past 2 weeks, and there had been no direction from the ED or DON regarding those residents. Until [DATE] there had been no smoking policy regarding separation of smokers who were in isolation from those that were not isolated. There was no cleaning of the smoking area pavilion between isolated and non-isolated residents. Cleaning of the mechanical lifts was supposed to happen after each use by the staff member using it, and each resident should have had their own lift sling. PPE for resident care of those in isolation included gloves, gown, N95 and face shield. There should have been a sign on the resident door to explain PPE needed. PPE was to be doffed after resident care, and thrown away in a red box in the resident's rooms. The red PPE disposal boxes had just been put out on [DATE]. Before [DATE], PPE was being thrown away in the open trash in the resident room at bedside. Staff were wearing face shields that were disposable and cleaning them was not possible as the bleach wipes degraded them. Face shields should have been changed between each resident. N95 masks should have been taken off when staff left a resident room, placed in a paper bag for storage, and an appropriate mask donned. The previous week, two unauthorized visitors had been observed in the fenced smoking area without masks, among seven or more residents smoking without mask, and were asked to leave. This had happened more than once and the ED was aware of the occurrences. Residents who were in isolation should not have been sitting in the hallway visiting with other residents. Residents who refuse to be COVID tested , and were known to wander, had not been isolated, and Resident D had since tested positive in the past week. If a resident's COVID Screen was marked as possible exposure, there should have been appropriate follow up of a physician's order for isolation, and testing. On [DATE] at 3:15 p.m., RN 14 indicated, Resident P was considered recovered after testing positive on [DATE]. The resident was moved into her current room last week with her current roommate who continued to be in isolation due to possible exposure. On [DATE] at 4:20 p.m., LPN 7 provided a hand written care plan, undated, which indicated Resident P had a history of [REDACTED]. There were no interventions to indicate the resident had been placed in isolation. 6. On [DATE] at 10:15 a.m., LPN 7 and LPN 8 were observed in an office, with no masks and not socially distanced. When ap (TRUNCATED)

Based on record review and interview, the facility failed to ensure interventions were implemented, the physician was notified of weight loss, and weekly weights were obtained resulting in harm for 1 of 3 residents reviewed for nutrition when the resident had a significant weight loss and a change in body mass index (BMI) from normal weight to underweight (Resident 84). The facility failed to ensure the physician was notified of weight loss (Resident 45), and failed to obtain a reweight and weekly weights (Resident 72) for 2 of 3 residents reviewed for nutrition that did not result in harm. Findings include: 1. Resident 84's record was reviewed on 5/2/19 at 10:07 a.m. A significant change Minimum Data Set (MDS) assessment, dated 4/2/19, indicated the resident was a significant weight loss, and was not on a physician prescribed weight loss regimen. A weight flow sheet, created by the Dietician on 5/3/19, indicated weights and body mass index (BMI): 9/26/18: 152 pounds (lbs.), 19.5 BMI (normal) 11/6/18: 137 lbs., 17.6 BMI (underweight). 12/11/18: 140 lbs., 17.8 BMI (underweight). 1/11/19: 131.2 lbs., 16.8 BMI (underweight). 2/12/19: 133.2 lbs., no BMI noted. A resolved care plan, undated, indicated the resident was at risk for nutritional decline. Interventions, included but were not limited to, monitor and evaluate weight/weight changes, obtain weights weekly until stable and then monthly and record, notify Dietician, and physician of significant weight changes, and provide snacks between meals three times daily per resident request. The medical record lacked documentation of a physician's order for snacks or amount consumed by the resident. A physician's progress note, dated 9/25/18, indicated the resident had a sore throat and to refer to Ear, Nose, Throat (ENT) specialist. A review of nurse's progress note, dated 9/26/18, indicated the resident had an ENT appointment on 12/3/18 related to complaints of a lump in his throat. A review of dietary progress notes, dated (MONTH) (YEAR), lacked documentation the Dietician had addressed the resident's significant weight loss of 9.9 percent (%). A review of weights, dated (MONTH) (YEAR), lacked documentation for weekly weights the weeks of: 11/12/18, and 11/26/18. A review of nurse's progress notes, dated (MONTH) (YEAR), lacked documentation the physician was notified of the resident's significant weight loss that resulted in an underweight BMI of 17.6. A review of weights, dated (MONTH) (YEAR), lacked documentation for weekly weights the weeks of: 12/3/18, 12/17/18, 12/24/18, and 12/31/18. A transportation form, dated 12/3/18, indicated the transportation service did not show up to take the resident to his ENT appointment. The appointment was rescheduled for 1/23/19. A physician's progress note, dated 12/4/18, indicated the resident had an appointment with ENT and to continue with current care for now. A dietary progress note, dated 12/10/18, indicated the resident had a significant weight loss and to add Ensure plus (supplement) 120 milliliters (ml) between meals to promote weight stabilization. The supplement was increased on 1/11/19 to 240 ml three times daily. A review of nurse's progress notes, dated (MONTH) 2019, lacked documentation the physician was notified of the resident's significant weight loss of 6.3 % that resulted in a lower underweight BMI of 16.8. A review of weights, dated (MONTH) 2019, lacked documentation for weekly weights the weeks of: 1/14/19, 1/21/19, and 1/28/19. A transportation form, dated 1/23/19, indicated the transportation service did not show up to take the resident to his ENT appointment. The appointment was rescheduled for 3/7/19. During an interview, on 5/3/19 at 9:33 a.m., the Dietician indicated there was not a specific policy for weight loss, and that a resident with significant weight loss should be monitored weekly until weights were stable, interventions should be implemented and re-evaluated for effectiveness, and the physician should be notified of significant weight loss. The resident had a normal range BMI of 19.5 during (MONTH) (YEAR). On 11/6/19 the resident had a weight of 137 lbs., an approximate 9.9 % weight loss in 6 weeks that resulted in an underweight BMI of 17.6. At this time, the resident was care planned to have snacks between meals, three times daily per resident preference. She was unable to find the date this was initiated or resolved. There was no physician's order or monitoring of the snacks and the amount consumed. A supplement of Ensure plus was added on 12/7/19 per her recommendation, she was unable to find where the physician had been notified of the resident's significant weight loss. On 12/11/19, the resident's weight was 140 lbs. and had an underweight BMI of 17.8. The resident's weights lacked documentation of weekly weights on 11/12/18, 11/26/18, 12/3/18, 12/17/18, 12/24/18, and 12/31/18. The resident should have been weighed weekly due to the significant weight loss during this time. On 1/11/19, the resident's weight was 131.2, a 6.3% weight loss and an underweight BMI of 16.8. She was unable to find where the physician had been notified of the continued weight loss that resulted in a lower underweight BMI. The resident was monitored by the interdisciplinary team for weight loss every couple of weeks, but they did not document everything discussed during the weight loss meeting. The resident should have been monitored weekly during his significant weight loss. 2. Resident 45's record was reviewed on 4/30/19 at 8:59 a.m. Resident 45 was admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) assessment, dated 12/13/18, indicated the resident weighed 184 pounds. A quarterly MDS assessment, dated 3/16/19, indicated the resident weighed 160 pounds, was not on a physician prescribed weight loss regimen and was not a weight loss of 10% or more in the last six months. Resident 45's weight from the admission assessment to the quarterly assessment was a 24 pound weight loss or 13% weight loss. A weight flow sheet, created by the Dietician on 5/3/19, indicated weights and body mass index (BMI): 1/17/19: weight recorded as 180.6 lbs. (pounds) with BMI at 28.3 3/6/19: weight recorded 166.2 lbs. with BMI at 26.0 3/6/19: re-weight requested on this date verbally per clinical meeting and per RD (Registered Dietician) recommendation sheet. 3/12/19: Physician order for [REDACTED].>3/20/19: Request for current weight to be entered into PCC (Point Click Care) per RD recommendation sheet. The weight flow sheet indicated the following weights: 12/7/18: weight 178.4 lbs. (pounds) 12/10/18: weight 183.8 lbs. 12/17/18: weight 180.0 lbs. 12/31/18: weight 178.2 lbs. 1/9/19: weight 179 lbs. 1/17/19: weight 180.6 lbs. 3/4/19: weight 166.2 lbs. 3/6/19: weight 154.2 lbs. 3/22/19: weight 160.4 lbs. 4/2/19: weight 164.2 lbs. 4/5/19: weight 158.8 lbs. 4/24/19: weight 160.4 lbs. 4/30/19: weight 161.3 lbs. A Dietary Nutritional Review, dated 3/6/19, indicated Resident 45 was on a regular diet and was noted for weight loss of 14 lbs. over a 2 month span. A care plan, initiated on 3/6/19, with a target date of 6/16/19, indicated a focus of Resident 45 was at risk for nutritional decline related to decreased self-feeding with physical impairment as evidenced by use of adaptive equipment with a goal to maintain weight at 160 - 170 lbs. Interventions included, but were not limited to, monitor/evaluate meal percentage intake records and observations. A physician order, dated 4/26/19, indicated [MEDICATION NAME] Solution (laxative) 10gm (gram)/15 ml (milliliters) by mouth one time a day for high ammonia levels. Medication Administration Records (MAR) and Treatment Administration Records (TAR) from 12/6/18 through 5/2/19 did not indicate any documentation of an order for [REDACTED]. Nurse's notes from 12/6/18 to 5/2/19 did not indicate any physician or family notification of Resident 45's weight loss. A dietary progress note, dated 5/2/19 at 9:17 p.m., indicated the Dietician had spoken with Resident 45 this day related to weight. Resident had indicated that he had always weighed around what he was; current weight was recorded as 161.3 lbs. Resident voiced that he did not want to gain any weight or lose too much. Resident denied having any weight loss in the past year, although, weight records show it. Recorded as consuming greater than or equal to 76% of most meals. Resident can make dietary wants and needs known. Resident voiced that if he wanted a snack, he would ask for it, but did not want one sent every day (or routinely). He also voiced that he got plenty to eat at his meals and did not want anything extra. Resident stated that the only thing that he wanted was to get out of here and go home because no one came to visit him much. Spoke with DON (Director of Nursing) related to history of weight loss, as staff had mentioned early on that resident did not appear to have lost weight. DON voiced that resident had been on [MEDICATION NAME] and had frequent bowel movements and that could be a contributor to his weight loss. Recommend weekly weights x 4 weeks to monitor for further weight stability. Encourage adequate nutrition and hydration. During an interview on 5/3/19 at 9:45 a.m., the Dietician indicated, Resident 45 was discussed in clinical meeting in March. She did not realize that [MEDICATION NAME] had an impact on the resident's bowel functions that would cause him to lose weight. She knew it was a laxative, but did not realize it would cause weight loss. We talk about weight in the clinical meetings, but do not write down what we have discussed about the resident. The Dietician indicated she had documented the request to re-weigh the resident, but nothing else. The facility did not have a specific policy related to weight loss, but the physician should have been notified of Resident 45's weight loss. 3. Resident 72's record was reviewed on 5/2/19 at 12:18 p.m. A significant change Minimum Data Set (MDS) assessment, dated 3/27/19, indicated the resident had a severe cognitive impairment. [DIAGNOSES REDACTED]. Census information on the resident's profile indicated the resident had a hospital stay from 3/18/19 to 3/20/19. The resident returned to the facility on [DATE]. A review of the resident's weights, included, but were not limited to: 11/29/18: 140.2 pounds. 12/26/18: 145.6 pounds. 1/21/19: 142.2 pounds. 2/25/19: 141.5 pounds. 3/4/19: 142.5 pounds. 3/18/19: 142.5 pounds. 4/11/19: 143.3 pounds. 4/19/19: 116.2 pounds. The record lacked documentation the resident was re-weighed on 4/19/19. 5/2/19: 112.6 pounds. A care plan, target dated 7/24/19, indicated the resident was at nutritional risk. Interventions included, but were not limited to, obtain weekly weights until stable, then monthly and record, and monitor and evaluate weight and weight changes. A care plan, target dated 7/24/19, indicated the resident had inadequate/suboptimal oral food/beverage intake related to recent illness, hospitalization , and disease process. Interventions included, but were not limited to, monitor and evaluate weight and weight changes. During an interview, on 5/3/19 at 10:07 a.m., the Registered Dietitian (RD) indicated the resident should have been weighed weekly since her last hospital return. The facility policy was weekly weights for four weeks after a hospital return, the staff should have known to weigh her. The resident should have been re-weighed on 4/19/19 related to the large change in her weight. The re-weight was not done, and some of the weekly weights had been missed. She was not sure why. On 5/3/19 at 9:12 a.m., the Director of Nursing (DON) provided a document titled, Resident Weight, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: It is the policy of this facility that a resident's weight will be accurately obtained within 24 hours of admission if the resident is able, with changes in condition or as ordered by the physician or practitioner .3) On Admission: .b) Obtain weekly weights times 4 weeks (X 4 weeks) for baseline .d) Unstable residents will be reviewed by IDT team to determine weekly or other i) Update Interdisciplinary Care Plan as needed .6) Reweight Parameters: a) A plus/minus of 5 pounds of weight in one week will result in: i) Reweight within 24 hours. (1) Validation with nurse for accurate weight. (2) Notify IDT team/doctor/family, if indicated 3.1-46(a)(1)

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents for 1 of 3 residents reviewed for falls. This deficient practice resulted in Resident B sustaining a hematoma (swelling containing blood) to the right temporal area (area of the head). Finding includes: On [DATE] at 11:45 a.m., CNA #3 was interviewed. The CNA indicated she had been providing personal care to the resident and had been changing the bed linens. She indicated the resident had been positioned on her left side, facing the window. The CNA had gone to the opposite side of the bed to obtain a wash cloth to wash the resident's back and the resident fell out of the bed. She called for assistance from LPN (Licensed Practical Nurse)/ Unit Manager #2. The CNA indicated information that regarded care of the resident was on an electronic Kardex. On [DATE] at 12:03 p.m., the Unit Manager #2 was interviewed. The manager indicated she had been providing wound care to another resident when CNA #3 called for help with Resident B as she had fallen and was the first to respond. While in route to the room she had called the DON. She indicated she found the resident on the floor, on the left (window) side of the room, between the bed and wall, lying on her right side facing the bed. She indicated she had called 911. Due to the resident's severe upper and lower body contracturers, the resident had been moved to the bed with a mechanical lift so a more thorough assessment could have been done. The resident had responded verbally with repetitive statements of hurry up. After a lift pad and additional help arrived in the room, the resident had been transferred with a mechanical lift into the bed. The manager indicated the resident's head had been on the floor, she had not felt any bumps or seen blood. During the transfer into the bed she had noticed the resident had stopped talking and her pupils were fixed. She indicated the resident's breathing changed after being put in the bed. She indicated there had been one CNA who had been providing care to the resident. On [DATE] at 10:50 a.m., with the DON (Director of Nursing) and Vice President of Clinical Operations, discharged Resident B's room was observed. The resident's bed was observed on the window side of the two bed room, positioned with headboard against the wall in the center of the space. A bedside table was observed on the right side of the bed and a chest of drawers on the left. No siderails were observed on the bed. The staff explained the resident had received incontinence care, had been positioned on her right side when she had fallen to the floor from the bed. The DON indicated the resident had expired shortly after being transferred to the bed. She indicated the remains had been sent to the Coroner's office for autopsy. The DON indicated the resident had been on an air flow mattress, the bed had been raised higher than standard height during provision of care. She indicated the Certified Nursing Assistant (CNA) #3 had been going side to side providing resident care. On [DATE] at 12:15 p.m., with Unit Manager #2 and Vice President of Clinical Operations, the resident's room was observed. The manager indicated when she first arrived to the room the bed had been at working height (measured at approximately 32 inches). There had been an air mattress 'Span Pressure Guard Easy Air' (still present in the room) on the bed. The manager indicated the resident's knees had been so contracted she had to have fallen from the left side of the bed and turned towards the bed on the way down. She indicated the resident required assistance of one to two for bed mobility. After the resident had been returned to bed a quarter sized hematoma had been observed on the right temporal area with a scant amount of blood in her hair. The resident's breathing became more labored, oxygen had been applied. She indicated a chest assessment had been done, the pupils had been fixed, and 25 minutes after the fall, the resident was gone. 911 had been canceled. At time of exit, [DATE] at 4:00 p.m., results of the autopsy had not been received. The resident's clinical record was reviewed on [DATE] at 2:17 p.m. [DIAGNOSES REDACTED]. A progress note, dated [DATE] at 10:10 a.m., included Note Text: Notified of patient fall from bed onto the floor. (sic) reported by nurse she sustained a small hematoma to right temple. Resident was placed back into the bed to enable a more extensive evaluation. At 1019 (sic) I assessed patient. She was having very labored breathing Unable (sic) to detect a radial pulse. Skin was sallow in color. Noted to have mottling of both feet. Placed on 4 L (liters) 02 (oxygen) per NC (nasal cannula). [DIAGNOSES REDACTED] (marked increase) breathing began. I assessed the head and temple are (sic). Small amount of blood noted near the hematoma. The hematoma was aprox (approximately) 2 cm (sic) (centimeters) in size. Bruising noted to the right cheek. At 10:20 Puplis (sic) fixed no response to verbal or pain stimuli. All V/S (vital signs) ceased at 10:25 AM (sic). A 60 day Medicare MDS (Minimum Data Set) assessment dated [DATE], coded the resident with a brief interview for mental status score of severe cognitive impairment. The functional status of the resident was assessed as total dependence of two for physical assistance with bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. The assessment coded the resident with range of motion limitations on upper and lower body, both sides. The assessment indicated the resident had not had a history of [REDACTED]. An annual MDS dated [DATE], indicated the resident required extensive assistance of two for bed mobility, dressing, toileting and extensive assistance of one for hygiene. A plan of care initiated on [DATE], and identified as current, addressed the focus of the resident had ADL (activities of daily living) self care performance deficit related to deterioration in ADL's Interventions, with most recent revision date of [DATE], included, but were not limited to, BED MOBILITY: (resident name) requires one sometimes two staff participation to reposition and turn in bed BATHING: (resident name) is totally dependent on staff to provide a bath (FREQ) and as necessary BED MOBILITY: (resident name) is totally dependent on staff for repositioning and turning in bed. A printed form Kardex (no date) identified as information provided for nursing staff to utilize for resident care needs, provided by the Vice President of Clinical Operations on [DATE] at 12:45 p.m., included but was not limited to, DRESSING: (resident name) is totally dependent on staff for dressing BED MOBILITY: (resident name) is totally dependent on staff for repositioning and turning in bed. BED MOBILITY: (resident name) requires one sometimes two staff participation to reposition and turn in bed A facility policy with policy subject of Plan of Care Guidelines (no date) provided as current by LPN #10 on [DATE] at 3:45 p.m., included but was not limited to, Procedure: 2. Resident Care Plans shall be reviewed at least quarterly to ensure that the care plans are specific to the current needs of the resident, and all changes and additional assessments will be noted on the resident's quarterly review. The manufacturer's directions (no date) for the 'Span Pressure Guard Easy Air' mattress was reviewed on [DATE] at 1:59 p.m. The directions included but were not limited to, .side rail use is based on facilitys' assessments of residents. In accordance with Federal and State guidelines siderails are considered to be an entrapment risk This Federal tag relates to Complaint IN 004. 3XXX,[DATE](a)

A. Based on observation, interview, and record review, the facility failed to ensure interventions implemented to detour Residents B, C, and N from eloping did not pose safety hazards when an emergency exit door was obstructed by a tall linen cart for 1 of 2 emergency exits from the Reflections (dementia) unit. This deficient practice had the potential to affect 21 of 21 residents on the dementia unit (Residents B, C, D, E, F, G, H, I, J, K, L, M, N, O, P, Q, R, S, T, U, and V). B. In addition to the residents in immediate jeopardy, the facility failed to ensure a cognitively impaired resident was supervised when she went to a medical appointment resulting in the physician refusing to examine and treat the resident for 1 of 1 resident reviewed for supervision during medical appointments. The Immediate Jeopardy was identified on 02/23/2016 and began on 2/18/16 when the facility implemented an interventions of blocking an emergency exit door with a linen cart. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on 2/23/16 at 10:57 a.m. The Immediate Jeopardy was removed on 2/24/16, but noncompliance remained at the lower scope and severity of isolated, no actual harm, with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: During an initial tour of the dementia unit on 2/18/16 at 8:50 a.m., an emergency exit door that opened to a parking lot had a tall linen cart with a bed/chair alarm clipped to the cover and attached to Velcro strips on the door frame blocking an emergency exit. Licensed Practical Nurse (LPN) #1 stated, You do not see that! I was supposed to have moved it already! The LPN indicated the cart was placed in front of the exit door to keep residents with dementia from leaving the unit. She indicated the intervention had been in place for a while, but could not provide a specific date. The dementia unit had a total of 4 exit doors, 2 of which opened to the skilled nursing facility, 1 that opened to an enclosed courtyard and 1 that opened to a parking lot. During an observation on 02/18/16 at 11:10 a.m. with the Administrator and Director of Nursing (DON) present, the emergency exit door in the Reflections unit was closed. A sensor alarm sounded when a beam sensor was crossed. The emergency exit bar was depressed for 15 seconds. An alarm sounded and the emergency door opened. The Administrator indicated the sensor alarm was placed after a resident eloped from the facility. During an interview on 02/18/2016 at 9:43 a.m., the Assistant Director of Nursing (ADON) indicated the facility began placing the linen cart in front of the emergency exit door in November 2015 and used the clip alarm to alert staff when residents attempted to move the cart and open the exit door. During an interview on 02/18/2016 at 9:44 a.m., the Reflections Program Director indicated the linen cart and clip alarm had been used for quite a while as a method to alert staff when a resident attempted to elope. During an interview on 2/18/16 at 11:08 a.m., the Administrator indicated the linen cart should not have obstructed the exit door. Resident B's record was reviewed on 02/23/2016 at 11:26 a.m. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 1/16/16, indicated Resident B was cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 11 out of 15 and the resident had a behavior of wandering. An elopement care plan, initiated 7/13/15, and revised 10/16/15, indicated Resident B had a history of [REDACTED]. The care plan indicated Resident B enjoyed keeping busy with familiar homelike tasks such as wiping tables and folding towels and indicated the activities were good distractions between group activities and meals. An additional intervention was to provide structured activities of toileting, walking inside and outside, and reorientation strategies including signs and pictures, offering books or magazines to read and asking her to read it to you. A Wanderguard was initiated 10/16/15 A behavior summary sheet, dated January 2016, indicated Resident B had exit seeking behaviors 120 times during the month. A behavior summary sheet, dated February 2016, indicated Resident B had exit seeking behaviors 92 times from February 1-24, 2016. Resident C's record was reviewed on 2/24/16 at 11:29 a.m. [DIAGNOSES REDACTED]. A MDS assessment, dated, 1/6/15, indicated Resident C was cognitively impaired and scored 0 of 15 on the BIMS assessment and indicated the resident had hallucinations and wandered daily. A care plan, initiated 6/10/15 and revised on 2/23/16, indicated Resident C had a behavior of intrusive wandering. The plan indicated the resident usually looked for a bathroom or somewhere to sit and rest or to look out the window and was at risk for elopement. The care plan indicated the resident had decreased safety awareness and wandered near exit doors and did not voice when she wanted to leave the facility. Interventions included, but were not limited to, anticipate and meet needs, caregivers to provide opportunity for positive interaction and attention, stop and talk with resident as passing by, offer a walk outside in the courtyard if weather is appropriate, offer snack, redirect away from doorways, Wanderguard, take to quiet location to sit and provide a program of activities of interest. The care plan indicated the resident liked to go outdoors. A behavior summary sheet, dated January 2016, indicated Resident C had exit seeking behaviors 140 times during the month. A behavior summary sheet, dated February 2016, indicated Resident C had exit seeking behaviors 82 times from February 1-24, 2016. Resident N's record was reviewed on 02/22/2016 at 11:11 a.m. [DIAGNOSES REDACTED]. A MDS assessment, dated 1/18/16, indicated Resident N had a BIMS score of 9 out of 15 an was cognitively impaired. An elopement care plan, initiated 10/8/15 and revised 11/3/15, indicated Resident N had delusional thought that family is on the other side of the door or outside or thinking cars in the parking lot belong to family and they can't get in to see her. Interventions included, but were not limited to, placement on Reflections unit, distract from wandering by offering pleasant diversions, structured activities, food, conversation, and television. The plan indicated the resident preferred religious programs on TV, liked black coffee, had a Wanderguard and indicated she would be offered a room change when a non-parking lot room within Reflections Unit was available. Additional interventions included, don't challenge her delusional thought, but instead offer reassurance to her concerns, promote cognitive stimulation with current events, reminiscing, spiritual programs, and word games, and provide a secured environment on the Reflections unit. A behavior summary sheet, dated January 2016, indicated Resident N had exit seeking behaviors 9 times during the month. A behavior summary sheet, dated February 2016, indicated Resident N had exit seeking behaviors 3 times from February 1-24, 2016. A facility accident and supervision policy, dated 04/29/11, and identified as current, was provided by the DON on 2/24/16 at 10:05 a.m. The policy indicated, .Unsafe Wandering or Elopement: 23. Center addressed both safety issued and evaluates a patient exhibiting non-goal-directed or aimless wandering to identify root causes to the degree possible .24. Center clearly defines the mechanisms and procedures that can help mitigate the risk of a patient from leaving a safe area without supervision. 25. Patients are assessed for the risk of elopement. Patients identified at risk have interventions in their comprehensive care plan to address the potential for elopement An undated preventative maintenance sheet was provided by the Administrator on 2/24/16 at 10:50 a.m., and indicated, .Means of Egress Free From All Furnishings or Other Objects Placed not to Obstruct Access of Visibility B. During an interview on 2/19/16 at 2:45 p.m., Resident G's daughter indicated a physician refused to see her mother when she was sent to a medical appointment unaccompanied by facility staff or another responsible party, because the resident could not communicate her health needs to the physician. During an interview on 2/22/16 at 9:36 a.m., Transcare ambulance employee indicated Resident G was transported by their wheelchair van independently to a doctor's appointment on 2/4/16. During an interview on 2/22/16 at 9:39 a.m., the receptionist at the Neurology doctor's office indicated Resident G's appointment scheduled on 2/4/16 had been canceled by the physician because the resident had been transported to the doctor's office without anyone accompanying her. During an interview on 2/22/16 at 12:00 p.m., Unit Manager # 6 indicated the facility should send a staff member with a resident if family did not accompany the resident. She further indicated Resident G used a wheelchair and was on continuous oxygen therapy. During an interview on 2/22/15 at 2:08 p.m., the Unit Manager # 7 indicated Resident G went out to a doctor's appointment and was returned to the facility because the medical doctor (MD) would not see the resident without someone accompanying her to the appointment. During an interview on 2/23/16 at 3:30 p.m., RN # 4 indicated Resident G was transported to a doctor's appointment on 2/4/16 per wheelchair via a medical transport van. RN # 4 indicated she assumed the daughter was meeting Resident G at the doctor's office. RN # 4 indicated she did not speak with the daughter personally about the doctor's appointment. Resident G's record was reviewed on 2/23/16 at 3:30 p.m. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 2/9/16, indicated Resident G had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 4 out of 15. Occupational Therapy Plan of Care dated 2/5/16, indicated Resident G had severe cognitive impairment and was orientated to person only. Resident G required moderate/maximum assistance with upper body dressing and was near total dependence for lower body dressing. An Interim Plan of Care, initiated on 2/2/16, indicated Resident G required assistance of two staff for ambulation and transfers. Also, indicated resident used wheelchair for mobility. A wheelchair transportation report dated 2/4/16 was reviewed. The report indicated Resident G left the faciity on [DATE] at 1:45 p.m. and arrived to doctor's office at 2:13 p.m. Transportation was then dispatched to the doctor's office at 3:18 p.m. Transportation arrived to doctor's office for pick up at 3:43 p.m. and returned to facility at 4:18 p.m. A Resident Appointments Outside the Center policy, dated 4/28/09, and identified as current, was provided by the Unit Manager on 2/22/16 at 2:40 p.m. The policy indicated, .1. Notify family/responsible party of the scheduled appointment in advance so they may accompany resident . 3. In the event the family/responsible party is unable to accompany the resident, determine if the resident is physically and mentally able to go the appointment unattended The Immediate Jeopardy that began on 2/18/16 was removed on 2/24/16 when the facility removed the physical restriction of the linen cart blocking an exit and staff were in-serviced regarding placement of linen carts and obstructing emergency exits. The noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because of need for continued monitoring for abuse prevention and reporting and physical restrictions. This Federal tag relates to complaints IN 728 and IN 147. 3.1-19(c) 3.1-45(a)(1)

Based on observation, interview, and record review, the facility failed to ensure residents with dementia were not intimidated by staff who attempted to detour exit seeking behaviors by telling residents a boogy or bad man, sick people or a hairy spider were on the other side of the door resulting in a resident requesting a knife to kill the bad man and another resident reporting people outdoors were trying to hurt her for 3 of 3 residents reviewed for mental abuse (Residents B, C, N). The Immediate Jeopardy was identified on 02/23/2016 and began on 2/18/16 when facility staff attempted to scare Residents B, C, and N to prevent them from eloping and implemented an intervention of placing a linen cart in front of the emergency exit door. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on 2/23/16 at 10:57 a.m. The Immediate Jeopardy was removed on 2/24/16, but noncompliance remained at the lower scope and severity of isolated, no actual harm, with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: 1. During an initial tour of the dementia unit on 2/18/16 at 8:50 a.m., an emergency exit door that opened to a parking lot had a tall linen cart with a bed/chair alarm clipped to the cover and attached to Velcro strips on the door frame blocking an emergency exit. Licensed Practical Nurse (LPN) #1 stated, You do not see that! I was supposed to have moved it already! The LPN indicated the cart was placed in front of the exit door to keep residents with dementia from leaving the unit. She indicated the intervention had been in place for a while, but could not provide a specific date. The dementia unit had a total of 4 exit doors, 2 of which opened to the skilled nursing facility, 1 that opened to an enclosed courtyard and 1 that opened to a parking lot. During an interview on 02/23/2016 at 8:54, the Reflections unit Program Director indicated she told residents with dementia there were sick people on the other side of the 2 doors that exited to the nursing facility and indicated she told the residents, You don't want to get sick. You don't want to go into the nursing home. During an interview on 02/23/2016 at 9:03 a.m., CNA #3 indicated she heard a rumor that someone told residents on the dementia unit there was a big man in the courtyard. During an interview on 02/23/16 at 9:13 a.m., CNA #2 indicated she heard other staff tell residents who tried leave the dementia unit through the emergency exit door a hairy spider was outside. She indicated staff also told residents aboogy man was in the courtyard and would get you if you go out the door. The CNA indicated Resident B mentioned the incident several times and asked for a knife to kill the bad man. The CNA indicated she did not report staff's attempts to scare the resident to the Administrator. During an interview on 02/23/2016 at 9:19 a.m., the Activity Director indicated she would never scare residents to redirect from attempts to elope, but indicated she told residents with dementia there might be a bug to redirect them away from the door. During an interview on 2/25/16 at 3:18 p.m., the Administrator indicated there were no reportable incidents of abuse and indicated she was not aware staff tried to scare residents to keep them from leaving the dementia unit. Resident B's record was reviewed on 02/23/2016 at 11:26 a.m. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 1/16/16, indicated Resident B was cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 11 out of 15 and the resident had a behavior of wandering. A behavior summary sheet, dated January 2016, indicated Resident B had exit seeking behaviors 120 times during the month. A behavior summary sheet, dated February 2016, indicated Resident B had exit seeking behaviors 92 times from February 1-24, 2016. An elopement care plan, initiated 7/13/15, and revised 10/16/15, indicated Resident B had a history of [REDACTED]. The care plan indicated Resident B enjoyed keeping busy with familiar homelike tasks such as wiping tables and folding towels and indicated the activities were good distractions between group activities and meals. An additional intervention was to provide structured activities of toileting, walking inside and outside, and reorientation strategies including signs and pictures, offering books or magazines to read and asking her to read it to you. A Wanderguard was initiated 10/16/15 A care plan, initiated 7/23/15, indicated Resident B had a history of [REDACTED]. 2. Resident C's record was reviewed on 2/24/16 at 11:29 a.m. [DIAGNOSES REDACTED]. A MDS assessment, dated, 1/6/15, indicated Resident C was cognitively impaired and scored 0 of 15 on the BIMS assessment and indicated the resident had hallucinations and wandered daily. A care plan, initiated 6/10/15 and revised on 2/23/16, indicated Resident C had a behavior of intrusive wandering. The plan indicated the resident usually looked for a bathroom or somewhere to sit and rest or to look out the window and was at risk for elopement. The care plan indicated the resident had decreased safety awareness and wandered near exit doors and did not voice when she wanted to leave the facility. Interventions included, but were not limited to, anticipate and meet needs, caregivers to provide opportunity for positive interaction and attention, stop and talk with resident as passing by, offer a walk outside in the courtyard if weather is appropriate, offer snack, redirect away from doorways, Wanderguard, take to quiet location to sit and provide a program of activities of interest. The care plan indicated the resident liked to go outdoors. A care plan, initialed 1/27/15, and revised 3/20/15, indicated Resident C had impaired cognitive function related to short term and long memory loss, [MEDICAL CONDITIONS] drug use, and pain. The plan indicated the resident got lost in the hall and didn't know where to go. Interventions included, but were not limited to, cue resident to destinations she wants to go to if found in hall looking bewildered, engage in simple, structured activities that avoid overly demanding tasks. The plan indicated the resident preferred music, current events, and spiritual activity. Additional interventions included, consistent caregivers, close window blinds in the evening to reduce reflections, and communication techniques that facilitate interaction. A care plan, initiated 01/27/15, indicated Resident C had visual hallucinations and paranoia and her family indicated the resident believed reflections in the windows and mirrors were people trying to climb in the window to harm her. The plan indicated she was fearful of men and tended to pull away from caregivers, thinking they might hurt her. Interventions included, but were not limited to, don't challenge her hallucinations or delusions, offer reassurance, change of environment ad distract with snacks. Additional interventions included seating resident with her back to windows and closing blinds at night. A behavior summary sheet, dated January 2016, indicated Resident C had exit seeking behaviors 140 times during the month. A behavior summary sheet, dated February 2016, indicated Resident C had exit seeking behaviors 82 times from February 1-24, 2016. A Monthly Behavior Summary/Psychoactive Gradual Dose Reduction (GDR) Review, dated 2/9/2016, indicated, .(Resident named) has periods of hallucinations and delusions, sees reflections and thinks people are out doors trying to hurt her 3. Resident N's record was reviewed on 02/22/2016 at 11:11 a.m. [DIAGNOSES REDACTED]. An elopement care plan, initiated 10/8/15 and revised 11/3/15, indicated Resident N had delusional thought that family is on the other side of the door or outside or thinking cars in the parking lot belong to family and they can't get in to see her. Interventions included, but were not limited to, placement on Reflections unit, distract from wandering by offering pleasant diversions, structured activities, food, conversation, and television. The plan indicated the resident preferred religious programs on TV, liked black coffee, had a Wanderguard and indicated she would be offered a room change when a non-parking lot room within Reflections Unit was available. Additional interventions included, don't challenge her delusional thought, but instead offer reassurance to her concerns, promote cognitive stimulation with current events, reminiscing, spiritual programs, and word games, and provide a secured environment on the Reflections unit. A MDS assessment, dated 1/18/16, indicated Resident N had a BIMS score of 9 out of 15 an was cognitively impaired. An Interdisciplinary Review of Distressed Behavior, dated 1/28/16, indicated, (resident named) continues to have much the same mood/behavior. She has occasional delusional thought: that she is married or hallucination: talking to someone not there but was much improved from prior in-patient treatment A behavior summary sheet, dated January 2016, indicated Resident N had exit seeking behaviors 9 times during the month. A behavior summary sheet, dated February 2016, indicated Resident N had exit seeking behaviors 3 times from February 1-24, 2016. A facility abuse policy, dated 7/28/14 and identified as current, was received from the DON on 2/23/16 at 2:20 p.m. The policy indicated, .Verbal, sexual, physical, and mental abuse .are strictly prohibited .staff must report all alleged violations involving mistreatment, neglect, or abuse .immediately to a Senior Clinician, or Operational Leader at the facility, or District, or National Level and to other officials in accordance with State law The Immediate Jeopardy that began on 2/18/16 was removed on 2/24/16 when the facility suspended employees named in the allegations of abuse, and educated residents and responsible parties and in-serviced all staff regarding abuse and abuse reporting requirements. The noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because of need for continued monitoring for abuse prevention and reporting. This Federal tag relates to complaints IN 728 and IN 147. 3.1-27(a)(1)

A. Based on observation, interview, and record review, the facility failed to ensure physical, mental and psychosocial well-being of residents with dementia were maintained when staff used physical and verbal restrictions to detour residents from exit seeking behaviors by blocking an emergency exit with a linen cart and telling them a boogy or bad man, sick people or a hairy spider were on the other side of the door resulting in a resident requesting a knife to kill the bad man and another resident reporting people outdoors were trying to hurt her for 3 of 35 residents reviewed for psychosocial quality of care (Residents B, C, N). B. In addition to the residents in Immediate Jeopardy, the facility failed to ensure a resident's specific condition and treatment regimen were care planned to ensure palliative care continued when hospice services were terminated for 1of 3 residents reviewed for palliative care (Resident D). The Immediate Jeopardy was identified on 02/23/2016 and began on 2/18/16 when facility staff attempted to scare Residents B, C, and N to prevent them from eloping and implemented an intervention of placing a linen cart in front of the emergency exit door. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on 2/23/16 at 10:57 a.m. The Immediate Jeopardy was removed on 2/24/16, but noncompliance remained at the lower scope and severity of isolated, no actual harm, with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: A1. During an initial tour of the dementia unit on 2/18/16 at 8:50 a.m., an emergency exit door that opened to a parking lot had a tall linen cart with a bed/chair alarm clipped to the cover and attached to Velcro strips on the door frame blocking an emergency exit. Licensed Practical Nurse (LPN) #1 stated, You do not see that! I was supposed to have moved it already! The LPN indicated the cart was placed in front of the exit door to keep residents with dementia from leaving the unit. She indicated the intervention had been in place for a while, but could not provide a specific date. The dementia unit had a total of 4 exit doors, 2 of which opened to the skilled nursing facility, 1 that opened to an enclosed courtyard and 1 that opened to a parking lot. During an interview on 02/23/2016 at 8:54, the Reflections unit Program Director indicated she told residents with dementia there were sick people on the other side of the 2 doors that exited to the nursing facility and indicated she told the residents, You don't want to get sick. You don't want to go into the nursing home. During an interview on 02/23/2016 at 9:03 a.m., CNA #3 indicated she heard a rumor that someone told residents on the dementia unit there was a big man in the courtyard. During an interview on 02/23/16 at 9:13 a.m., CNA #2 indicated she heard other staff tell residents who tried leave the dementia unit through the emergency exit door a hairy spider was outside. She indicated staff also told residents aboogy man was in the courtyard and would get you if you go out the door. The CNA indicated Resident B mentioned the incident several times and asked for a knife to kill the bad man. The CNA indicated she did not report staff's attempts to scare the resident to the Administrator. During an interview on 02/23/2016 at 9:19 a.m., the Activity Director indicated she would never scare residents to redirect from elopement, but indicated she told residents with dementia there might be a bug to redirect the resident away from the door. During an interview on 02/23/2016 at 1:36 p.m., the Social Service Director (SSD) indicated Resident B had increased behaviors of intrusive wandering, taking other residents' food, and accelerated movements in January 2016. The SSD provided behavioral tracking. Resident B's record was reviewed on 02/23/2016 at 11:26 a.m. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 1/16/16, indicated Resident B was cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 11 out of 15 and the resident had a behavior of wandering. A behavior summary sheet, dated January 2016, indicated Resident B had exit seeking behaviors 120 times during the month. A behavior summary sheet, dated February 2016, indicated Resident B had exit seeking behaviors 92 times from February 1-24, 2016. An elopement care plan, initiated 7/13/15, and revised 10/16/15, indicated Resident B had a history of [REDACTED]. The care plan indicated Resident B enjoyed keeping busy with familiar homelike tasks such as wiping tables and folding towels and indicated the activities were good distractions between group activities and meals. An additional intervention was to provide structured activities of toileting, walking inside and outside, and reorientation strategies including signs and pictures, offering books or magazines to read and asking her to read it to you. A Wanderguard was initiated 10/16/15 A care plan, initiated 7/23/15, indicated Resident B had a history of [REDACTED]. A2. Resident C's record was reviewed on 2/24/16 at 11:29 a.m. [DIAGNOSES REDACTED]. A MDS assessment, dated, 1/6/15, indicated Resident C was cognitively impaired and scored 0 of 15 on the BIMS assessment and indicated the resident had hallucinations and wandered daily. A care plan, initiated 6/10/15 and revised on 2/23/16, indicated Resident C had a behavior of intrusive wandering. The plan indicated the resident usually looked for a bathroom or somewhere to sit and rest or to look out the window and was at risk for elopement. The care plan indicated the resident had decreased safety awareness and wandered near exit doors and did not voice when she wanted to leave the facility. Interventions included, but were not limited to, anticipate and meet needs, caregivers to provide opportunity for positive interaction and attention, stop and talk with resident as passing by, offer a walk outside in the courtyard if weather is appropriate, offer snack, redirect away from doorways, Wanderguard, take to quiet location to sit and provide a program of activities of interest. The care plan indicated the resident liked to go outdoors. A care plan, initialed 1/27/15, and revised 3/20/15, indicated Resident C had impaired cognitive function related to short term and long memory loss, [MEDICAL CONDITIONS] drug use, and pain. The plan indicated the resident got lost in the hall and didn't know where to go. Interventions included, but were not limited to, cue resident to destinations she wants to go to if found in hall looking bewildered, engage in simple, structured activities that avoid overly demanding tasks. The plan indicated the resident preferred music, current events, and spiritual activity. Additional interventions included, consistent caregivers, close window blinds in the evening to reduce reflections, and communication techniques that facilitate interaction. A care plan, initiated 01/27/15, indicated Resident C had visual hallucinations and paranoia and her family indicated the resident believed reflections in the windows and mirrors were people trying to climb in the window to harm her. The plan indicated she was fearful of men and tended to pull away from caregivers, thinking they might hurt her. Interventions included, but were not limited to, don't challenge her hallucinations or delusions, offer reassurance, change of environment ad distract with snacks. Additional interventions included seating resident with her back to windows and closing blinds at night. A behavior summary sheet, dated January 2016, indicated Resident C had exit seeking behaviors 140 times during the month. A behavior summary sheet, dated February 2016, indicated Resident C had exit seeking behaviors 82 times from February 1-24, 2016. A Monthly Behavior Summary/Psychoactive Gradual Dose Reduction (GDR) Review, dated 2/9/2016, indicated, .(Resident named) has periods of hallucinations and delusions, sees reflections and thinks people are out doors trying to hurt her A3. Resident N's record was reviewed on 02/22/2016 at 11:11 a.m. [DIAGNOSES REDACTED]. An elopement care plan, initiated 10/8/15 and revised 11/3/15, indicated Resident N had delusional thought that family is on the other side of the door or outside or thinking cars in the parking lot belong to family and they can't get in to see her. Interventions included, but were not limited to, placement on Reflections unit, distract from wandering by offering pleasant diversions, structured activities, food, conversation, and television. The plan indicated the resident preferred religious programs on TV, liked black coffee, had a Wanderguard and indicated she would be offered a room change when a non-parking lot room within Reflections Unit was available. Additional interventions included, don't challenge her delusional thought, but instead offer reassurance to her concerns, promote cognitive stimulation with current events, reminiscing, spiritual programs, and word games, and provide a secured environment on the Reflections unit. A MDS assessment, dated 1/18/16, indicated Resident N had a BIMS score of 9 out of 15 an was cognitively impaired. An Interdisciplinary Review of Distressed Behavior, dated 1/28/16, indicated, (resident named) continues to have much the same mood/behavior. She has occasional delusional thought: that she is married or hallucination: talking to someone not there but was much improved from prior in-patient treatment A behavior summary sheet, dated January 2016, indicated Resident N had exit seeking behaviors 9 times during the month. A behavior summary sheet, dated February 2016, indicated Resident N had exit seeking behaviors 3 times from February 1-24, 2016. A facility abuse policy, dated 7/28/14 and identified as current, was received from the DON on 2/23/16 at 2:20 p.m. The policy indicated, .Verbal, sexual, physical, and mental abuse .are strictly prohibited .staff must report all alleged violations involving mistreatment, neglect, or abuse .immediately to a Senior Clinician, or Operational Leader at the facility, or District, or National Level and to other officials in accordance with State law A facility accident and supervision policy, dated 04/29/11, and identified as current, was provided by the DON on 2/24/16 at 10:05 a.m. The policy indicated, .Unsafe Wandering or Elopement: 23. Center addressed both safety issued and evaluates a patient exhibiting non-goal-directed or aimless wandering to identify root causes to the degree possible .24. Center clearly defines the mechanisms and procedures that can help mitigate the risk of a patient from leaving a safe area without supervision. 25. Patients are assessed for the risk of elopement. Patients identified at risk have interventions in their comprehensive care plan to address the potential for elopement B. During an interview on 2/22/16 at 9:25 a.m., Business Office Manager (BOM) indicated Resident D was taken off of Hospice care on 11/2/15 and added to Medicare services. During an interview on 2/22/16 at 12:00 p.m., Director of Nursing indicated facility's Registered Dietician assessed his nutritional needs, but there was not a physician's orders [REDACTED]. During an interview on 2/22/15 at 4:18 p.m., Resident D's daughter indicated she had visited him at the facility on 11/8/15 and Resident D had not attempted to eat or drink and appeared dehydrated. During an interview on 2/23/16 at 11:14 a.m., Social Service Director (SSD) indicated Resident D had no orders for palliative care after hospice was discontinued on 11/2/15. During an interview on 2/23/16 at 11:25 a.m., Resident D's sister in law indicated she had visited him at the facility on 11/8/15 and Resident D's tongue was discolored, hard, and dry. Resident D's sister in law indicated Resident D was not eating or drinking. Resident D's record was reviewed on 2/22/16 at 11:00 a.m. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 11/10/15, indicated Resident D had severe cognitive impairment. Resident D's clinical record lacked documentation of an order for [REDACTED]. An emergency room record from Union Hospital dated 11/11/15, indicated Resident D was poorly groomed with poor personal hygiene, and had dry, cracked mucus membranes. A hospital Case Management note dated 11/12/15, indicated Resident D had a hospital admitting [DIAGNOSES REDACTED]. A blood test results dated 11/11/15, indicated Resident D had an elevated Sodium level of 153 (135-148 normal range), elevated Blood Urea Nitrogen (BUN) level of 59 (5-25 normal range), elevated Creatinine level of 1.50 (0.50-1.40 normal range), elevated White Blood Count (WBC) level of 16.6 (4.5-10.8 normal range). A Urinalysis lab result dated 11/11/15, indicated Resident D had red color urine and was positive for Bilirubin, [MEDICATION NAME], Blood, Protein, and White Blood Cells in his urine. A End of Life Care policy, dated 1/08/13 and identified as current, was provided by Director of Nursing on 2/23/16 at 2:20 p.m. The policy indicated, .Palliative Care: Patient and family centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information, and choice The Immediate Jeopardy that began on 2/18/16 was removed on 2/24/16 when the facility removed the physical restriction of the linen cart blocking an exit, suspended employees named in the allegations of abuse, educated residents and responsible parties and in-serviced all staff regarding abuse and abuse reporting requirements. The noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because of need for continued monitoring for abuse prevention and reporting and physical restrictions. This Federal tag relates to complaints IN 728 and IN 913. 3.1-37(a)

Based on record review and interview, the facility failed to ensure 1 of 3 residents reviewed for falls in a sample of 5 did not have a fall with a head injury, requiring staples to repair, after receive a medication prescribed for another resident with side effects, including but not limited to, syncope (medical term for fainting or passing out). (Resident E). Findings include: During the initial tour of the facility on 3/4/14 at 10:40 A.M., Resident E was observed sitting in the central lounge area with an irregular shaped, nickel sized, scabbed area on the top of his forehead. The record for Resident E was reviewed on 3/5/14 at 10:00 A.M. Resident E's [DIAGNOSES REDACTED]. A care plan, dated 9/20/12 and last revised on 3/5/13, indicated the resident was at low risk for falls related to occasional forgetfulness. The care plan then noted he had a fall with injury on 2/17/14. The Annual Fall Risk Assessment, dated 8/14/13, indicated the resident was not at risk for falls. The Fall Risk Assessment, dated 2/18/14 indicated he was at high risk for falls. Nursing Progress Notes indicated: 2/17/14 "20:15 (military time for 8:15 P.M.) Resident received incorrect medications...Resident placed on 15 minute checks per facility policy." 2/17/14 "21:05 Left resident's room, resident resting quietly in chair, heard noise as leaving room, re-entered resident room, found resident on floor at the end of his bed. Bleeding from forehead, laceration noted, resident alert, answering questions appropriately, PERRLA (sic) (pupils equal react to light), vital signs within normal limits." 2/17/14 "21:10 Another nurse with resident, this nurse notified MD, new order to send resident to (name of hospital) ER for eval (evaluation) and treat. Family and DNS (Director of Nursing Services) notified." 2/18/14 "00:45 Resident returned from (name of hospital) ER via stretcher...Resident assisted to bed. Resident has laceration to forehead w/ (with) 7 seven staples intact w/ some bruising noted around laceration, also noted possible bruising under left eye...." No other falls were documented in Resident E's record. During an interview with the Administrator on 3/4/14 at 2:45 P.M., she indicated she did not remember Resident E having another fall during the 2 years he had been in the facility. A "Medication Variance Report Worksheet" was provided by the DNS on 3/4/14 at 12:45 P.M. This form indicated Resident E had received another resident's medications on 2/17/14 at 8:15 P.M. A list of the medications given in error had been provided by the DNS on 3/4/14 at 12:25 P.M. The list included, but was not limited to the drug Flexeril. The 2010 Nursing Spectrum Drug Handbook indicated Flexeril under "Precautions" should be given cautiously in elderly patients. The drug handbook also indicated "Adverse Reactions" included, but were not limited to, dizziness and syncope (fainting or passing out), weakness, and abnormal gait. A "Resident Event Report Worksheet" was provided by the DNS (Director of Nursing Services) on 3/4/14 at 12:45 P.M. This form indicated Resident E had a fall on 2/17/14 at 9:05 P.M. It indicated he fell while transferring from a chair and it was unwitnessed. It also indicated he had hit his head and sustained a laceration to his forehead. During an interview with the Administrator on 3/4/14 at 2:45 P.M., she indicated "we don't know for sure if the med (medication) error caused the fall." This federal tag relates to Complaint IN 077. 3.1-45(a)(1)

Based on record review and interview, the facility failed to ensure 1 of 3 residents reviewed for medication errors in a sample of 5 did not receive a medication prescribed for another resident with side effects, including but not limited to, [MEDICAL CONDITION] ([MEDICAL CONDITION] or passing out) resulting in a fall with a head injury that required staples to repair. (Resident E). Findings include: The record for Resident E was reviewed on 3/5/14 at 10:00 A.M. Resident E's [DIAGNOSES REDACTED]. A care plan, dated 9/20/12 and last revised on 3/5/13, indicated the resident was at low risk for falls related to occasional forgetfulness. The care plan then noted he had a fall with injury on 2/17/14. The Annual Fall Risk Assessment, dated 8/14/13, indicated the resident was not at risk for falls. The Fall Risk Assessment, dated 2/18/14 indicated he was at high risk for falls. Nursing Progress Notes indicated: 2/17/14 "20:15 (military time 8:15 P.M.) Resident received incorrect medications...Resident placed on 15 minute checks per facility policy." 2/17/14 "21:05 Left resident's room, resident resting quietly in chair, heard noise as leaving room, re-entered resident room, found resident on floor at the end of his bed. Bleeding from forehead, laceration noted, resident alert, answering questions appropriately, PERRLA (sic) (pupils equal react to light), vital signs within normal limits." 2/17/14 "21:10 Another nurse with resident, this nurse notified MD, new order to send resident to (name of hospital) ER for eval (evaluation) and treat. Family and DNS (Director of Nursing Services) notified." 2/18/14 "00:45 Resident returned from (name of hospital) ER via stretcher...Resident assisted to bed. Resident has laceration to forehead w/ (with) 7 seven staples intact w/ some bruising noted around laceration, also noted possible bruising under left eye...." The February, 2014, Recapitulation of physician's orders [REDACTED]. Resident E had been receiving the [MEDICATION NAME] since 2012, and the [MEDICATION NAME] had been ordered 1/10/14. The physician's orders [REDACTED]. The 2010 Nursing Spectrum Drug Handbook indicated side effects/adverse reactions for [MEDICATION NAME] included, but were not limited to, dizziness, fatigue and depression. The side effects/adverse reactions of [MEDICATION NAME] included, but were not limited to, drowsiness, dizziness and fatigue. The record lacked evidence Resident E had exhibited side effects or adverse reactions to these drugs before 2/17/14. Medication error reports were provided by the DNS on 3/4/14 at 12:05 P.M. She indicated at that time, there was only 1 medication error, there hadn't been any others in a long time. The Medication Variance Report Worksheet indicated the medications given were to the wrong resident. A list of the medications Resident E received in error was provided by the DNS on 3/4/14 at 12:25 P.M. This list indicated Resident E had received [MEDICATION NAME] 100 mg, [MEDICATION NAME] 20 mg, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 100 mg,[MEDICATION NAME] mg, [MEDICATION NAME] 5 mg, [MEDICATION NAME] 20 mg, and [MEDICATION NAME] 10 mg, which were the bedtime medications prescribed for another resident. The 2010 edition of the Nursing Spectrum Drug Handbook indicated adverse reactions for three of these medications were: [MEDICATION NAME] - dizziness, drowsiness, light-headedness, disorientation, and confusion. Ambien -confusion, [MEDICAL CONDITION], and dizziness. [MEDICATION NAME] - dizziness, drowsiness, [MEDICAL CONDITION] ([MEDICAL CONDITION], passing out), confusion, weakness, disorientation, and abnormal gait. During an interview with LPN #1 on 3/5/14 at 11:30 A.M., she indicated she had set up another resident's medications when Resident E approached the Medication Cart. LPN #1 asked Resident E if he was ready for his medications and he indicated he was. LPN #1 indicated she stopped what she was doing and immediately set up Resident E's medications as he had been refusing his medications at times, and she wanted to catch him when he was ready. She indicated she handed him a glass of water and a medicine cup with pills. She then noticed she had handed him the wrong medicine cup and said "no" and looked at him and he had all the pills in his mouth, was drinking water and was swallowing the pills. LPN #1 indicated she should have given the other resident her medications before she set up Resident E's medications and this wouldn't have happened. This federal tag relates to Complaint IN 077. 3.1-48(c)(2)