Every finding on record at Springs at Lafayette, The

Based on interview and record review, the facility failed to ensure there was documentation a bed hold policy was provided to the resident or resident's representative for 1 of 4 residents reviewed for transfer and discharge. (Resident 3)Findings include: The clinical record for Resident 3 was reviewed on 9/19/25 at 8:12 a.m. The diagnoses included, but were not limited to, chronic kidney disease, cerebral infarction, gastrostomy, chronic obstructive pulmonary disease, hypertension, congestive heart failure and bipolar disorder. A nursing progress note, dated 9/8/25, indicated Resident 3 had received 1000 milliliters (ml) of intravenous fluids with minimal improvement. Resident 3's son wanted the resident sent to the hospital. There was no documentation in the Electronic Health Record (EHR) of a bed hold policy being given to the resident or resident's representative at the time of transfer.During an interview, on 9/23/25 at 12:15 p.m., the Clinical Support nurse indicated she was aware the bed hold policy needed to be given to the resident or the resident's representative when being transferred and there was no documentation a bed hold policy was given to the resident representative when Resident 3 was sent to the hospital. A current facility policy, titled Transfer and Discharge (including AMA), revised 5/3/17 and received from the DON on 9/23/25 at 2:30 p.m., indicated .Written information regarding the bed-hold policy under the State plan and the facility's bed-hold policy will be provided to the resident and/or the resident's representative of the bed-hold and admission policies .Social Service should review the documentation in CCM the following business day to assure written information was provided to the resident and a family member or legal representative of the bed-hold and admission policies. Notification of Bed-Hold Policy and readmission should be provided via certified mail in the event notification was not provided as part of the discharge process A current facility policy, titled Bed Hold Policy, revised 11/18/16 and received from the DON on 9/23/25 at 2:30 p.m., indicated .The campus will properly inform residents in advance of their option to make bed-hold payments or well as the amount of the facility's charge to hold a bed, for this optional payment, the campus must make clear that the resident/responsible party must affirmatively elect to make them prior to being billed 3.1-12(a)(6)(A)(i)3.1-12(a)(6)(A)(ii)3.1-12(a)(6)(A)(iii)3.1-12(a)(6)(A)(iv)

Based on observation, interview and record review, the facility failed to ensure the physician was notified of weight gains as ordered for 1 of 1 resident reviewed for physician notification. (Resident 9)Findings include: During an observation, on 9/19/25 at 10:09 a.m., Resident 9 had edema (swelling) in his bilateral lower extremities. During an observation, on 9/22/25 at 1:43 p.m., Resident 9's lower extremities had edema. During an observation, on 9/24/25 at 10:51 a.m., Resident 9 continued to have moderate swelling in his lower extremities. The clinical record for Resident 9 was reviewed on 9/19/25 at 11:31 a.m. The diagnoses included, but were not limited to, edema, hemiplegia and hemiparesis following a cerebral infarction, atrial fibrillation, bipolar disorder, heart failure, vascular dementia, Alzheimer's disorder, and diabetes mellitus.A care plan, dated 6/30/25, indicated Resident 9 had experienced significant weight gain related to edema and congested heart failure. The interventions included, but were not limited to, obtain weight as ordered. A physician's order, dated 8/20/25, indicated weigh Resident 9 daily and if the weight was greater than 3 pounds in 24 hours or greater than 5 pounds in 1 week to notify the cardiologist. a. On 6/26/25, Resident 9's weight was 304.0 pounds. On 6/27/25, the weight was 307.2 pounds. There was no documentation to indicate the cardiologist was notified of a 3.2-pound weight gain in 24 hours. b. On 7/6/25, Resident 9's weight was 300.0 pounds. On 7/7/25, the weight was 304.2 pounds. There was no documentation to indicate the cardiologist was notified of a 4.2-pound weight gain in 24 hours.c. On 9/23/25, Resident 9's weight was 291.8 pounds. On 9/24/25, the weight was 295.2 pounds. There was no documentation to indicate the cardiologist was notified of a 3.4-pound weight gain in 24 hours. During an interview, on 9/24/2025 at 11:59 a.m., LPN 2 indicated staff were to follow the physician's orders and call the physician for a weight gain of more than 3 pounds in one day.During an interview, on 9/24/25 at 1:59 a.m., the Director of Nursing (DON) indicated the facility did not have a policy related to notifying the physician. 3.1-5(A)(2)3.1-5(A)(3)

Based on interview and record review, the facility failed to ensure an accurate Preadmission Screening and Resident Review (PASARR) was completed for 2 of 3 residents reviewed for PASSAR. (Resident 2 and 35)Findings include:1. The clinical record for Resident 2 was reviewed on 9/22/25 at 9:41 a.m. The diagnoses included, but were not limited to, major depressive disorder, congestive heart failure, and cardiac arrhythmia. A PASARR level I, dated 2/27/19, did not include the major depressive disorder diagnosis or a mood stabilizing medication. A physician's order, dated 11/11/24, indicated to administer Depakote (a mood stabilizing medication) 125 milligrams (mg) twice a day for increased moods due to paranoia. During an interview, on 9/22/25 at 10:50 a.m., the Social Services Director indicated the resident had a PASARR level I completed without the diagnosis or medication, and another screening should have been implemented. 2. The clinical record for Resident 35 was reviewed on 9/22/25 at 9:55 a.m. The diagnoses included, but were not limited to, metabolic encephalopathy, depression, anxiety, and attention-deficit/hyperactivity disorder. A PASARR level I, dated 9/8/25, did not include any mental health diagnoses or medications. A physician's order, dated 9/10/25 with an end date of 9/24/25, indicated to administer alprazolam (a medication used for anxiety) 0.5 mg as needed once a day for anxiety. A physician's order, dated 9/10/25, indicated to administer sertraline 50 mg once a day for depression. During an interview, on 9/22/25 at 10:55 a.m., the SSD indicated the resident had a PASARR level I completed without the diagnosis or medication, and another screening should have been implemented. A current facility policy, titled State Required Pre-admission Screening, undated and received from the Director of Nursing (DON) on 9/23/25 at 2:30 p.m., indicated .PASRR is a federal requirement to help ensure that individuals are not inappropriately placed in nursing facilities for long term care. PASRR requires that 1) all applicants to Medicaid-certified nursing facility be evaluated for serious mental illness (SMI) and/or intellectual disability; 2) be offered the most appropriate setting for their needs .and 3) receive the services they need in those settings. Campuses must follow the state mandated process for all Health Center move-ins and internal transfers from residential service lines 3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

Based on observation, interview and record review, the facility failed to ensure a physician's ordered fluid restriction was followed for 1 of 1 resident reviewed for quality of care. (Resident 9) Findings include: During an observation, on 9/19/25 at 10:09 a.m., Resident 9 had edema (swelling) in his bilateral lower extremities.During an observation, on 9/22/25 at 1:43 p.m., Resident 9's lower extremities had edema. During an observation, on 9/24/25 at 10:51 a.m., Resident 9's legs continued to have moderate swelling. The clinical record for Resident 9 was reviewed on 9/19/25 at 11:31 a.m. The diagnoses included, but were not limited to, edema, hemiplegia and hemiparesis following a cerebral infarction, edema, atrial fibrillation, bipolar disorder, heart failure, vascular dementia, Alzheimer's disorder, and diabetes mellitus.A care plan, dated 6/18/25, indicated Resident 9 received a diuretic medication for congested heart failure. The interventions included, but were not limited to, encourage fluids throughout the day if not contraindicated and observe the cardiovascular system and fluid status to determine the effectiveness of the diuretic therapy. A physician's order, dated 9/11/25, indicated to encourage a 1500 milliliter (ml) daily fluid restriction. The resident was to receive 240 ml per meal, 360 ml on day shift from nursing, 240 ml on evening shift from nursing and 180 ml on night shift from nursing. The Medication Administration Record (MAR), dated 9/1/25 through 9/30/25, indicated the resident received the following which was more than 1500 ml of fluids per day:a. On 9/2/25, the resident received 1540 ml of fluids.b. On 9/6/25, the resident received 1620 ml of fluids.c. On 9/9/25, the resident received 1620 ml of fluids.d. On 9/11/25, the resident received 1540 ml of fluids.e. On 9/13/25, the resident received 1540 ml of fluids.f. On 9/14/25, the resident received 1600 ml of fluids.g. On 9/16/25, the resident received 1620 ml of fluids.h. On 9/21/25, the resident received 1680 ml of fluids. During an interview, on 9/23/25 at 7:56 p.m., Resident 9's family member indicated she was very concerned the facility was not taking the resident's fluid restriction and daily weights seriously. The facility did not follow the resident's fluid restriction order. She was concerned he would develop fluid overload like he did in June 2025. The resident was sent to the hospital in June for excess weight gain and fluid overload. The hospital took a large amount of fluid off the resident during his last hospital admission. During an interview, on 9/24/25 at 11:25 a.m., LPN 2 indicated when she gave Resident 9 his medication, she used a 240 ml cup and filled it with water leaving 1 inch from the top. Resident 9 would drink all the water. She administered the resident pills three times during her shift and gave Resident 9 more than the ordered amount of water. She needed to better monitor the amounts of water she gave. A current facility policy, titled Guidelines for Fluid Restriction, undated and received from the DON on 9/23/25 at 2:13 p.m., indicated .Intake monitoring shall be initiated upon receipt of the order .Fluid consumption shall be reviewed in order to meet their established fluid needs. The resident and/or responsible party should be educated regarding the reason and importance of fluid restriction .Should the resident and/or responsible party should be educated regarding the reason and importance of fluid restriction .Should a resident and/or responsible party chose not to comply with the recommended fluid restriction a Self Determination of Care or Informed Refusal and Non-Compliance observation should be completed explaining the risk(s) of noncompliance 3.1-37(a)

Based on interview and record review, the facility failed to contact the resident's representative regarding a fall for 1 of 1 resident reviewed for notification. (Resident 25) The deficient practice was corrected on 2/21/24, prior to the start of the survey, and therefore was past noncompliance. Finding includes: During an interview, on 9/4/24 at 12:24 p.m., Resident 25's representative indicated she was not aware of a fall on 2/1/24. The clinical record for Resident 25 was reviewed on 9/6/24 at 2:58 p.m. The diagnoses included, but were not limited to, Parkinson's disease, Alzheimer's disease, dementia, and cognitive communications. A nursing progress note, dated 2/1/24 at 8:55 p.m., indicated the resident had a fall during a transfer to bed and hit her head on the dresser. A fall event, dated 2/1/24 at 8:42 p.m., indicated the resident had a fall on 2/1/24. The resident's representative was notified on 2/6/24. An IDT (interdisciplinary team) fall note, dated 2/2/24 at 4:36 p.m., indicated the resident's responsible party was not notified at the time of the fall. The progress notes did not include any notification to the resident representative to indicate the resident had a fall. During an interview, on 9/10/24 at 11:41 a.m., the Clinical Support Nurse indicated nurses should notify the family and physician of incidents the day of the event. A current policy, titled Notification of Change in Condition, dated 12/31/23 and received from the Clinical Support nurse on 9/10/24 at 3:00 p.m., indicated .To ensure appropriate individuals are notified of change of condition. The facility must inform the resident, consult with the resident's physician and if known notify the resident's legal representative when: An accident involving the resident which results in an injury and has the potential for requiring physician interventions .The resident representative/provider should be notified of change in condition or diagnostic testing results in a timely manner The deficient practice was corrected by 2/21/24, after the facility implemented a systemic plan which included audits, education, ensuring fall events were completed at the time of event, and proper documentation of physician and family notifications were completed. 3.1-5(a)(1)

Based on observation, interview and record review, the facility failed to ensure medications were secured for residents who self-administer medications for 2 of 2 residents reviewed for self-medication administration. (Resident 23 and 6) Finding includes: 1. During a medication administration observation, on 9/6/24 at 9:35 a.m., Resident 23 had Flonase nasal spray (an allergy nasal spray) sitting on her over the bed table. The resident was asleep upon entry to the room. A physician's order, dated 6/1/24, indicated Flonase Allergy Relief spray suspension 2 puffs in each nostril. Special Instructions: May keep at bedside (MKAB) once daily. 2. During an interview, on 9/6/24 at 11:30 a.m., Resident 6 indicated she had her eye drops stored in the basket of her walker. They were not secured in a locked container. During a medication administration observation, on 9/6/24 at 9:51 a.m., Resident 6 had an order for eye drops to be kept at bedside. A physician's order, dated 1/24/24, indicated Brimonidine 0.2% ophthalmic (eye) 1 drop in both eyes three times (TID) daily MKAB. A physician's order, dated 1/24/24, indicated Dorzolamide drops 2% 1 drop in both eyes twice daily (BID) MKAB. A physician's order, dated 1/24/24, indicated Restasis 0.05% 1 drop in both eyes BID MAB. A physician's order, dated 1/24/24, Timolol Maleate gel forming solution 0.05% 1 drop in both eyes MKAB. During an interview, on 9/6/24 at 11:15 a.m., the Clinical Support nurse indicated the medications for self-administration should be secured. A current policy, titled Medication Storage in the Facility-Bedside Medication Storage, dated as revised November 2018 and received from the Clinical Support nurse on 9/10/24 at 3:00 p.m., indicated .bedside storage of medication is indicated on the resident administration record (MAR) and in the care plan for the appropriate medication .for residents who self-administer medications .the following conditions are met for bedside storage to occur .the manner of storage prevents access by other residents .lockable drawers or cabinets are required only if unlocked storage is deemed inappropriate .bedside medication storage is routinely monitored by facility designee A current policy, titled Guidelines for Self-Administration of Medications, dated as reviewed on 12/31/23 and received from the Clinical Support nurse on 9/6/24 at 11:30 a.m., indicated .the medication will be kept in a locked drawer in the residents' room .the resident will maintain a key, as well as a key will be maintained by the licensed nurse or QMA 3.1-25(m)

Based on interview and record review, the facility failed to ensure a cognitively impaired resident was safe from elopement for 1 of 3 residents reviewed for wandering. (Resident 27) The deficient practice was corrected on 8/24/24, prior to the start of the survey, and therefore was past noncompliance. Finding includes: The clinical record for Resident 27 was reviewed on 9/5/24 at 11:22 a.m. The diagnoses included, but were not limited to, dementia, schizoaffective disorder, bipolar disorder, major depressive disorder, and anxiety disorder. A care plan, dated 3/25/24, indicated the resident demonstrated exit seeking behaviors. The interventions included, but were not limited to, assess the need for a roam alert band and apply as appropriate and to re-direct the resident away from doors and exits as needed. An incident report, dated 8/4/24 at 7:33 p.m., indicated the resident was found outside the building unattended. The resident was wearing a roam alert band. The alarm did not sound when the resident exited the building. A checklist for suspected elopement and missing resident document indicated the resident was found by the dumpster approximately 200 feet from the main entrance of the facility. A statement of witness form, dated 8/4/24, indicated QMA 2 was leaving the facility and witnessed Resident 27 sitting in front of a white fence located by the trash dumpster. The resident was barefoot and wearing pajamas. QMA 2 told the resident she was not safe to be outside. A statement of witness form, dated 8/4/24, indicated RN 3 was flagged down by QMA 2 when she brought Resident 27 back to the 300-hallway. QMA 2 reported she was driving in the front parking lot when she noticed the resident in her wheelchair on the sidewalk by the loading dock. A physician's order, dated 8/19/24, indicated to check the function of the roam alert band daily. A physician's order, dated 8/19/24, indicated to check the placement of the roam alert band on every shift. During an interview, on 9/9/24 at 2:48 p.m., the Clinical Support Nurse indicated a resident noticed Resident 27 outside in her wheelchair sitting on the sidewalk. The roam alert alarm did not go off when the resident exited the building. A staff member was going out to her car and noticed the resident. During an interview, on 9/9/24 at 4:21 p.m., QMA 2 indicated she was leaving for the evening and witnessed the resident sitting in front of a white fence located by the trash dumpster. The resident was barefoot and wearing pajamas. During an interview, on 9/10/24 at 9:38 a.m., the Clinical Support Nurse indicated the code to the roam alert alarm was posted by the keypad. A current policy, titled Guideline for Elopement/Missing Resident, dated as revised 12/31/23 and received from the Clinical Support nurse on 9/10/24, indicated .Disoriented Resident (already deemed an elopement risk) observed exiting the campus door: Attempt to prevent the departure and re-direct. Obtain assistance from other staff members in the immediate vicinity .Instruct another staff member to inform the charge nurse or Director of Health Services that a resident has left/is leaving the campus .Notify the provider and responsible party for the resident. Complete an exit seeking event form. Attach progress note to an open exit seeking event .Upon return of the Resident to the facility (unwitnessed exit events) Examine resident for injuries. Contact the attending physician, report the findings and condition of the resident. Notify the responsible party for the resident The deficient practice was corrected by 8/24/24, after the facility implemented a systemic plan which included audits, staff education, elopement drills were conducted, the elopement binder was audited to ensure accuracy, daily audits on wander guard system was completed, a tech from wander guard system was scheduled to inspect the system, and the wander guard alarm system code was changed. 3.1-45(a)(1)

Based on interview and record review, the facility failed to ensure a cognitively impaired resident with a diagnosis of post-traumatic stress disorder was free from verbal and mental abuse for 1 of 2 residents reviewed for abuse. (Resident C) This deficient practice resulted in Resident C experiencing emotional distress. The deficient practice was corrected on [DATE], prior to the start of the survey, and was therefore past noncompliance. Findings includes: An Indiana Department of Health report indicated, on [DATE] at 11:00 p.m., Resident C was verbally assaulted by two staff members during resident care. Staff Member 2 and 3 were overheard by staff to verbally insult Resident C. Resident C indicated she had been verbally assaulted by the staff. The clinical record for Resident C was reviewed on [DATE] at 12:50 p.m. The diagnoses included, but were not limited to type 2 diabetes mellitus, heart failure, dementia, and post-traumatic stress disorder. Her Brief Interview for Mental Status (BIMS) score was a 7 which indicated a severe cognitive impairment. A facility investigation note, dated [DATE] at 9:52 a.m., indicated during an interview with Resident C, she indicated she was upset with the way the staff talked to her last evening. They were yelling with raised voices. A facility investigation note, dated [DATE], was written by Staff Member 5. She witnessed Staff Member 3 when giving a report, on [DATE], referring to Resident C as the b****. The resident was within hearing distance when the comment was made by the staff member. A facility investigation note, dated [DATE], was written by Staff Member 6. She overheard Staff Member 3 while pushing Resident C down the hallway to her room, on [DATE] at 11:00 p.m., say I am f****** tired of taking care of her. When Resident C was in her room, Staff Member 2 was heard to tell the resident, she was tired of cleaning s*** out from under her nails and she was f****** nasty. Staff Member 6 stayed with Resident C, gave her care, and put her to bed after sending the other staff members out of the room. Staff Member 6 then reported the incident to the supervisor. A facility investigation note, dated [DATE], was written by Staff Member 2. She indicated she did not raise her voice to the resident and did not speak inappropriately to her. Staff Member 3 during report referred to Resident C as This b****. A facility investigation note, dated [DATE], was written by Staff Member 3. She indicated she did not speak inappropriately to Resident C. She may have raised her voice to speak over other noises. She may have referred to the resident as This B**** during the report and was not aware the resident overheard her comment. A facility investigation note, dated [DATE], was written by Staff Member 7. She indicated she heard Resident C yelling with Staff Member 2 and 3. She overheard Staff Member 2 indicate to the resident she and Staff Member 3 were tired of taking care of her. She separated the resident from Staff Member 2 and 3. She overheard Staff Member 3 say she was tired of taking care of the resident. The resident was able to hear the staff member. The facility personnel records were reviewed, on [DATE] at 3:15 p.m., and indicated Staff Member 2 and 3 were terminated for substantiated resident abuse. During an interview, on [DATE] at 12:51 p.m., Resident C indicated two (2) staff members were mean to her the other day. They said bad things about her. When she was asked to describe what things were said to her the resident started to cry, was very tearful, and could not continue. When the resident was asked if she was afraid to be in the facility, she said not now, the two (2) staff members were gone, and no longer working. She indicated she had good support with the Assistant Director of Nursing (ADON), the Director of Nursing (DON) and other staff members who were nice to her and listened to her. She indicated she had a rough life and all her family, and friends have died . During an interview, on [DATE] at 4:55 p.m., Staff Member 8 indicated Staff Member 2 and 3 were suspended during the investigation and terminated for verbally abusing the resident. She indicated all staff members were re-educated on abuse and reporting abuse. A current facility policy, titled Abuse and Neglect Procedural Guidelines, dated [DATE] and received from Staff Member 8 on [DATE] at 2:10 p.m., indicated .ABUSE .It includes verbal abuse, sexual abuse, physical abuse and mental abuse .Willful, is used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm The deficient practice was corrected by [DATE], after the facility implemented a systemic plan which included a house wide physical assessment of each resident, house wide interviews with all capable residents on abuse allegations, reporting, and knowledge of abuse, and in servicing of all staff regarding abuse and reporting. Staff Member 2 and 3 were terminated for abuse. This citation relates to Complaints IN00435669 and IN00436493. 3XXX,d+[DATE](a) 3XXX,d+[DATE](b)

Based on observation, interview and record review, the facility failed to ensure a resident was able to have a personal recliner in her room, a resident was allowed to have undisturbed privacy, and a resident was provided adequate access and space for personal clothing for 3 of 3 residents reviewed for room space. (Resident 21, 26 and 3) Findings include: 1. The record for Resident 21 was reviewed on 07/19/23 at 10:24 a.m. Diagnoses included, but were not limited to, dementia with psychotic disturbance, delusional disorders, anxiety disorder, history of falling, presence of a right artificial hip joint, unsteadiness on feet, other lack of coordination, and repeated falls. During an interview, on 07/17/23 at 10:32 a.m., Resident 21 indicated she was admitted to the facility 06/23/2023. The room was small. She was not offered the choice of another room. Her roommate's television set was on the wall of her side of the room. The dresser was at the end of her bed, and she was only able to open drawers halfway. She did not have a closet to hang her clothes, since her roommate used the whole closet. There were no visitor chairs in her room. During an observation of room [ROOM NUMBER], on 07/17/23 at 10:32 a.m., the following were observed in room [ROOM NUMBER]: a. There were 2 residents in the room (Resident 21 and 26). The room had 2 beds, 2 dressers, 2 nightstands, 2 televisions on the wall, 1 double closet, and no visitor chairs. Both residents had wheelchairs. b. The distance of the dresser drawer to the foot of the bed measured 11 inches. c. Resident 21 was not able to access her clothing from the dresser drawers due to the limited space between the foot board of bed and the dresser. d. The resident was not able to have a chair in her room. 2. The record for Resident 26 was reviewed on 07/17/23 at 10:22 a.m. Diagnoses included, but were not limited to, major depressive disorder, expressive language disorder, difficulty in walking, cognitive communication deficit, muscle weakness, history of falling, and dependence on a wheelchair. A notice of room transfer, dated 05/30/23 at 9:54 a.m., indicated the resident and resident representative were informed of the room change which would occur on 06/01/23. The reason for the room change was for a facility renovation. The resident was previously in a private room. A progress note, dated 06/02/23 at 4:00 p.m., indicated Resident 26 became tearful when asked how she was liking her room. She expressed dissatisfaction with the room change. During a phone interview, on 07/14/23 at 11:10 a.m., Resident 26's daughter indicated she had concerns over the size of the room. She indicated the resident was not given a choice of another room. Her mother's nightstand and head of the bed were in front of the heating and cooling unit. The dresser was halfway in front of the closet. Her mom's roommate complained about the room size. Before her mom was moved to the new room she had a recliner, which the family brought from home. The recliner was not currently in her mother's room. She asked where the recliner was and had not received an answer from facility. During an interview, on 07/17/23 at 2:25 p.m., the Executive Director indicated rooms [ROOM NUMBERS] were the same set up. One resident in room [ROOM NUMBER] slept in a recliner per preference. They did find Resident 26's recliner. It was placed in storage, and he would notify the daughter. The Executive Director submitted a generic diagram of room [ROOM NUMBER]. The diagram indicated room [ROOM NUMBER] was 194 square feet. The diagram submitted showed 2 beds, 2 dressers, 2 chairs, 2 nightstands, a single closet and 1 wardrobe in the room. Resident 26 was not able to have a recliner in her room even though the diagram showed space for chairs. With the resident's bed, nightstand and dresser in the room, there was not enough space for a personal recliner or a chair. During observations of the rooms on the 300 hall, all rooms had 2 chairs except rooms [ROOM NUMBERS]. Both had 1 chair. The only room on the 300 hall without chairs was room [ROOM NUMBER]. A standard chair measured 3-foot-tall by 2 foot 4 inches wide by 1 foot 8 inches depth from front to back. 3. During a resident council meeting, on 7/17/23 at 2:31 p.m., Resident 3 indicated a lot of the residents did not like being in a two-person room. She had nothing against her roommate (Resident 19) although the roommate made a lot of noise, had to have the light on quite a bit and Resident 3 needed total darkness to sleep. She had to move her wheelchair every time the roommate would come in the room because there was not enough room for both wheelchairs. The record for Resident 3 was reviewed on 7/18/23 at 2:44 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, heart failure, macular degeneration, presence of a cardiac pacemaker and anxiety disorder. A notice of room transfer, dated 5/30/23 at 12:59 p.m., indicated the resident and resident representative were informed of the room change which would occur on 6/1/23. The reason for the room change was for a facility renovation. The resident was previously in a private room. During an interview, on 7/18/23 at 10:49 a.m., Resident 3's daughter indicated there was issues with two people being in the room. Her mom slept in a recliner and when the staff would assist the roommate in or out of her bed the staff had to move her mom's recliner. There was no other place to put the recliner since the television was mounted on the left side of the room and this was where the resident could see it. The resident was not given a choice of rooms. She had asked for the resident not to be in a room at the end of the hallway and the Executive Director indicated he would take this into consideration. The resident was still moved to a room at the end of the hallway. She had to put masking tape on the floor to show where the recliner would go since the staff kept moving the recliner when they assisted Resident 19 and didn't put it back where the resident could see the television. During an interview, on 7/18/23 at 11:16 a.m., LPN 3 indicated Resident 3, and her roommate could not have both of their wheelchairs in the room at the same time as there was not enough space. The staff would have to move Resident 3's chair to be able to get the roommate in the room or out of the room and the staff would not always put the wheelchair back where Resident 3 could access the chair. Resident 3 was able to transfer herself from the recliner to the wheelchair. The staff could leave the recliner in place they just had to move the wheelchair out of the room to get the Resident 19 in the room. It was rough due to the space in the room. The residents did not get much notice before the room changes and the room changes were due to the facility renovation for a dementia unit. Resident 3 was not able to have undisturbed privacy in her room if the staff were assisting Resident 19. During an observation, on 7/18/23 at 4:00 p.m., the distance from Resident 3's recliner to the roommate's bed was 3 feet and 10 inches. There was a space of 2 feet and 1 inch from the front of the recliner to the right side of the dresser to allow the resident to recline to sleep. A standard wheelchair measures 36 inches tall, 25 inches wide, and 32 inches long. The space of 3 feet and 10 inches between Resident 3's recliner/wheelchair would have to accommodate Resident 19's wheelchair and the two staff who were needed to assist Resident 19 in and out of bed. 4. The record for Resident 19 was reviewed on 7/19/23 at 3:40 p.m. Diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, orthopedic aftercare following surgical amputation, aphasia (loss of ability to speak), and cellulitis of the left lower leg. A care plan, dated 2/1/2019, indicated the resident was at a risk for falls related to weakness, and right sided hemiplegia. The interventions included, but were not limited to, two staff to assist with transfers and a bariatric bed (a heavy-duty bed designed to comfortably and safely accommodate large individuals) to have more room for the resident to turn. A current policy, titled Resident Rights Guidelines, dated as revised on 5/11/17 and received from the Clinical Support on 7/19/23 at 1:47 p.m., indicated .To ensure resident rights are respected and protected and provide an environment in which they can be exercised .Resident shall not leave their individual personalities or basic human rights behind when they move to a health campus .Our residents have a right to .Be treated with dignity and respect .Privacy .Be treated fairly, courteously and with respect by staff .Personalize their apartment . 3.1-3(v)(1) 3.1-19(f)(5) 3.1-19(k) 3.1-19(m)(4)

Based on observation, interview and record review, the facility failed to obtain a physician's order and to ensure care plan interventions were in place for the use of a wanderguard monitoring bracelet for 1 of 2 residents reviewed for accidents. (Resident 1) Finding include: During an observation, on 07/17/23 at 10:44 a.m., Resident 1 was sitting in a recliner, in the lounge area, with her feet elevated and her eyes closed. The resident had a monitoring bracelet (used for residents who wander) on her right ankle. During an observation, on 07/18/23 at 10:17 a.m., the resident was sitting in a recliner with her feet elevated and her eyes closed. The resident had a monitoring bracelet intact to her right ankle. The record for Resident 1 was reviewed on 07/14/23 at 3:07 p.m. Diagnoses included, but were not limited to, fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, and dementia. There was no order in the record for the monitoring bracelet. There was no care plan to indicate the resident had a monitoring device. During an interview, on 07/18/23 at 2:31 p.m., the Director of Health Services indicated there was no order for wanderguard (monitoring bracelet) placement or for checking the function of the bracelet. There was no consent for the device and the facility had no policy for the use of a wanderguard. A current policy, titled Elopement Risk Assessment and Prevention, dated 5/1/2017 and received from the Director of Health Services on 7/19/23 at 1:17 p.m., indicated .each resident will be assessed for elopement risk upon admission, quarterly and with change in condition .a plan of care will be developed and implemented for each resident identified .facilities with wander alert detection systems should place a wander alert bracelet on the resident .a check will be completed of alarmed doors and individual resident alarms to ensure proper functioning 3.1-45(a)(1)

Based on interview and record review, the facility failed to educate the resident and/or the resident's representative about the potential risks of antipsychotic medications for 1 of 5 residents reviewed for unnecessary medications. (Resident 28) Finding includes: The record for Resident 28 was reviewed on 7/17/23 at 10:09 a.m. Diagnoses included, but were not limited to, dementia with behavioral disturbances, delusional disorder, muscle weakness, psychotic disorder with hallucinations, anxiety disorder, adult failure to thrive, and depression. A physician's order, dated 11/5/22, indicated the resident was taking Risperdal (an antipsychotic) 0.5 milligrams once per day. During a resident first meeting, dated 6/28/23 at 2:10 p.m., the facility indicated a review of medications were conducted with the resident's daughter. The resident first meeting did not include the names of the medications reviewed and did not include if the potential side effects were reviewed. During a family interview, on 7/19/23 at 1:45 p.m., the resident's daughter indicated the facility did not educate her on the current medications and their potential side effects. During an interview, on 7/19/23 at 2:35 p.m., the DHS (Director of Health Services) indicated the facility did not have an informed consent policy. The current Nursing Drug Handbook indicated Risperdal had a black box warning. Older adults with dementia related psychosis treated with antipsychotics were at an increased risk for death. The drug was not appropriate to treat older adults with dementia related psychosis. A current policy, titled Resident Rights Guidelines, received from the Clinical Support on 7/19/23 indicated .Be given the information necessary to participate in decisions which affect them individually and corporately 3.1-48(a) 3.1-48(a)(6) 3.1-4(c)

Based on observation, interview and record review, the facility failed to ensure a resident received bathing as scheduled in the months of May and June 2023 for 1 of 1 resident reviewed for ADL (activities of daily living) care. (Resident 27) Findings include: During an observation, on 07/14/23 at 10:13 a.m., the resident was in her bed with the head of the bed elevated and her hair had a greasy appearance. The record for Resident 27 was reviewed on 07/17/23 at 2:55 p.m. Diagnoses included, but were not limited to, malignant neoplasm of the brain, acute respiratory failure with hypoxia, type 2 diabetes, acute kidney failure, morbid obesity, sequalae of cerebral infarct, depression, anxiety, and epilepsy. A review of the point of care documentation, dated May 2023, indicated a bath did not occur on 5/11, 5/13, 5/14, 5/29, and 5/30/23. There was no documentation regarding the reason the bath did not occur. The documentation indicated the resident required extensive assistance with shower and partial assistance with a shower. A review of the point of care documentation, date June 2023, indicated a bath did not occur on 6/24, 6/25, 6/26 and 6/27. There was no documentation regarding the reason the bath did not occur. The documentation indicated the resident required extensive assistance with shower and partial assistance with a shower. There was no documentation in the progress notes for the dates the baths did not occur to indicate the reason for the baths not occurring. During an interview, on 7/14/23 at 10:15 a.m., Resident 27 indicated she had not had a bath in a week. She pulled at her hair and stated look at my greasy hair. A staff member came in and ask if she wanted a shower, the resident agreed, and the staff member never returned. A current policy, titled Caregiver New Hire Checklist, dated 3/20/23 and received from the Director of Health Services on 7/19/23 at 4:13 p.m., indicated .back care, partial, shower, bed bath .documentation of refusals There was no policy for ADL care. 3.1-38(a)(2)(A)

Based on interview and record review, the facility failed to thoroughly investigate an incident involving a CRCA (Certified Resident Care Assistant) and a resident for 1 of 1 resident reviewed for abuse. (Resident 27) Finding includes: During an interview, on 07/14/23 at 10:10 a.m., Resident 27 indicated shortly after her admission, a CRCA was verbally abusive to her. She indicated the CRCA used foul language, was written up, and fired. The record for Resident 27 was reviewed on 07/17/23 at 2:55 p.m. Diagnoses included, but were not limited to, malignant neoplasm of the brain, sequalae of cerebral infarct, depression, anxiety, and epilepsy. An admission MDS (Minimum Data Set) indicated the resident's BIM's (brief interview for mental status) score was 15 (cognitively intact). A typed document, dated 3/20/23, received from the Director of Health Services indicated the Assistant Director of Health Services spoke with the resident about the incident. The resident was upset over the treatment she had received by the CRCA. She stated the CRCA had not changed her all night and she was left to sit in her urine. She was concerned about other residents who were unable to speak for themselves. The resident became tearful and indicated the CRCA used the word f*** when she couldn't get the residents blankets in order. The incident made the resident hesitant to use the call light the rest of the night. A resident concern form, dated 3/20/23 at 11:00 a.m., indicated the CRCA had not changed her brief all night. The resident woke up soaked and had to sit in her own urine. The CRCA used foul language which was against policy. The Assistant Director of Health Services indicated she would investigate the allegation and take appropriate action with the CRCA. The resolution on the form was to terminate the CRCA. A personnel action form, dated 3/6/23, indicated the CRCA was suspended due to allegations of poor care and possible neglect. After the investigation, it was determined it was not neglect, but below facility standards. As of 3/6/23, the facility decided to separate employment. There were no resident or staff interviews included in the investigation to indicate residents or staff had been interviewed. During an interview, on 07/17/23 at 3:40 p.m., the resident indicated shortly after her admission to the facility, a CRCA was pulling sheets around on her bed and wasn't getting it quite right. The CRCA said f*** and the resident found the word offensive. The Executive Director, Director of Health Services and Assistant Director of Health Services investigated the incident. She had not seen the CRCA since the incident. During an interview, on 07/17/23 at 3:54 p.m., the Director of Health Services indicated she believed the CRCA involved was terminated for customer service issues. The resident did not feel intimidated or complain of abuse. The resident was upset about the language. During an interview, on 07/18/23 at 2:15 p.m., the Clinical Support Nurse indicated the 3 forms submitted (typed document with interview of the resident, resident concern form and personnel action form) were the complete investigation. No resident or staff interviews were documented. A current policy, titled Abuse and Neglect Procedural Guidelines, dated June 2023 and received from the Director of Health Services on 7/20/23 at 3:39 p.m., indicated .upon identification of suspected abuse or neglect immediately provide for the safety of the resident .suspend suspected employee(s) pending outcome of the investigation .identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations .providing complete and thorough documentation of the investigation 3.1-28(d)

Based on observation, interview and record review, the facility failed to ensure physician's orders and care plan interventions were followed for 1 of 2 residents reviewed for pressure ulcers. (Resident 10) Finding includes: During an observation, on 7/17/23 at 11:53 a.m., Resident 10 did not have a Prevalon boot (pressure relieving device) on his right foot while his left foot was covered up with a blanket. The record for Resident 10 was reviewed on 7/17/23 at 11:26 a.m. Diagnoses included, but were not limited to, pressure ulcer of left heel, hemiplegia (paralysis) and hemiparesis (weakness) on left side, and muscle weakness. A current care plan, dated 3/3/22, indicated the resident was to have Prevalon boots on his bilateral (both) feet at all times. A physician's order, dated 4/28/23, indicated Prevalon boots were to be on at all times. The MAR (Medication Administration Record) on 7/17/23 indicated the resident had Prevalon boots on although no boots were observed. During an interview, on 07/18/23 at 11:03 a.m., LPN 4 indicated she was unsure if the resident' Prevalon boots were on and if they were not on then they should be put on right away. A current policy, titled GUIDELINES FOR MEDICAL RECORDS CLIINICAL DOCUMENTATION, received from the Director of Health Services on 7/19/23 at 1:47 p.m., indicated .Entries in a residents record need complete and are authenticated and dated by the person responsible for ordering, providing, or evaluating the service in a prompt manner. Any corrections to the resident record are made by authorized persons in accordance with acceptable standards of practice 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure the diagnoses was appropriate for the use of antipsychotic medication, the resident symptoms for the continued use of the antipsychotic medication were documented, gradual dose reductions (GDR) were recommended and addressed timely by the prescriber for 4 of 8 residents reviewed for unnecessary medications (Resident 5, 6, 30 and E). Findings include: 1. The record for Resident 5 was reviewed on 8/5/22 at 11:28 a.m. Diagnoses included, but were not limited to, unspecified dementia with behavioral disturbance, depression and [CONDITION(S)]. A physician's order, dated 9/5/21, indicated [MEDICATION(S)] (an antipsychotic) 12.5 mg (milligram) at bedtime. A physician's order, dated 9/27/21, indicated [MEDICATION(S)] 25 mg twice daily for worsening behavior. A physician's order, dated 1/14/22 through 7/12/22, indicated [MEDICATION(S)] 50 mg twice daily for a diagnosis of dementia with behavioral disturbance. A physician order, dated 7/12/22, indicated [MEDICATION(S)] take 25 mg in the am and 50 mg at bedtime. There was no diagnosis with the physician order dated 7/12/22. An order set for target behaviors, 8/30/21, indicated to monitor for agitation and aggression and at the end of the shift mark frequency of the behavior and how the resident responded to interventions. The Medication Administration Record (MAR), dated 7/1/22 through 8/5/22, indicated the resident had behaviors of agitation and aggression for 9 out of 70 shifts. The MAR did not include notes on the exact behaviors the resident displayed. The progress notes from 7/1/22 through 8/5/22 did not include any resident behaviors. A Initial Behavior Care Solutions report, dated 7/13/22, indicated the resident had a history of yelling out and resisting care. The assessment and plan indicated the resident had unspecified dementia with behavioral disturbance. The resident had traits concerning for EPS (movement disorder caused by the use of antipsychotic medication). The resident had been on the [MEDICATION(S)] for a year and a GDR would be completed to reduce the chance of side effects, motor issues and increased mortality in the elderly. The [MEDICATION(S)] was also available for as needed agitation and distress. The resident had abnormal movements of the tongue, upper extremities and lower extremities. The report did not include a diagnosis of [CONDITION(S)], delusions or hallucination. A care plan, dated 2/16/22, indicated the resident demonstrated inappropriate behaviors including tapping the tables loudly and being disruptive to the environment and yelling out at times. The resident utilized an antipsychotic medication. The goal indicated the resident's behaviors would not result in disruption of others environment. The interventions included, but were not limited to, assess for unmet needs, assist resident to stay away from other residents as needed, determine cause for inappropriate behaviors, encourage participation in structured activities. A care plan, dated 12/14/21, indicated the resident was receiving an antipsychotic medication for aggressive behaviors. The interventions included, but were not limited to, administer medication per physician orders, attempt a GDR in two separate quarters during the first year, attempt to give the lowest dose possible, observe and report signs of extrapyramidal (inability to sit still, involuntary muscle contractions, tremors, involuntary facial movements)symptoms. During an interview, on 8/5/22 at 2:09 p.m., the Director of Health Services (DHS) indicated the resident had agitation and aggression. She would yell out, tap and clap and repeat specific words. She would hit at staff during care. The DHS did not include the resident having any symptoms of delusions, hallucinations or [CONDITION(S)]. The Nursing Drug Handbook, indicated [MEDICATION(S)] had a black box warning and the risk of death was increased in elderly patients with dementia-related [CONDITION(S)] and the drug was not indicated for use in elderly patients with dementia-related [CONDITION(S)]. The drug can cause extrapyramidal signs and symptoms and needs monitored for tardive dyskinesia (causes stiff, jerky movements of the face and body which can't be controlled). 2. The record for Resident 6 was reviewed on 8/5/22 at 4:23 p.m. Diagnoses included, but were not limited to, [CONDITION(S)], Alzheimer's disease, dementia with behavioral disturbance, anxiety disorder, depression and psychotic disorder with delusions due to known physiological condition. A physician's order, dated 11/1/21, indicated [MEDICATION(S)] sprinkles (a mood stabilizer) to give 125 mg once a day. A physician's order, dated 11/1/21, indicated to give [MEDICATION(S)] sprinkles 250 mg at bedtime. A physician's order, dated 4/6/22, indicated to give [MEDICATION(S)] 25 mg twice a day. A target behavior set, dated 8/10/21, indicated to monitor each shift for aggression, grabbing, hitting and document frequency and how the resident responded to redirection. A target behavior set, dated 8/10/21, indicated to monitor for anxiety, restlessness and irritability each shift and document frequency and response to redirection. During an interview, on 8/9/22 at 5:06 p.m., the DHS indicated the original order for the [MEDICATION(S)] (mood stabilizer) was dated 7/2/21. A care plan, dated 1/21/22 and revised on 5/9/22, indicated the resident at times refused care, yelled out and cried. The interventions included, but were not limited to, observe and document changes in mood, behaviors and pain, offer phone call to family, as needed pain medication as ordered, attempt care at a later time. A care plan, dated 8/10/21 and last revised on 5/9/22, indicated the resident demonstrated physically abusive and resistive behaviors toward staff during hands on care with grabbing and hitting. The interventions included, but were not limited to, approach resident in a calm and unhurried manner to deliver care and provide services, explain process prior to delivery of care, observe for signs of sensory overstimulation and offer choices in hands on care. A care plan, dated 8/6/21 and last revised on 5/9/22, indicated the resident was at risk for adverse consequences related to receiving antipsychotic medication. The interventions, included, but were not limited to, administer medication per physician's orders, attempt GDR in two separate quarters, unless contraindicated, attempt to give the lowest dose possible. During an interview, on 8/9/22 at 3:02 p.m., the DHS indicated the GDR request from the pharmacy for [MEDICATION(S)], dated 2/9/22, was not addressed by the nurse practitioner (NP) until 3/2/22. The [MEDICATION(S)] was decreased on 3/2/22 and then the resident had behaviors of throwing cookies and threatened to call the police so the [MEDICATION(S)] was a failed GDR and increased again. There was no GDR on the [MEDICATION(S)]. She was not sure why it took from 2/9/22 until 3/2/22 for the NP to address the GDR for the [MEDICATION(S)]. The [MEDICATION(S)] and the [MEDICATION(S)] were prescribed for the dementia with aggressive behaviors. During an interview, on 8/9/22 at 3:19 p.m., the DHS indicated there was no GDR requested for [MEDICATION(S)] and only one request for a GDR for the [MEDICATION(S)]. The [MEDICATION(S)] should have had the diagnosis of psychotic disorder due to known delusions and the [MEDICATION(S)] did not have a diagnosis related to it. 3. The record for Resident 30 was reviewed on 8/3/22 at 3:22 p.m. Diagnoses included, but were not limited to, major depressive disorder, anxiety disorder, cerebral infarction, [CONDITION(S)] and chronic pain. A physician's order, dated 11/18/21, indicated [MEDICATION(S)] 20 mg once a day for depression. A pharmacy recommendation, dated 2/9/21, indicated the resident had the following medications due for evaluation an order for [MEDICATION(S)] (an antidepressant) 20 mg daily and [MEDICATION(S)] 1 mg every morning, 2 mg every evening and 2 mg at bedtime. The recommendation was to decrease the [MEDICATION(S)]. The NP addressed the [MEDICATION(S)] and did not respond to the recommendation for the [MEDICATION(S)]. During an interview, on 8/9/22 at 4:30 p.m., the DHS indicated the resident did not have a GDR for the [MEDICATION(S)] in the electronic health record. 4. The record for Resident E was reviewed on 08/03/22 at 12:06 p.m. Diagnoses included, but were not limited to, positive Covid-19, [CONDITION(S)] (damage or disease affecting the brain), dementia without behavioral disturbance, cerebral infarction and anxiety disorder. A physician's order, dated 06/30/22, indicated to give [MEDICATION(S)] (an antipsychotic medication) 5 mg (milligrams) one tablet at bedtime for a diagnosis of [CONDITION(S)]. A care plan, dated 07/12/22, indicated the resident was at risk for adverse consequences related to receiving an antipsychotic medication for a diagnosis of acute [CONDITION(S)]. Interventions included, but were not limited to, pharmacy consultant review as needed. An order set for target behaviors, dated 07/30/22, indicated to monitor for hallucinations, delusions, etc. twice a day. The MAR, dated between 07/30/22 and 08/05/22, indicated the only behavior was on 07/30/22. The type of behavior was not indicated on the MAR. A facility form, titled Trilogy - Pharmacy Recommendation, dated 07/27/22, indicated the resident was taking [MEDICATION(S)] with a diagnoses [CONDITION(S)]. The resident lacked an allowable diagnoses to support its use. The pharmacist recommended the facility to note the appropriate diagnosis. If an appropriate diagnosis did not exist, the facility should consider a reduction to begin tapering off the medication. During an interview, on 08/05/22 at 2:09 p.m., the DHS indicated she witnessed the resident having hallucinations. Resident E would say her son was walking down the hall. The son was not even there. The DHS also indicated her son would visit often. These issues did not cause the resident any distress. The Nursing Drug Handbook, indicated [MEDICATION(S)] had a black box warning to include the medication may increase the risk of cardiovascular or infection related death in elderly patients and was not appeared to treat patients with dementia related [CONDITION(S)]. A current policy, titled [CONDITION(S)] Medication Usage and Gradual Dose Reduction, revised 10/09/17 and received from the DHS on 08/09/22 at 5:08 p.m., indicated .To ensure effort is made for residents receiving psychoactive medications to obtain the maximum benefit with minimal unwanted side effects through appropriate use, evaluation and monitoring by the interdisciplinary team .Residents shall receive [CONDITION(S)] medications only if designated medically necessary by the prescriber, with appropriate diagnosis or documentation to support its usage. The medical necessity will be documented in the resident's medical record and in the care planning process .Regular monthly review of antipsychotics in CAR for continued need, appropriate dosage, side effects, risks and/or benefits will be conducted, to ensure the use of psychopharmacological medications are therapeutic and remain beneficial to the resident .A gradual dose reduction (GDR) will be attempted for two (2) separate quarters (with at least one month between attempts) .Gradual dose reduction must be attempted annually thereafter, unless medically contraindicated 3.1-48(a)(2) 3.1-48(a)(4)

Based on observation, interview and record review, the facility failed to date oxygen tubing and humidity bottles for (Resident 157 and D), to administer the correct amount of oxygen as ordered by the physician for (Resident 35) and failed to use the correct route as ordered by the physician for (Resident 22) for 4 of 5 residents reviewed for supplemental oxygen. Findings include: 1. During an observation, on 8/1/22 at 1:37 p.m., Resident 157's oxygen tubing and humidity bottle were not dated and the oxygen concentrator was set a 2 L (liters per minute). The record for Resident 157 was reviewed on 8/3/22 at 4:33 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's order, dated 7/22/22, indicated the resident was to receive 2 liters (2 L/min) of oxygen continuously. A care plan, dated 8/4/22, indicated the resident was at risk for shortness of breath. Interventions included, but were not limited to, administer oxygen as ordered. During an interview, on 8/1/22 at 1:40 p.m., RN 3 indicated the oxygen tubing and humidity bottle should be dated. 2. During an observation, on 8/1/22 at 1:31 p.m., Resident D's oxygen tubing was not dated and the oxygen concentrator was set at 2 liters. The record for Resident D was reviewed on 8/5/22 at 12:08 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's order, dated 7/22/22, indicated the resident was to receive 2 liters of oxygen continuously. A care plan, dated 8/1/22, indicated the resident was at risk for shortness of breath. Interventions included, but were not limited to, administer oxygen as ordered. During an interview, on 8/1/22 at 1:40 p.m., RN 3 did not enter the residents room. She indicated if the tubing or humidity bottle did not have a date I trust you and walked away. The night shift was supposed to change the tubing and bottles. 3. During an observation, on 8/4/22 at 5:06 p.m., Resident 35 was in the dining room with the portable oxygen tank set on 2 liters. During an observation, on 8/9/22 at 1:45 p.m., the resident was in her room and was not wearing any oxygen. The record for Resident 35 was reviewed on 8/5/22 at 9:01 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's order, dated 5/6/22, indicated the resident was to receive 4 liters of oxygen continuously. A care plan, dated 5/9/22, indicated the resident was at risk for respiratory distress. The interventions included, but were not limited to, administer oxygen as ordered. During an interview, on 8/9/22 at 1:47 p.m., LPN 2 indicated the physician gave her a verbal order a week ago to reduce the oxygen liters and to start weaning the oxygen. She did not enter the order into the electronic health record. During an interview, on 8/9/22 at 3:24 p.m., the Director of Health Services (DHS) indicated the nurse did not put the verbal order in the computer for the oxygen reduction. 4. During an observation on 8/1/22, the Resident 22 had oxygen to the [CONDITION(S)] at two liters. During an observation, on 8/5/22 at 10:53 a.m., the resident was noted to have oxygen at 2 liters per nasal cannula in place. The record for Resident 22 was reviewed on 8/5/22 at 2:34 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's order, dated 5/18/21, indicated [CONDITION(S)] oxygen at 2 liters. A physician's order did not include nasal cannula administration. A care plan, dated 5/19/21, indicated the resident had the potential for shortness of breath while lying flat related to asthma and chronic respiratory failure. The approaches included, but were not limited to, administer oxygen per MD order and as needed, [CONDITION(S)] care as ordered, elevate head of bed or place in upright position as needed. During an interview, on 8/8/22 at 10:00 a.m., the DHS indicated the order had been changed to oxygen two liters per nasal cannula dated 8/6/22. A current policy, titled Guidelines for Medication Orders, dated 5/2016 and received from the DHS on 8/9/22 at 5:10 p.m., indicated .To establish the uniform guidelines in the receiving and recording of medication orders .When recording oxygen orders .The rate of flow, route and rationale 3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure showers were completed and documented for 3 of 3 residents reviewed for bathing (Residents B, D and E). Findings include: 1. During an interview, on 8/4/22 at 3:31 p.m., Resident B indicated when she was being isolated for Covid-19, she was not given assistance to shower for the first 14 days after being admitted to the facility. Different staff had told the resident they would come back to assist her to shower and then did not return. She received a shower on the last day of her isolation for Covid-19. The record for Resident B was reviewed on 8/3/22 at 2:18 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Point of Care (POC) ADL (activities of daily living) report, dated 11/6/21 through 11/30/21, indicated the resident did not have a bath or shower on 11/6/21,11/7/21, 11/8/21, 11/9/21, 11/10/21, 11/11/21 or 11/12/21. A comprehensive care plan, dated 11/23/21, indicated the resident was at risk for falling related to needing assistance with ADL care and the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview, on 8/9/22 at 5:05 p.m., the Director of Health Services (DHS) indicated the resident did not have bathing preferences listed on the care plan and there was no documentation in the electronic health record of the resident receiving showers from 11/6/21 through 11/12/21. The resident went 7 days without having any documentation of a shower or bathing being completed. 2. During an observation, on 8/8/22 at 3:50 p.m., Resident E was sitting at the nurses station. The resident's hair was dirty and not brushed. The record for Resident E was reviewed on 8/3/22 at 12:06 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Point of Care (POC) ADL report, dated 6/30/22 through 8/8/22, indicated the resident did not have a bath or shower on 7/4/22, 7/11/22, 7/28/22 and 8/8/22. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 7/22/22, indicated the resident's profile care guide had showers scheduled for Tuesday and Friday on evening shift. During an interview, on 8/8/22 at 4:00 p.m., CNA 9 indicated the resident's shower days were Monday and Thursday. The hospice aide gave her showers to her. She could only find record of 3 showers given to the resident. 3. The record for Resident D was reviewed on 8/5/22 at 12:08 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Point of Care (POC) ADL report, dated 7/20/22 through 8/8/22, indicated Resident D had 1 bed bath and 1 shower from 7/20/22 through 8/8/22. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 8/3/22, indicated the residents profile care guide had showers scheduled for Monday and Thursday on nightshift. During an interview, on 8/9/22 at 2:20 p.m., CNA 4 indicated if a resident was in isolation she would gather up all her supplies and go into the room. The showers were charted in the computer. During an interview, on 8/9/22 at 2:56 p.m., the DHS indicated the residents with Covid-19 have their own room with a shower. The residents normally have showers twice a week. Once a shower was completed the CNAs were supposed to document the showers in point of care or on a shower sheet. The CNA would give the shower sheet to the nurse for review. The facility document, titled Point of Care ADL Category Report (MDS 3.0), indicated if the form was marked with an 8 the bathing was not done. Resident D was admitted on [DATE]. The only bath she had received was on 7/26/22. A current policy, titled Nursing ADL Documentation Guidelines, revised 5/10/16 and received from the DHS on 08/09/22 at 5:10 p.m., indicated .Completion of ADL services will be validated through the use of the CARE ASSIST ADL reports .ADL services will be conducted and documented by the CNA each shift at the point of care or as reasonably possible after care .The paper format shall be submitted to the MDS Coordinator This Federal Tag relates to Complaint IN 472. 3.1-38(b)(2)

Based on interview and record review, the facility failed to ensure a resident was free of staff using their cellular phone on face time while in the resident's room for 1 of 3 residents reviewed for respect and dignity. (Resident C) Finding includes: During an interview, on 8/2/22 at 11:13 a.m., Resident C indicated about a year ago a female staff who was no longer employed at the facility, was on face time while she was helping her go to the bathroom. She told the staff nurse on duty what happened and the nurse talked to the administrator. The staff who used her phone in the room came back and told Resident C she was on the phone with her husband and he was not able to see the resident on the toilet. Resident C did not give the name of the staff and indicated she did not want to complain about the staff. The record for Resident C was reviewed on 8/4/22 at 12:07 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A BIMS (brief interview for mental status) completed on 7/6/22 was 15 which indicated intact cognition. A care plan, dated 8/7/19, indicated the resident had impairment in functional status in regards to bed mobility, transfers and toileting related to her weakness. The interventions included, but were not limited to, the resident required extensive assist with toileting. During an interview, on 8/4/22 at 11:52 a.m., CRMA (certified resident medication aide) 10 indicated, GCRCA (graduate certified resident care assistant) 11, had been fired for using her cellular phone. She was face timing while she was in the residents' rooms. During an interview, on 8/4/22 at 11:59 a.m., LPN 2 indicated GCRCA 11 was very loud and made everyone uncomfortable and was reported to the administration several times for using her phone and being on face time. LPN 2 also requested her to stop using her phone. GCRCA 11 had used her phone while in Resident C's room while she was assisting her to the toilet. This was reported to the scheduler who was now the payroll staff. During an interview, on 8/4/22 at 12:19 p.m., the payroll staff indicated GCRCA 11 was reported to have been on her phone and did a video call when she was on duty. She did not handle the situation and did not know where GCRCA 11 was located when she made the video call. During an interview, on 8/4/22 at 3:47 p.m., with the Administrator and the DHS (Director of Health Services), the Administrator indicated GCRCA 11 was terminated due to leaving the facility in the middle of the shift to go on break and did not come back. During March 2022, there were a lot of complaints about GCRCA 11 using her cellular phone on the floor. There were no complaints from residents about the use of cellular phones by staff. The Administrator did not interview residents about the staff use of cellular phones. The DHS indicated when she first was employed, she had issues with staff carrying cellular phones and GCRCA 11 indicated she had used her cellular phone while working due to an upcoming court case. GCRCA 11 always took her break at 4:00 p.m., and did not come back one evening after her break. There were no reports of GCRCA 11 being in residents' rooms using her cellular phone. A Personnel Action Form, dated 5/16/22, indicated GCRCA 11 was terminated effective 5/14/22 for job abandonment due to walking out in the middle of her shift and not returning. The termination was approved by the Administrator on 5/16/22. A current policy, titled Resident Rights Guidelines, dated as revised 5/11/17 and received at entrance from the Administrator, indicated .To ensure resident rights are respected and protected and provide an environment in which they can be exercised .Residents shall not leave their individual personalities or basic human rights behind when they move to a health campus. The following is a list of rights recognized by staff at Trilogy Health Services .Be treated with dignity and respect .Privacy .Be treated fairly, courteously and with respect by staff .Be free of physical, verbal, fiduciary or psychological abuse from staff, family and other residents .Including all other state specific resident rights according to their public health code This Federal Tag relates to Complaint IN 237. 3.1-3(p)(4)

Based on record review and interview, the facility failed to ensure a resident's code status had been updated for 1 of 4 residents reviewed for advanced directives (Resident 47). Finding includes: The record for Resident 47 was reviewed on 08/05/22 at 9:38 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's face sheet on the electronic health record indicated full code status. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 07/02/22, indicated the resident/resident representative had chosen a full code. Approaches included, but were not limited to, review the advanced directives quarterly and as needed. An advance directive form, dated 7/26/22 and signed by the resident's representative indicated DNR (do not resuscitate). The form was signed by the physician on 8/2/22. On 8/3/22 at 9:30 a.m., the SSD indicated a new post form and a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A current policy, titled, Guidelines for Advanced Directive, dated 1/7/19 and received from the social services director on 8/9/22 at 11:00 a.m., indicated, ' .To ensure facility staff obtains and follows resident's advanced directives regarding end-of-life care .Advanced Directives will be reviewed with resident and/or resident representative by the Customer Service representative or designee at time of admission, with the quarterly comprehensive assessment and PRN [as needed] .The resident or representative will advise the CSR [customer service representative]/designee regarding wishes for end of life directives and code status. The 'DNR' form will be completed documenting these desires and scanned into the medical record .The nursing staff will obtain an order from the attending physician for the desired code status .Designation of code status and obtainment of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 3.1-4(f)(4)(ii)

Based on record review and interview, the facility failed to ensure a PASARR (Preadmission Screening and Resident Review) was completed when the resident was prescribed an antipsychotic medication and given a mental health diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Finding includes: The record for Resident E was reviewed on 8/3/22 at 12:06 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A PASARR level I, dated 4/26/22, indicated the resident was not on any antipsychotic medication. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview, on 8/9/22 at 10:06 p.m., the Social Service Director (SSD) indicated a PASARR Level I was not completed. The resident was on [MEDICATION(S)] 5 mg and she should have done a PASARR Level I. A current policy, titled Indiana PASRR Standard Operating Procedure Revenue Billing & Collections, not dated and received on 8/9/22 at 5:06 p.m., from the Director Nursing Services (DNS) indicated . Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are appropriately placed in nursing facilities for long-term care. PASRR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental illness (SMI) and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care settings); and 3) receive the services they need in those settings .Change in status and Level II follow up .Social Services ensures paperwork is submitted. They will print out the outcome letter and upload to Matrix file . 3.1-16(d)(1)(A)

Based on record review, observation and interview, the facility failed to assess and provide interventions to prevent weight loss for 1 out of 4 residents reviewed for weight loss and nutrition. The resident had a weight loss of 10% in 22 days without intervention. (Resident #130). Findings include: The record for Resident #130 was reviewed on 4/20/16 at 11:12 a.m. [DIAGNOSES REDACTED]. A care plan dated 4/6/16, for Resident #130, indicated interventions for nutrition included, but were not limited to, offer alternate food and beverage items as needed, please assist me with meals as needed, obtain my weight as ordered/needed. An initial Nutrition assessment dated [DATE] at 8:48 p.m., indicated resident needed extensive assist while eating and will monitor weight and physical parameters to evaluate that diet and intake meet actual nutrition needs and resident goals. Current weight was 130 pounds. Oral intake meets 76-100% of estimated needs. A nutrition progress note dated 4/22/16 at 10:48 a.m., indicated Resident #130's current weight was 117 pounds, down 13 pounds (10%) from initial assessment on 4/06/16. A Vitals Report indicated the following weights: 3/31/16 130 pounds, 4/07/16 125 pounds, 4/11/16 125 pounds and 4/21/16 119 pounds. A fax communication form to the physician dated 4/16/16 indicated Resident #130 had notable increase of jerking (involuntary movements) of the bilateral upper extremities and trunk, especially right upper extremity. A nursing order dated 3/31/16 at 3:48 p.m., indicated to record meal and fluid intake on day shift and afternoon shift including breakfast, a.m. snack, lunch, p.m. snack, supper, HS (hour of Sleep) snack and fluids. A Vitals Report indicated the following dates and times did not have food intake recorded: 4/2/16 breakfast and lunch 4/3/16 lunch 4/4/16 breakfast, lunch and dinner 4/5/16 breakfast, lunch and dinner 4/6/16 breakfast and lunch 4/7/16 breakfast, lunch and dinner 4/8/16 breakfast and lunch 4/9/16 dinner 4/10/16 dinner 4/11/16 breakfast and lunch 4/12/16 lunch 4/13/16 breakfast, lunch and dinner 4/14/16 breakfast, lunch and dinner 4/15/16 breakfast, lunch and dinner 4/17/16 breakfast and lunch 4/18/16 breakfast and lunch 4/19/16 breakfast, lunch and dinner Observations on the following dates: On 4/18/16 at 1:34 p.m., LPN #13 stated you better eat your lunch honey. No staff assisted Resident #130 to eat. On 4/18/16 at 1:37 p.m., Resident #130 pulling at clothing protector, picked up bread from plate, dropped it twice, hands were shaking, had not taken a bite of food. On 4/18/16 at 1:40 p.m., Resident #130 picked up bread and took one bite. On 4/18/16 at 1:47 p.m., Resident #130 was noted to be struggling to pick up bread and eat it, had shaking hands, tried to pick up fork and not able to hold fork in her hand. On 4/18/16 at 1:52 p.m. Resident #130 again tried to pick up the fork and dropped it on the tray and was unable to get a bite of food with the fork. On 4/18/16 at 2:00 p.m., Resident #130 tried to eat lasagna with a spoon and was unable to get a bite of the lasagna with the spoon. On 4/18/16 at 2:49 p.m., Resident #130 had picked up pieces of lasagna with her fingers and ate it. On 4/19/16 at 10:38 a.m., Resident #130 picked up food with her fingers and ate a bite. On 4/19/16 at 1:36 p.m., Resident #130 was sitting in a wheelchair at the dining table on unit and had food tray in front of her and not eating. On 4/19/16 at 1:43 p.m., Resident #130 picked up fork and moved fork around although not able to get a bite of food on fork. On 4/20/16 at 1:44 p.m., Resident #130 was sitting at table on the unit, was not eating and not getting assistance from staff. On 4/20/16 at 2:13 p.m., Resident #130 was still sitting at table, was not eating and no assistance from staff was given. On 4/20/16 at 2:34 p.m., Resident #130 was sitting at the table, food tray was in front of her, no staff was assisting. On 4/20/16 at 2:57 p.m., Resident #130 was sitting at the table, same food tray was in front of her, no staff or other residents were present at table. On 4/20/16 at 3:07 p.m., Resident #130 was sitting at the table, same food tray was in front of her on table. During an interview on 4/20/16 at 11:14 a.m., LPN#2 indicated residents only get monthly weights. During an interview on 4/22/16 at 8:57 a.m., the Registered Dietician #14 indicated she did not observe Resident #130 eat a meal. The Registered Dietician also indicated it is difficult to get an accurate picture of a resident's food consumption due to the electronic system only allows either a 1-25%, 26-50%,51-75% or 76-100% intake to be recorded. A policy titled Guidelines for Weight Tracking dated 11/07 received from the Director of Post Acute Services on 4/20/16 at 2:50 p.m. The policy indicated .to ensure resident weight is monitored for weight gain and/or loss to prevent complications arising from compromised nutrition/hydration .The facility dietician or representative will review the resident's nutritional status, usual body weight and current weight to implement a nutritional program when warranted .The physician, responsible party and dietician shall be notified of a weigh variance of > (greater than) 5% 3.1-46 (a)(1)

Based on record review and interview, the facility failed to assess a resident's pressure ulcer and follow the resident's plan of care causing the pressure ulcer to increase in size from a stage 2 to a Stage 4 for 1 of 3 residents review for pressure ulcers. (Resident B) Findings include: The clinical record for Resident B was reviewed on 3/17/16 at 10:00 a.m. [DIAGNOSES REDACTED]. Hospital wound notes, dated 2/7/16, indicated 3 wounds located on the resident's left buttocks and measured at 0.7 cm (centimeters) length by 2.5 cm width, 0.1 cm length by 2 cm width, and 0.1 cm length by 0.8 cm width. Facility nursing notes, dated 2/9/16, indicated the resident was admitted and was very weak. Required maximum assistance of 2 possibly 3 staff for turns. Needed a hoyer lift and physical therapy to get stronger. Clinical documentation, dated 2/10/16, indicated Resident B's skin was warm, dry and no other skin impairments Nursing notes, dated 2/16/16, indicated .Resident has not been transferred since being admitted due to lower back stenosis .Writer called to resident room to exam resident coccyx wound. Writer noted the top layer skin excoriated with red and bloody skin .Resident encouraged to turn side to side at least every two hours .Wound measures 13 cm x 8.5 cm x 1 cm in depth Physician orders, dated 2/16/16, indicated to start [MEDICATION NAME] ointment. Apply to coccyx area three times a day and as needed for soilage. Nursing notes, dated 2/24/16, indicated new order received for wound care referral. An appointment with the wound care clinic was scheduled. No measurements were evident in the nursing notes. Nursing notes, dated 2/29/16, indicated a dressing was changed to the coccyx wound. Skin was noted to be dark and nonblanchable. The Director of Health Services was called to assess the wound. A new order was received for [MEDICATION NAME] Extra alginate wound dressing to be applied everyday after cleaning with normal saline. No measurements were evident in the nursing notes. Nursing notes, dated 3/1/16, indicated a new order received for [MEDICATION NAME] to the coccyx wound three times a day. No measurements were evident in the nursing notes. Resident B's plan of care, dated 2/18/16, indicated the resident was identified as at risk for impaired skin integrity related to [MEDICAL CONDITION] and decreased mobility. Interventions included, but were not limited to, weekly skin assessments by nursing staff and if you notice any opened or persistently reddened areas on my skin, please tell my nurse so he/she can do an assessment and notify the doctor as needed. Notes from the wound clinic, dated 3/4/16, received on 3/17/16 at 4:07 p.m., indicated .1. Left buttock to sacrum. Length of wound: 13.5 cm. Depth of wound: unable to determine true depth as the ulcer is 100% covered in dry firm black eschar. Width of wound: 10.0 cm . 2. Right buttock to sacrum. Length of wound: 8.5 cm. Depth of wound: unable to determine true depth as the ulcer is 100% covered in dry firm black eschar. Width of wound: 7.0 cm . General Surgeon arrived to observe the patient's pressure ulcers and he agreed that the ulcers are severe and the patient needs surgery to debride the eschar and a plastics consult for surgery and flap future reconstruction is necessary During an interview on 3/17/16 at 3:00 p.m., with the Director of Post Acute Care Services, she indicated she was unable to located any other measurements for Resident B's coccyx wounds. Review of the facility policy, titled Pressure/Stasis/Diabetic Wound Condition Guidelines, no date, received from the Director of Post Acute Care Services on 3/18/16 at 11:15 a.m., indicated .Policy .4. Re-assessment/measurement weekly or with significant change in wound noting the current treatment, medical interventions provided and comments as needed This Federal tag relates to Complaint IN 552. 3.1-40(a)(1) 3.1-40(a)(2)