Every finding on record at St Elizabeth Healthcare Center

Based on interview and record review, the facility failed to ensure a PASARR (Preadmission Screening and Resident Review) was completed when the resident had a new mental health diagnosis added for 1 of 5 residents reviewed for PASARR. (Resident 24)Findings include:The clinical record for Resident 24 was reviewed on 3/6/26 at 10:20 a.m. The diagnoses included, but were not limited to, post-traumatic stress disorder (PTSD), bipolar disorder, cognitive communication deficit, borderline personality disorder, and anxiety disorder. A PASARR level II, dated 6/19/22, had the diagnosis of post-traumatic stress disorder (PTSD) handwritten on the document. During an interview, on 3/9/26 at 3:15 p.m., the Director of Nursing (DON) indicated Resident 24 had a diagnosis of PTSD. During an interview, on 3/11/26 at 10:40 a.m., the PASARR help desk indicated they did not have any records of Resident 24 having a diagnosis of PTSD on the PASARR level II, dated 6/19/22. Whenever a resident had a new mental health diagnosis added, a new PASARR level I needed to be completed, and it was not. The facility should have a new PASARR complete as soon as possible.During an interview, on 3/11/26 at 12:20 p.m., the Social Service Director (SSD) indicated when a resident had a new mental health diagnosis or mental health medication added, a new PASARR level I needed to be completed. The resident did not have a diagnosis of PTSD on her PASARR level II, dated 6/19/22, and she did not know why PTSD was handwritten on the PASARR. An Indiana PASARR document indicated .Change in status and Level II follow up .Social Services ensures paperwork is submitted. They will print out the outcome letter and upload.A PASARR policy was not provided by the facility prior to exit. 410 IAC (Indiana Administrative Code) 16.2-3.1-16(d)(1)(A)410 IAC (Indiana Administrative Code) 16.2-3.1-16(d)(1)(B)

Based on observation, interview and record review, the facility failed to ensure a comprehensive assessment, person-centered care plan, and physician's orders were implemented for the use of an assistive device with transfers for 1 of 1 resident reviewed for range of motion and mobility. (Resident 44)Findings include:The clinical record for Resident 44 was reviewed on 3/5/26 at 2:19 p.m. The diagnoses included, but were not limited to, displaced spiral fracture of the shaft of the right femur, venous insufficiency, moderate protein-calorie malnutrition, history of falls, fracture of the shaft of the left tibia and left fibula, difficulty walking, osteoporosis, disorders of bone density and structure, and osteoarthritis.A nursing progress note, dated 12/11/25 at 3:20p.m., indicated Resident 44 had returned to the facility from a hospital stay for a right femur fracture.A therapy recommendation, dated 12/12/25, indicated a slide board was placed in Resident 44's room. The recommendation indicated the slide board was to be used for transfers with two people and a gait belt. The slide board was to be placed towards the good leg (left).A quarterly Minimum Data Set (MDS) assessment, dated 12/31/25 at 2:21 p.m., indicated Resident 44 used a wheelchair and was dependent on staff for mobility and transfers.A quarterly MDS assessment, dated 2/20/26 at 8:00 p.m., indicated Resident 44 used a wheelchair and was dependent on staff for mobility and transfers.During an observation, on 3/9/26 at 2:02 p.m., Certified Nursing Assistant (CNA) 6 and Qualified Medication Aide (QMA) 7 transferred Resident 44 from a wheelchair to the bed using a gait belt and a slide board.The electronic medical record did not contain a physician's order or a comprehensive person-centered care plan for the use of a slide board for transfers.During an interview, on 3/9/26 at 2:43 p.m., the Director of Nursing (DON) indicated there was no physician's order or care plan in place for the use of a slide board with transfers.A current facility policy, titled Comprehensive Care Plan Guidelines, dated as last reviewed 5/22/18 and received from the Social Service Director on 3/11/26 at 12:22 p.m., indicated .to ensure appropriateness of services and communication that will meet the resident's needs, severity/stability of conditions, impairment, disability, or disease in accordance with state and federal guidelines .A comprehensive care plan will be developed.Comprehensive care plans need to remain accurate and current 410 IAC (Indiana Administrative Code) 16.2-3.1-42(a)(1)410 IAC (Indiana Administrative Code) 16.2-3.1-42(a)(2)

Based on interview and record review, the facility failed to ensure a resident received a medication timely according to the scheduled administration time and to ensure a resident had a physician's order in place for a non-pressure skin impairment for 2 of 3 residents reviewed for quality of care. (Resident 24 and 56) Findings include: 1. During an interview, on 3/5/26 at 10:21 a.m., Resident 24 indicated she did not always receive her medication on time. She had to turn her call light on, ask for her pills, and would have to wait a very long time. The clinical record for Resident 24 was reviewed on 3/6/26 at 10:20 a.m. The diagnoses included, but were not limited to, post-traumatic stress disorder (PTSD), osteoarthritis of the left shoulder, bipolar disorder, cognitive communication deficit, borderline personality disorder, and anxiety disorder. A care plan, dated 6/3/24, indicated Resident 24 had the potential for cardiovascular distress. Interventions included, but were not limited to, administer medications as ordered. A physician's order, dated 2/28/25, indicated to administer one half a tablet of isosorbide dinitrate (a nitrate medication used to prevent and manage chronic chest pain by relaxing the blood vessels) 30 milligrams (mg) twice a day. A Medication Administration Record (MAR) indicated the medication was scheduled to be administered at 8:00 a.m., and 6:00 p.m. The MAR indicated the medication was administered later than the scheduled administration time on the following dates and times: a. On 1/1/26, the 8:00 a.m. dose was administered at 9:52 a.m. The 6:00 p.m. dose was administered at 11:25 p.m. b. On 1/2/26, the 6:00 p.m. dose was administered at 8:23 p.m. c. On 1/3/26, the 6:00 p.m. dose was administered at 8:23 p.m. d. On 1/4/26, the 8:00 a.m. dose was administered at 11:39 a.m. The 6:00 p.m. dose was administered at 7:12 p.m. e. On 1/5/26, the 6:00 p.m. dose was administered at 8:08 p.m. f. On 1/6/26, the 6:00 p.m. dose was administered at 7:28 p.m. g. On 1/7/26, the 6:00 p.m. dose was administered at 7:49 p.m. h. On 1/10/26, the 6:00 p.m. dose was administered at 9:10 p.m. i. On 1/13/26, the 6:00 p.m. dose was administered at 9:02 p.m. During an interview, on 3/9/26 at 10:33 a.m., the Director of Nursing (DON) indicated the facility had an extended medication pass for most medications. If the resident had a medication scheduled at a certain time, the nurse would have one hour before and one hour after the pill was scheduled to administer the medication. During an interview, on 3/11/26 at 11:17 a.m., the Clinical Support Nurse indicated the nurse could administer a medication one hour before or after the scheduled medication time. During an interview, on 3/11/26 at 12:37 p.m., Registered Nurse (RN) 8 indicated the facility normally used an extended medication pass time. When a pill had a scheduled time assigned, the nurse would have one hour before and after to administer the medication. During an interview, on 3/11/26 at 12:43 p.m., the Assistant Director or Nursing (DON) indicated the facility used an extended medication pass. When a medication had a designated time, the nurse had one hour before and one hour after to administer the medication. 2. During an observation, on 3/5/26 at 11:09 a.m., Resident 56 had a one-inch white island dressing (a highly absorbent, non-adherent central pad surrounded by a breathable adhesive border) on her right temple which was initialed and dated 3/2/26. Old blood was visible through the dressing. During an observation, on 3/6/26 at 2:32 p.m., Resident 56 had a one-inch white island dressing on her right temple, dated 3/6/26. The dressing was clean. During an observation, on 3/9/26 at 11:35 a.m., Resident 56 had a one-inch white island dressing on her right temple, dated 3/8/26. During an observation, on 3/10/26 at 10:37 a.m., Resident 56 had a Band-Aid on her right temple. The resident indicated she did not like the island dressing and liked the Band-Aid better. The clinical record for Resident 56 was reviewed on 3/6/26 at 11:34 a.m. The diagnoses included, but were not limited to, myocardial infarction, pulmonary disease, long term use of anticoagulants, and adult failure to thrive. A care plan, dated 2/6/26, indicated the resident was at risk for skin breakdown. Interventions included, but were not limited to, treatments when ordered. A physician's order, initiated on 2/21/26 with an end date of 3/2/26, indicated to cleanse the temple wound with wound cleanser or normal saline, pat dry, apply skin prep and cover with a border dressing as needed if dislodged or soiled. The clinical record for Resident 56 did not contain a current physician's order related to the treatment of the right temple wound after 3/2/26. During an interview, on 3/9/26 at 10:24 a.m., the Director of Nursing (DON) indicated the wound care order was discontinued, on 3/2/26, and there was no current physician's order for treatment. During an interview, on 3/9/26 at 2:02 p.m., the DON indicated she removed Resident 56's dressing and had replaced it with a Band-Aid at Resident 56's request. She felt Resident 56 needed a treatment order continued and needed to contact the physician. A current facility policy, titled Dressing Changes, dated 12/16/24 and received from the DON on 3/10/26 at 9:25 a.m., indicated .Follow doctor's recommendations for treatment. 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on interview and record review, the facility failed to ensure a comprehensive person-centered care plan was developed and implemented for 1 of 2 residents reviewed for care plans. (Resident 24)Findings include:The clinical record for Resident 24 was reviewed on 3/6/26 at 10:20 a.m. The diagnoses included, but were not limited to, post-traumatic stress disorder (PTSD), bipolar disorder, cognitive communication deficit, borderline personality disorder, and anxiety disorder. A PASARR level II, dated 6/19/22, had a diagnosis of PTSD handwritten on the document. The clinical record indicated the diagnosis of post-traumatic stress disorder was added to the resident's diagnoses list on 5/5/24.There was no care plan located in Resident 24's electronic record related to post-traumatic stress disorder.During an interview, on 3/9/26 at 3:15 p.m., the Director of Nursing (DON) indicated the resident had a diagnosis of PTSD. During an interview, on 3/11/26 at 12:20 p.m., the Social Service Director (SSD) indicated Resident 24 did not have a care plan for PTSD and should have one. A current facility policy, titled Trauma Informed Care, dated 10/24/24 and received from the Clinical Support Nurse on 3/10/26 at 2:01 p.m., indicated .Facility will ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice to eliminate or mitigate triggers that may cause re-traumatization of the resident .Social services will update the care plan and resident profile with any trauma and cultural needs 410 IAC (Indiana Administrative Code) 16.2-3.1-35(a)410 IAC (Indiana Administrative Code) 16.2-3.1-35(b)(1)410 IAC (Indiana Administrative Code) 16.2-3.1-35(b)(2)

Based on interview and record review, the facility failed to ensure alternative food choices were offered to residents who chose to receive meals in their room for 3 of 3 residents reviewed for resident rights. (Resident 4, 40 and 41)Findings include:During an interview, on 3/5/26 at 2:04 p.m., Resident 4 indicated the alternative food choices offered on the menu were not available to residents who chose to eat their meals in their rooms. During an interview, on 3/9/26 at 11:47 a.m., Resident 40 indicated she chose to eat in her room and not eat in the dining room. She had to go to the dining room to pick up her meal and bring it back to the room herself in order receive food from the alternative menu. Resident 40 indicated this was a recent new change and she had not always had to do that.During an interview, on 3/9/26 at 11:51 a.m., Resident 41 indicated a new policy had recently been put in place and he was unable to receive food choices from the alternative menu unless he went to the dining room to eat for meals.During an interview, on 3/9/26 at 3:04 p.m., the Director of Nursing (DON) indicated the facility had a corporate policy titled All Day Dining. There was a corporate policy which indicated the residents, who chose to eat in their room, could not have the option for alternative menu choices. The corporate policy had been put in place about a year ago and this facility had activated it in January.During an interview, on 3/10/26 at 11:00 a.m., the Administrator indicated residents who chose to eat in their rooms could not receive an alternative to the meal unless they physically went to the dining room and picked up the alternative. If they were unable to propel themself to the dining room, someone would have to take them, or their family could obtain the alternate for the resident. The Administrator indicated there was no facility policy which indicated this process.During an interview, on 3/10/26 at 2:00 p.m., the Corporate Support Nurse indicated she had contacted their corporation and there was no dining policy in place related to the residents who chose to eat in their room not receiving the alternative menu options.During an interview, on 3/10/26 at 3:37 p.m., the Corporate Support Nurse indicated there was no policy related to not being able to receive a selection from the alternative menu if the residents chose to eat in their room. The process should not have been in place and needed to be fixed.A facility admission agreement, provided upon entrance to the facility, indicated the resident had the right to be free of interference, coercion, discrimination, and reprisal from the facility and had the right to make choices about aspects of his or her life in the facility that are significant to the resident.A policy related to alternative menu selections was not provided by the facility.410 IAC (Indiana Administrative Code) 16.2-3.1-3(a)(2)(c)410 IAC (Indiana Administrative Code) 16.2-3.1-3(t)410 IAC (Indiana Administrative Code) 16.2-3.1-3(u)(3)

Based on observation, interview and record review, the facility failed to ensure a physician's order for the use of oxygen was implemented for 1 of 1 resident reviewed for respiratory care. (Resident 62) Findings include:During an observation, on 3/6/26 at 10:03 a.m., Resident 62's oxygen concentrator (a device used to provide supplemental oxygen therapy) was set on 3 liters per minute (L). During an observation, on 3/6/26 at 9:38 a.m., the resident was receiving 2 L of oxygen. The clinical record for Resident 62 was reviewed on 3/6/26 at 10:03 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), Alzheimer's disease, major depressive disorder, and hypertension.A care plan, dated 6/18/24, indicated Resident 62 received oxygen therapy. Interventions included, but were not limited to, monitor oxygen saturation, monitor signs and symptoms of respiratory distress, and administer oxygen by nasal cannula as ordered.A physician's order was not implemented until after Resident 62 was observed receiving oxygen therapy.The physician's order, dated 3/6/26, indicated Resident 62 was to receive 2 L of oxygen continuously and staff could titrate to ensure oxygen saturations remained greater than 90% but not to exceed 4 liters without physician notification.During an interview, on 3/5/26 at 10:25 a.m., Resident 62's family indicated the resident had been on oxygen since being admitted to the facility on [DATE]. The resident had been short of breath and needed oxygen. During an interview, on 3/6/25 at 9:40 a.m., the Director of Nursing (DON) indicated the facility had noticed Resident 62 did not have an oxygen order and the liter flow was confirmed today. The resident had been on oxygen therapy since she was admitted to the facility on [DATE] and did not have an order. The resident needed a physician's order if the resident received oxygen therapy.A current facility policy, titled Administration of Oxygen, dated as last reviewed 12/13/24 and received from the DON on 3/6/26 at 9:47 a.m., indicated .Guidelines to properly Administering Oxygen and any Respiratory procedure .Verify physician's order for the procedure.410 IAC (Indiana Administrative Code) 16.2-3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure the care strategies to meet the individual needs of a resident who had a history of post-traumatic stress disorder (PTSD) were documented and implemented for 1 of 1 resident reviewed for post-traumatic stress disorder. (Resident 24)Findings include:The clinical record for Resident 24 was reviewed on 3/6/26 at 10:20 a.m. The diagnoses included, but were not limited to, post-traumatic stress disorder (PTSD), panic disorder, major depressive disorder, bipolar disorder, cognitive communication deficit, borderline personality disorder, and anxiety disorder. The clinical record indicated post-traumatic stress disorder was added to the resident's diagnoses list on 5/5/24.The clinical record did not contain a care plan related to post-traumatic stress disorder, the root cause, the triggers to watch for, or the interventions to implement in response to a trigger.Resident 24's profile care guide indicated Cultural Preferences and Trauma Triggers: There was no documentation after the statement to indicate what the cultural preferences or trauma triggers were. The care guide indicated the resident was care in pairs and male staff to remain out of the room if possible due to staffing.A care plan, dated 5/7/24, indicated Resident 24 was cognitively intact and was alert and oriented.A care plan, dated 5/13/24, indicated Resident 24 was at risk for adverse consequences related to receiving an antipsychotic medication for bipolar disorder. The care plan did not include the diagnosis or root cause of the post-traumatic stress disorder.A care plan, dated 5/16/24, indicated Resident 24 demonstrated inappropriate behaviors including: false accusations towards staff and stating staff did not administer medications. The care plan did not indicate if the inappropriate behaviors were related to the resident's diagnosis or root cause of the post-traumatic stress disorder.A care plan, dated 5/16/24, indicated Resident 24 had a diagnosis of bipolar and borderline personality disorder which was treated with antipsychotic medication. The care plan did not include the diagnosis or root cause of the post-traumatic stress disorder.A care plan, dated 5/16/24, indicated Resident 24 had a diagnosis of bipolar disorder and demonstrated altered mood, affect, and behaviors. The care plan did not include the diagnosis or root cause of the post-traumatic stress disorder.A care plan, dated 6/10/24, indicated Resident 24 demonstrated inappropriate behaviors including: sexually inappropriate talk or comments to staff. The care plan did not indicate if the inappropriate behaviors were related to the resident's diagnosis or root cause of the post-traumatic stress disorder.A care plan, dated 7/8/24, indicated Resident 24 demonstrated inappropriate behaviors including: having family bring in supplements, keeping them in her room, and not telling clinical staff. The care plan did not indicate if the inappropriate behaviors were related to the resident's diagnosis or root cause of the post-traumatic stress disorder.A care plan, dated 7/8/24, indicated Resident 24 demonstrated inappropriate behaviors including: repetitive complaints, refusal of care, negative statements, and only allowing certain staff in the room or to provide care. The care plan did not indicate if the inappropriate behaviors were related to the resident's diagnosis or root cause of the post-traumatic stress disorder.A care plan, dated 9/16/24, indicated Resident 24 demonstrated inappropriate behaviors including: self-determination of care, refusal to get out of bed, non-compliance with diet, non-compliance of medications, and refusal to let some staff enter her room to perform care. The care plan did not indicate if the inappropriate behaviors were related to the resident's diagnosis or root cause of the post-traumatic stress disorder.A care plan, dated 9/16/24, indicated Resident 24 demonstrated verbally abusive behaviors. The care plan did not indicate if the verbally abusive behaviors were related to the resident's diagnosis or root cause of the post-traumatic stress disorder.A care plan, dated 1/24/25, indicated Resident 24 demonstrated altered behaviors including visual hallucinations. The care plan did not indicate if the altered behaviors including visual hallucinations were related to the resident's diagnosis or root cause of the post-traumatic stress disorder.A care plan, dated 2/10/25, indicated Resident 24 demonstrated inappropriate behaviors including: refusing to allow staff to round at night and did not want to be woken to be changed. The care plan did not indicate if the behaviors were related to the resident's diagnosis or root cause of the post-traumatic stress disorder.A trauma screening tool was not completed until at least 9 months after the post-traumatic stress disorder was added to Resident 24's diagnosis list.The trauma screening tool, dated 2/21/25, indicated the resident had experienced a potential traumatic experience of PTSD. The screening indicated Resident 24 did not exhibit a substance abuse issue, an eating disorder, and was not fearful of others. She did not have overwhelming guilt or shame, did not have irritability, anger outbursts, or aggressive behavior, was not easily startled, frightened or fearful, and did not appear to be on guard for danger. No triggers or cultural trauma were voiced or identified. A referral was recommended but the resident denied services. The form indicated a care plan was implemented and included the trauma identified and the triggers which might re-traumatize the resident.During an interview, on 3/11/26 at 12:20 p.m., the Social Service Director indicated a trauma screening was not completed for Resident 24 prior to 2/21/25. During an interview, on 3/11/26 at 12:28 p.m., the Clinical Support Nurse indicated the facility was not trained on the trauma informed information until June of 2024.During an interview, on 3/11/26 at 12:29 p.m., the Social Service Director indicated a trauma screening was not completed when the resident's diagnosis was first added. A current facility policy, titled Trauma Informed Care, dated 10/24/24 and received from the Clinical Support Nurse on 3/10/26 at 2:01 p.m., indicated .will ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice to eliminate or mitigate triggers that may cause re-traumatization of the resident .This includes identifying triggers that may be stressors or cause re-traumatization to the resident .Information can be gathered by speaking with resident, family, POA, staff, and information provided by previous provider .Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being .Social services will complete the social history observation upon admission, annually, and with significant change which incorporates identifying trauma, triggers, and cultural preferences .Social services will update the care plan and resident profile with any trauma and cultural needs 410 IAC (Indiana Administrative Code) 16.2-3.1-43(a)(2)

Based on interview and record review, the facility failed to ensure staff had documented training prior to administering 2 step Mantoux skin tests for tuberculosis (TB) and all parts of the procedure were documented to ensure accuracy for 1 of 5 employees and 3 of 7 residents reviewed for infection control. (CNA 16, Resident 2, 20, and 50) Findings include: 1. A facility tuberculin testing for employees' form indicated CNA 16 was given a second step Mantoux test on 4/10/24 and read on 4/12/24. There was no documentation to indicate the time the second step test was given or read to ensure there was a 48-hour lapse before reading the test. 2. The clinical record for Resident 2 was reviewed on 5/1/25 at 11:49 a.m. The diagnoses included, but were not limited to, spina bifida with hydrocephalus, type 2 diabetes mellitus, paraplegia, cerebral palsy, major depressive disorder with psychotic symptoms, anxiety disorder, and neuromuscular dysfunction of bladder. A TB skin test record, dated 2/2/24, indicated LPN 3 administered the skin test. There was no documentation to indicate LPN 3 was trained to administer TB tests. 3. The clinical record for Resident 20 was reviewed for 5/2/25 at 9:47 a.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus with hyperglycemia, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, chronic diastolic congestive heart failure, dementia, and schizoaffective disorder bipolar type. A first step TB skin test record indicated the skin test was administered on 2/20/25 at 8:23 p.m., by RN 8. The skin test was read on 2/22/25 with no time recorded to indicate the time the second step test was read to ensure there was a 48-hour lapse before reading the test. There was no documentation to indicate RN 8 was trained to administer TB tests. A second step TB skin test record indicated the skin test was administered on 3/7/25 at 11:54 p.m., by RN 9. The skin test was read on 3/8/25 with no time recorded. The test was read before the 48 hours. There was no documentation to indicate RN 9 was trained to administer TB tests. 4. The clinical record for Resident 50 was reviewed on 5/1/25 at 2:26 p.m. The diagnoses included, but were not limited to, metabolic encephalopathy, Parkinson's disease, dementia, delirium, delusional disorders, major depressive disorder, anxiety disorder, depression, visual hallucinations, and hydrocephalus. A physician's order, dated 4/16/25, indicated to administer Aplisol (TB) solution intradermally (into the skin) on 4/16/25. The Medication Administration Record (MAR) indicated the skin test was administered late on 4/17/25 at 2:41 a.m., by RN 9. The skin test was read on 4/18/25. 48 hours had not passed before the test was read. There was no documentation to indicate RN 9 was trained to administer TB tests. During an interview, on 5/7/25 at 1:54 p.m., the Infection Prevention Nurse indicated 2 step TB tests should be completed upon admission for all residents. The test should be read between 48 and 72 hours after administration. The clinical record should have included the time the test was administered. The nurses who administer and read the tests must be trained. During an interview, on 5/7/25 at 1:54 p.m., the Director of Nursing (DON) indicated 2 step TB tests were required upon admission and should have been read within the 48-to-72-hour window to be considered valid. She indicated LPN 2, LPN 3, RN 5, LPN 6, RN 7, RN 8, and RN 9 did not have the required training to give or read TB tests. The facility could not verify if LPN 4 was certified because she was no longer in their system. A current facility policy, titled Mantoux Test Procedure, dated 12/16/24 and provided by the Clinical Support Nurse on 5/6/25 at 10:02 a.m., indicated .Record administration of Mantoux Test (date, time .) . Read the Mantoux Test results in 48-72 hours A current facility policy, titled Guidelines for TB Control Plan for Residents-Indiana, dated 4/2/24 and provided by the DON on 5/5/25 at 2:56 p.m., indicated .tuberculin skin test .administered by persons having documentation of training from a department approved program .Upon admission a baseline two-step TST shall be completed 3.1-18(e) 3.1-18(h)

Based on interview and record review, the facility failed to ensure the written reason for discharge and the bed hold policy with cost information was provided to the resident and resident's representative for 4 of 4 residents reviewed for hospitalization . (Resident 2, F, 23 and 27) Findings include: 1. The clinical record for Resident 2 was reviewed on 5/1/25 at 11:49 a.m. The diagnoses included, but were not limited to, cervical spina bifida, pressure ulcer, type 2 diabetes mellitus, paraplegia, hydrocephalus, cerebral palsy, major depressive disorder, anxiety disorder, neuromuscular dysfunction of the bladder, and mood affective disorder. A notice of transfer discharge, dated 4/30/25, indicated the reason for the discharge and the bed hold policy was included. The notice did not include any indication of the charges for holding the bed while the resident was discharged . The notice did not indicate Resident 2 was provided with a written copy of the notice or the bed hold policy information. A nursing progress note, dated 4/30/25 at 3:47 p.m., indicated the resident was taken to the hospital by emergency medical service (EMS) at 3:40 p.m., for suicidal ideation. The nursing note did not indicate any transfer or bed hold information given to Resident 2 by the facility. A nursing progress note, dated 4/30/25 at 3:23 p.m., indicated the resident notified staff of thoughts of suicide. The staff verbally notified the resident and resident's family of the plan to discharge to the hospital. During an interview, on 5/5/25 at 2:44 p.m., Resident 2 indicated he did not remember receiving a copy of the discharge information or bed hold policy. 44598 2. The clinical record for Resident F was reviewed on 5/1/25 at 11:46 a.m. The diagnoses included, but were not limited to, congestive heart failure, pulmonary edema, hypertension, diabetes mellitus, chronic kidney disease, dementia, depression, atrial fibrillation, and fibromyalgia. Resident F was transferred from the facility to the hospital on 1/2/25, 1/10/25 and 1/22/25. The documentation did not indicate a bed hold policy was given to the resident or responsible party. 3. The clinical record for Resident 23 was reviewed on 5/1/25 at 1:54 p.m. The diagnoses included, but were not limited to, Alzheimer's disease, diabetes mellitus, chronic obstructive pulmonary disorder, hypertension, depression, epilepsy, major depressive disorder, cardiomegaly, congestive heart failure, and dementia. Resident 23 was transferred from the facility to the hospital on 10/22/25, 3/25/25 and 4/22/25. The documentation did not indicate a bed hold policy was given to the resident or responsible party. 52091 4. The clinical record for Resident 27 was reviewed on 5/6/25 at 11:03 a.m. The diagnoses included, but were not limited to, displaced intertrochanteric fracture of left femur, pneumonitis due to inhalation of food and vomit, diabetes type 2, hypertension, depression, anxiety, dysphagia, pain, heart attack, stroke, and myalgia. A progress note, dated 4/29/25 at 11:35 a.m., indicated Resident 27 was sent to the emergency room for symptoms of a stroke. The record did not contain documentation to indicate Resident 27 or the resident's representative were given information in writing regarding the reason for the resident's transfer to the hospital or the facility's bed hold policy, including the facility's charge to hold a bed. During an interview, on 5/5/25 at 1:42 p.m., the Director of Nursing (DON) indicated the discharge paperwork was usually printed and sent to the hospital with the resident, but there was no specific indication in the chart the transfer form and the bed hold policy with charges were given to the residents and the residents' representative. During an interview, on 5/5/25 at 2:46 p.m., the Clinical Support Nurse indicated there was no documentation in the electronic health record to indicate the residents or the residents' representatives were given the bed hold policy. A current facility policy, titled Discharge/Transfer Notification Process Communicating Unplanned Discharges, dated 2/8/22 and received from the DON on 5/5/25 at 2:56 p.m., indicated .This communication must occur within 24 hours of receiving a 30-day notice, and/or PRIOR to conversation with families regarding internal service line transfers .If the campus is requesting a move out or choosing to change a resident's service level, communication must be sought A current facility policy, titled Bed Hold Policy, dated 2/1/11 and received from Director of Nursing on 5/5/25 at 11:00 a.m., indicated .the campus will properly inform residents in advance of their option to make bed-hold payments as well as the amount of the facility's charge to hold a bed . 3.1-12(a)(6)(A)(ii) 3.1-12(a)(6)(A)(iii) 3.1-12(a)(26)

Based on interview and record review, the facility failed to ensure staff obtained a follow-up weight to determine if a significant weight loss or gain had occurred and to document if a resident refused for 1 of 3 residents reviewed for nutrition. (Resident B) Findings include: The clinical record for Resident B was reviewed on 5/1/25 at 1:44 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, asthma, diabetes mellitus, morbid obesity, hypertension, major depressive disorder, post-traumatic stress disorder, major depressive disorder, panic disorder, bipolar disorder, anxiety disorder, and chronic pain. Resident B had the following weights: 1. On 11/2/24, the weight was 322.6 pounds. 2. On 12/16/24, the weight was 246.3 pounds. Resident B had a 23.65 % weight loss in 1 month. 3. On 1/1/25, the weight was 314.0 pounds. Resident B had a 27.49 % weight gain in 1 month. There was no documentation, between 11/1/24 to 5/7/25, of the significant gain or loss, no indication the resident was re-weighed, and no indication the physician, dietician, or family representative were notified. During an interview, on 5/6/25 at 2:39 p.m., the Clinical Support Nurse indicated the resident had refused some weights. The staff should attempt multiple times to obtain a resident's weight. During an interview, on 5/7/25 at 2:40 p.m., Licensed Practical Nurse (LPN) 11 indicated any staff member could weigh a resident. When a resident refused to be weighed, staff would attempt 1 or 2 more times to obtain the weight. Resident B was a mechanical lift weight. If the resident refused 3 times, management would be told. During an interview, on 5/7/25 at 2:41 p.m., Certified Nursing Assistant (CNA) 12 indicated when a resident refused to be weighed, she would inform the nurse, and the nurse would let management know. The nurse would normally get the resident to agree to be weighed, Resident B liked to be weighed before breakfast and CNA 12 did not know of anytime the resident refused. During an interview, on 5/7/25 at 2:46 p.m., Qualified Medical Assistant (QMA) 13 indicated Resident B did not normally refuse to be weighed. Resident B had never refused care when she asked. If a resident refused to be weighed, she would attempt multiple times and then inform management. During an interview, on 5/7/25 at 2:48 p.m., QMA 14 indicated she would attempt 2 or 3 times to obtain a weight. If a resident refused, she would tell management. During an interview, on 5/7/25 at 2:55 p.m., the Clinical Support Nurse indicated the facility did not have a documentation policy and they followed the state guidelines. A current facility policy, titled Guidelines for Weight Tracking, dated 12/17/24 and received from the Clinical Support Nurse on 5/6/25 at 2:39 p.m., indicated .Residents who have a weight that seem out of normal range shall be re-weighed to determine the accuracy of the original weight .The physician, resident representative and dietitian shall be notified of a weight variance of 5% in 30 days, 7.5% in 90 days, and 10% in 180 days. (Unless on a planned weight loss or gain program) A current facility policy, titled Clinical Services-Weight Management, dated 12/20/24 and received from the Clinical Support Nurse on 5/6/25 at 2:39 p.m., indicated .Review of error weights, daily, in CCM .Re-weights as needed .Correct weights as needed .Invalidate weights as needed 3.1-46(a)(1)

Based on interview and record review, the facility failed to ensure resident council concerns and grievances were resolved for 3 of 5 residents reviewed for resident council concerns. (Resident 28, 37 and B) Findings include: A meeting with the resident council was conducted on 5/5/25 at 10:01 a.m. The residents in attendance indicated call light wait times had been an ongoing concern. The resident council meeting minutes were reviewed and indicated: a. On 2/24/25, the residents indicated the call light waiting time was long. b. On 3/19/25, the residents indicated the call light response time remained untimely. The call light concerns from 2/24/25 were included with no resolution. c. On 4/21/25, the residents indicated there were concerns with the call lights being answered in a timely manner. The call light concerns from 3/19/25 were included with no resolution. 1. During an interview, on 4/30/25 at 10:34 a.m., Resident B indicated she had laid in her feces and urine before and there had been times when Resident B waited over an hour before someone cleaned her up. It could take anywhere from 30 minutes to over an hour for someone to answer the call light and provide care. The call lights continued to be an ongoing issue. 2. During an interview, on 5/5/25 at 10:01 a.m., Resident 28 indicated call lights could take up to 30 minutes before being answered and had been an issue for a while now. 3. During an interview, on 5/5/25 at 10:02 a.m., Resident 37 indicated call light wait times were an ongoing problem. During an interview, on 5/1/25 at 3:00 p.m., the Clinical Support Nurse provided a general form which indicated the names of the residents who had filled out a grievance, but no evidence of specific concerns or resolution. The Clinical Support Nurse indicated the grievances/concerns forms were filled out in a program on the computer and she could not print an individual form from the program with the information. During an interview, on 5/5/25 at 10:05 a.m., the Activity Director indicated she helped the residents fill out grievances/concerns forms. Management reviewed the concerns. Management has been invited to resident council meetings to address the concerns. 44598 During an interview, on 5/8/25 at 3:03 p.m., the Director of Nursing (DON) indicated the facility had completed call light audits. Call light audits from 4/1/25 to 4/29/25 were the only audits the facility could provide. A current facility policy, titled Resident Council, dated 6/2/16 and received from Director of Nursing (DON) 5/7/25 at 4:30 p.m., indicated .The Resident Council structure and process including staff liaison designation will be established with the residents .Residents are informed of council meetings and are encouraged to utilize the complaint resolution process .Minutes of the meeting will be recorded and maintained for a least 2 years. Minutes will not disclose specific individuals who voice concerns about the Campus. The group facilitator will determine the prevalence of the concerns/recommendations voiced to determine appropriate follow-up. The group's grievances and recommendations will be brought to the attention of the Executive Director who will forward the concerns to the appropriate department leader for attention and response. Responses regarding resolutions will be documented, reviewed by the Executive Director and kept with Resident Council minutes .Actions taken and/or considerations given to issues will be reported back to the Resident Council at the next meeting A current facility policy, titled Resident Concern Process, dated 11/13/19 and received from DON on 5/7/25 at 4:30 p.m., indicated .To provide a process of handling, tracking and resolving customer concerns to provide excellence in customer service .The facility staff will follow these basic steps in responding to a complaint: Listen to the concern without interruption .Take steps to correct the problem. Make the problem their own by following up to make sure it is resolved and stays resolved .Concerns are reviewed in morning meeting, noting new entries and assigning them for follow up and resolution .The Executive Director will review and manage the follow up of the concerns .The QAPI team will review the trends of the concerns and the action plans to resolve concerns on a monthly basis A current policy, titled Your Rights and Protections as a Nursing Home Resident, not dated and received from the Executive Director at entrance indicated .Make Complaints: You have the right to make a complaint to the staff of the nursing home, or any other person, without fear of punishment. The nursing home must address the issue promptly This citation relates to Complaint IN00452657. 3.1-3(l)

Based on observation, interview and record review, the facility failed to ensure staff followed infection control standards related to handwashing during food service, following enhanced barrier precautions during wound care, during incontinence care, for urinary catheters, for storing linens and clothes in rooms, and disposing of soiled linens for 6 of 6 staff and 3 of 3 residents randomly observed for infection control practices. (Assistant Food Director, Guest Relations 5, Director of Health Services, RN 6, QMA 2, Resident 40, Resident 5, Resident 149 and CNA7) Findings include: 1. During an observation, on 4/15/24 at 12:12 p.m., the Assistant Food Director served a plate of food to a resident without washing his hands between serving plates. During an observation, on 4/15/24 at 12:15 p.m., the Assistant Food Director served a plate of food to a resident without washing his hands between serving plates. During an observation, on 4/15/24 at 12:17 p.m., the Assistant Food Director served a plate of food to a resident without washing his hands between serving plates. During an observation, on 4/15/24 at 12:21 p.m., the Assistant Food Director served a plate of food to a resident without washing his hands between serving plates. During an observation, on 4/18/24 at 12:19 p.m., Guest Relations 5 was waving her apron towards her face as a fan and scratched her arm while she was waiting to serve food. During an observation, on 4/18/24 at 12:23 p.m., Guest Relations 5 served a plate of food to a resident without washing her hands. During an interview, on 4/18/24 at 12:28 p.m., the Assistant Food Director indicated he did notice he was not washing his hands between serving plates and he should have been washing his hands. Staff should also not touch their arms or surfaces before delivering trays. 2. During an observation, on 4/18/24 at 2:43 p.m., the DHS (Director of Health Services) and RN 6 went to complete wound care for Resident 2 who had a stage 3 or 4 pressure wound, a urinary catheter, and was in enhanced barrier precautions. The DHS and RN 6 walked into the room and put on gloves. They completed wound care and then changed the resident's brief, handling the resident's catheter tubing in the process. The DHS and RN 6 did not have a gown on during wound care. The clinical record for Resident 2 was reviewed on 4/18/24 at 3:00 p.m. The diagnoses included, but were not limited to, stage 3 pressure ulcer of the left buttocks, unstageable pressure ulcer of the sacral region, paraplegia, and osteomyelitis. A physician's order, with a start date of 4/1/24, indicated staff were to use enhanced barrier precautions, wearing gloves and a gown at a minimum during high-contact care activities. During an interview, on 4/18/24 at 3:06 p.m., the DHS indicated they should have put on gowns on for enhanced barrier precautions. 36454 3. During an observation of incontinence care for Resident 21, on 4/15/24 at 1:43 p.m., Qualified Medication Aide (QMA) 2 wiped the resident's peri-area with a disposable wipe. QMA 2 did not remove her gloves. She then pulled up the resident's blankets and tucked them in around her neck and chest area and handed the resident her touch pad call light. She had touched the blankets and the call light with the same gloves she used to wipe the resident's peri-area. During an interview, on 4/15/24 at 1:53 p.m., QMA 2 indicated she did not realize she had left the same gloves on and touched the resident's blankets and call light. The DNS was present and QMA 2 and the DNS walked away and did not go back into the resident's room to sanitize the touch pad call light. 44598 4. During an observation, on 4/15/24 at 11:32 a.m., Resident 40's catheter bag was laying on the floor. During an interview, on 4/15/24 at 11:38 a.m., the Executive Director indicated the catheter bag was not to be on the floor and she would get someone to assist the resident. 5. During an observation, on 4/15/24 at 11:49 a.m., Resident 5 had two pillows, a blanket, and one blue sock on the floor next to the bed. In the recliner next to the resident's bed, there were folded linen sheets, a quilt, a shirt, a gown, a blanket and two blue cushions. During an interview, on 4/15/24 at 11:54 a.m., CNA 8 indicated the pillows, the blanket, and the sock should not be on the floor and the other items should not be stored on the chair. 6. During an observation, on 4/15/24 at 11:58 a.m., Resident 149 had a soaked brief laying on the resident's bed. During an interview, on 4/15/24 at 11:47 a.m., the Minimum Data Set (MDS) Coordinator indicated she did not know why the brief was on the resident's bed. The resident was dependent on all incontinence care and the dirty brief should not have been left on the resident's bed. 7. During an observation, on 4/15/24 at 3:08 p.m., CNA 7 exited room [ROOM NUMBER] carrying a large amount of rolled up linen not in a bag down the 500 hall. The linen was touching the staff's left side while she carried the linen. CNA 7 then entered room [ROOM NUMBER] and left the room with the linen in a trash bag. During an interview, on 4/15/24 at 3:10 p.m., CNA 7 indicated she had just finished changing a resident and forgot to put the linen in a trash bag and she probably should not be carrying dirty linens down the hall without being in a trash bag. A current policy, titled Enhanced Barrier Precautions (EBP) Standard Operating Procedure, dated as approved 4/1/24 and received from the Clinical Support Nurse on 4/18/24 at 5:00 p.m., indicated .Enhanced Barrier Precautions (EBP) will be in place during high-contact care activities for residents with the following conditions: a. Residents at an increased risk of MDRO acquisition which include i. All Residents with chronic wounds, including but not limited to, pressure ulcers .All residents with indwelling medical devices 1. Includes but not limited to: catheters .At minimum, staff shall wear gloves and gowns during high-contact care activities A current policy, titled Preserving Dignity with Indwelling Catheter, dated as revised 4/19/24 and received from the Executive Director on 4/19/24 at 4:55 p.m., indicated .Urinary drainage bags and catheter tubing should be kept from touching the floor surface A current policy, titled Guidelines for Handwashing/Hand Hygiene, dated as revised 2/9/17 and received from the Executive Director on 4/19/24 at 4:55 p.m., indicated .All health care workers shall utilize hand hygiene frequently and appropriately .Health Care Workers (HCW) shall utilize hand hygiene at times such as: Reporting to work; before/after eating .Before/after preparing/serving meals, drinks, tube feedings, etc .before/after having direct physical contact with residents .After removing gloves worn per Standard Precautions for direct contact with excretions or secretions, mucous membranes A current policy, titled Perineal Care for Incontinence, dated as revised 11/9/17 and received from the Executive Director on 4/16/24 at 10:38 a.m., indicated .Residents may be cleaned using washcloths, wet wipes or dry wipes .Pay particular attention to infection prevention and control techniques when performing peri care, to prevent introduction of contamination that may lead to a urinary tract infection 3.1-18(b)(1) 3.1-18(l)

Based on observation, interview and record review, the facility failed to ensure oxygen tubing was dated, oxygen canisters were filled, and the oxygen was set on the flow liter as ordered by the physician for 3 of 4 residents reviewed for respiratory care. (Resident 23, 31 and 20) Findings include: 1. During an observation, on 4/16/24 at 11:06 a.m., Resident 23's oxygen (02) was set at 3 liters per minute by nasal cannula and there was no date on the tubing. The resident indicated her 02 was supposed to be set at 3 liters per minute. During an interview, on 4/16/24 at 11:08 a.m., Qualified Medication Aide (QMA) 2 indicated the oxygen tubing was not dated. During an observation, on 4/18/24 at 3:31 p.m., with the Clinical Support Nurse, Resident 23's 02 was set at 1.5 liters. During an interview, on 4/18/24 at 4:02 p.m., the Clinical Support Nurse indicated the resident's 02 was to be set at 2 liters during the day and 3 liters at night. The 02 should have been set at 2 liters instead of the 1.5 liters or 3 liters. The clinical record for Resident 23 was reviewed on 4/17/24 at 11:40 a.m. The diagnoses included, but were not limited to, chronic congestive heart failure, chronic obstructive pulmonary disease, chronic respiratory failure, shortness of breath, sarcoidosis (an inflammatory disease which affects the lungs), cerebral infarction, and dependence on supplemental oxygen. A care plan, dated 3/26/24 and last reviewed on 4/16/24, indicated the resident had a potential for shortness of breath related to the chronic obstructive pulmonary disease and required supplemental oxygen to maintain 02 saturations. The approaches included, but were not limited to, administer 02 as ordered by the medical doctor. A care plan, dated 3/26/22 and last reviewed on 3/28/24, indicated the resident had a potential for complications related to congestive heart failure. The approaches included, but were not limited to, oxygen as ordered by the medical doctor. A physician's order, dated 1/19/23 and open ended, indicated to change the 02 tubing monthly on the first day of the month. A physician's order, dated 3/8/23 and open ended, indicated 02 at 3 liters during the night. A physician's order, dated 4/16/24 and open ended, indicated 02 at 2 liters per nasal cannula continuous. 49891 2. During an observation, on 4/15/24 at 12:45 p.m., Resident 31 was wearing oxygen tubing connected to an empty portable oxygen tank. During an interview, on 4/15/24 at 12:49 p.m., CNA 10 indicated the portable tank was empty and the resident relied on supplemental oxygen. CNA 10 indicated she would fill up the tank. During an observation, on 4/16/24 at 10:28 a.m., the portable oxygen tank for Resident 31 was empty and the flow rate dial was set on 2.5 liters while he was sitting in the activities room in his reclining wheelchair (Broda chair). The nurse was notified. LPN 9 took the portable oxygen tank off Resident 31's Broda chair and refilled tank. LPN 9 returned the refilled portable oxygen tank to Resident 31 and reconnected the oxygen tubing. The flow rate remained at 2.5 liters of oxygen. During an observation, on 4/16/24 at 3:53 p.m., the oxygen tubing was not dated, and the flow rate was set at 3 liters. During an observation, on 4/17/24 at 3:31 p.m., Resident 31 was in bed, the oxygen tubing was not dated, and the flow rate was set at just under 3 liters of oxygen. During an observation, on 4/18/24 at 10:07 a.m., Resident 31 was asleep in his Broda chair in the activities room with the portable oxygen tank dial set at a flow rate of 2.5 liters. During an observation, on 4/18/24 at 2:36 p.m., Resident 31 was asleep in his room with the oxygen set on a flow rate of 2.5 liters. The clinical record for Resident 31 was reviewed on 4/18/24 at 12:22 p.m. The diagnoses included, but were not limited to, pneumonia, type 2 diabetes mellitus, chronic anemia, dementia, pleural effusion, atelectasis (partial collapse or closure of part of the lung), and diastolic congestive heart failure. A physician's order, dated 3/26/24, indicated 2 liters of continuous oxygen. A care plan, dated 4/16/24, indicated the resident required supplemental oxygen to maintain oxygen saturation. Interventions included, but were not limited to, administering oxygen per the physician's order. During an interview, on 4/18/24 at 10:23 a.m., LPN 1 indicated Resident 31 was on 2 to 3 liters of oxygen, only the nurses were allowed to adjust the oxygen flow rate, and the rate was to be set on the flow rate ordered by the physician. 3. During an observation, on 4/16/24 at 10:04 a.m., Resident 20's oxygen was at a flow rate of 5 liters with extended tubing which was not labeled with a date. During an observation, on 4/16/24 at 4:15 p.m., Resident 20 was wearing oxygen at a flow rate of 4 liters via nasal canula tubing which was not labeled with a date. During an observation, on 4/17/24 at 10:10 a.m., Resident 20 was wearing oxygen at a flow rate of 5 liters. During an observation, on 4/17/24 at 3:28 p.m., Resident 20 continued to wear oxygen at a flow rate of 5 liters. During an interview, on 4/17/24 at 10:10 a.m., Resident 20 indicated he would ask staff to turn up his oxygen when he was having trouble breathing, which happened a lot. The clinical record for Resident 20 was reviewed on 4/17/24 at 4:56 p.m. The diagnoses included, but were not limited to, type 2 diabetes, morbid obesity, chronic respiratory failure, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), paroxysmal atrial fibrillation, anxiety, cardiomegaly, dependence on continuous supplemental oxygen, pneumonia, pulmonary edema, and anemia. A profile care guide in the resident's care plan, dated 7/21/23, indicated an intervention of oxygen at 3 liters. A physician's order, dated 4/7/24, indicated 3 liters of continuous oxygen. During an interview, on 4/18/24 at 10:23 a.m., LPN 1 indicated Resident 20's oxygen order prior to his last hospital visit was for 3 to 5 liters for his comfort. LPN 1 indicated she did not realize it had changed to 3 liters. A current policy, titled Administration of Oxygen, dated as approved on 5/2018 and received from the Clinical Support Nurse on 4/18/24 at 1:30 p.m., indicated .Verify physician's order for the procedure .Date the tubing for the date it was initiated .Adjust the oxygen delivery device so that .the proper flow of oxygen is administered 3.1-47(a)(6)

Based on observation, interview and record review, the facility failed to assess and document the progress of a non-pressure skin wound, to assess and document the skin condition of a resident with a splint in place, to notify the physician when blood sugar readings were elevated, failed to follow the physician's orders for medications and to notify the physician per the physician's order for 5 of 5 residents reviewed for quality of care. (Resident 23, 37, 31, 29 and 16) Findings include: 1. During an observation, on 4/16/24 at 11:13 a.m., Resident 23 had a bandage on her right and left elbows and another bandage on her left forearm. She indicated the bandages on the elbows were used as a preventative. She had an area of open skin on the left forearm. The clinical record for Resident 23 was reviewed on 4/17/24 at 11:40 a.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus with diabetic neuropathy, depression, chronic obstructive pulmonary disease, and congestive heart failure. A progress note, dated 2/25/24 at 7:33 p.m., indicated the resident had an open area on her left arm which measured 3.1 centimeter (cm) in length and 2 cm in width. A physician's order, dated 2/26/24, indicated to clean the left forearm skin tear with cleanser or normal saline, apply skin prep to the peri wound, apply aquacel AG (an antimicrobial wound dressing) to the wound bed and to cover with a foam dressing every 5 days. The electronic health record (EHR) had no documentation of the open skin area since 2/25/24. During an interview, on 4/17/24, the Director of Nursing Services (DNS) indicated the resident had a skin issue which was caused from a hospitalization . She was not sure if the EHR had any documentation about the skin area after the initial measurements were entered on 2/25/24. During an interview, on 4/19/24 at 2:41 p.m., the DNS indicated she measured the left forearm wound two days ago and put in a late note. The wound should have been assessed and measured weekly since 2/25/24 when it was identified, and it had not been measured. 2. During an observation, on 4/16/24 at 12:04 p.m., Resident 37 had a left hand/wrist splint device in place which was wrapped with an elastic bandage. The resident's left wrist, hand and fingers were swollen. The resident indicated she broke her hand, and it was hurting. During an observation, on 4/17/24 at 11:25 a.m., the resident's left hand and fingers remained swollen. The clinical record for Resident 37 was reviewed on 4/18/24 at 2:09 p.m. The diagnoses included, but were not limited to, unspecified dementia without behavioral disturbance and hypertensive heart disease with heart failure. A physician's order, dated 4/8/24, indicated to monitor for blanching, color and odor related to the non-removable splint/cast three times a day. The electronic health record (EHR) did not have any documentation of edema for the resident's left wrist, hand, and fingers. During an interview, on 4/18/24 at 3:11 p.m., the Executive Director (ED) indicated the resident had self-ambulated in the hallway, had an unwitnessed fall, and sustained a fracture of the left radius (one of two bones of the forearm). During an interview, on 4/19/24 at 3:04 p.m., the DNS indicated the resident was followed by the orthopedic physician. She could not find documentation about the resident's swollen fingers and hand. The facility did not have any notes from the orthopedic physician. There was no care plan in place for the resident's fracture. During an observation with the DNS, on 4/19/24 at 3:27 p.m., the resident was lying in bed in her room. The resident's left hand and left fingers were very swollen. There was an open area on the left hand near the thumb which was about the size of a dime. The DNS indicated an edema event should have been initiated in the EHR and the open skin should have been measured and documented in the EHR. The DNS could not find any documentation in the EHR about the swelling. 49891 3a. The clinical record for Resident 31 was reviewed on 4/18/24 at 12:22 p.m. The diagnoses included, but were not limited to, pneumonia, type 2 diabetes mellitus, chronic anemia, dementia, pleural effusion, atelectasis (partial collapse or closure of part of the lung), and diastolic congestive heart failure. A care plan for Resident 31, dated 3/27/24, indicated the resident was at risk for hypo/hyperglycemia related to diabetes mellitus. A long-term goal indicated the resident would be free of symptoms of hypo/hyperglycemia through the next review. A physician's order, dated 3/8/24, indicated insulin Aspart U-100 per sliding scale and to call MD if blood sugar was greater than 400 mg/dL. A progress note, dated 3/8/24 at 5:20 p.m., indicated Resident 31 had a blood glucose level of 591 prior to dinner. The physician was called and gave a new order for NovoLog 6 units now and to recheck the blood glucose in 2 hours. If the repeat blood sugar was in normal range, the nurse did not need to call the provider. A vitals record, dated 3/8/24 at 4:49 p.m., indicated a blood sugar of 591 mg/dL. A vitals record, dated 3/8/24 at 7:52 p.m., indicated a blood sugar of 460 mg/dl. The listed acceptable (normal) range was 45-300 mg/dl. A vitals record dated 3/8/24 at 9:18 p.m. indicated a blood sugar of 460 mg/dl. The listed acceptable (normal) range was 45-300 mg/dl. The electronic medical record did not contain any physician notifications for the repeat blood sugars. During an interview, on 4/18/24 at 1:30 p.m., the Clinical Support Nurse indicated the facility could not provide any documentation of the physician notification of the abnormal repeat blood sugars of 460 mg/dL. 3b. A physician's order, dated 2/29/24 and discontinued 3/8/24, indicated Novolin 70-30 FlexPen (insulin nph and regular human) give 8 units subcutaneous each morning and 3 units each evening. A physician's order, dated 3/8/24 and discontinued 3/19/24, indicated Levemir FlexPen (insulin detemir u-100) insulin pen give 10 units subcutaneous twice a day. The electronic medical record did not contain hold orders for the Novolin 70-30 or the Levemir. A vitals record, dated 3/7/24 at 10:57 a.m., indicated a blood sugar of 349 mg/dL. The acceptable range listed was 45-300 mg/dL. A vitals record, dated 3/7/24 at 4:38 p.m., indicated a blood sugar of 286 mg/dL. The Medication Administration Record (MAR) for Resident 31 indicated the Novolin 70-30 insulin was held on 3/7/24 in the morning and the evening due to poor intakes. The MAR for Resident 31 indicated the Novolin 70-30 insulin was held on 3/8/24 in the morning due to poor intakes. The electronic medical record did not contain any physician notifications for the held insulin. During an interview, on 4/19/24 at 12:02 p.m., LPN 1 indicated she was not sure when or if 70/30 or Levemir should be held if there was not a specific order. She would look it up with her resources or ask the physician before holding it. The physician should be notified if a medication was held. During an interview, on 4/18/24 at 1:30 p.m., the Clinical Support Nurse indicated the facility could not provide any documentation of the physician notification for the held insulin. The endocrinology textbook chapter by [NAME] J Rushakoff, MD in Inpatient Diabetes Management (01/07/19) from https://www.ncbi.nlm.nih.gov/books/NBK278972/, accessed on 04/19/24, indicated basal insulin, such as Novolin 70-30 and Levemir, was needed even when a patient was not eating. 4. The clinical record for Resident 29 was reviewed on 4/16/24 at 3:52 p.m. The diagnoses included, but were not limited to, type 2 diabetes with diabetic chronic kidney disease, acute kidney failure, and atrophy (wasting away) of the kidney. A physician's order, with a start date of 5/23/23 and an end date of 7/26/23, indicated the resident received insulin glargine (insulin which works over a longer period of time) 12 units before breakfast. Hold the insulin if the blood sugar was less than 150. Resident 29's MAR (Medication Administration Record) indicated the following blood sugars: a. On 7/3/24, the blood sugar was 139. Insulin was administered. b. On 7/4/24, the blood sugar was 124. Insulin was administered. c. On 7/7/24, the blood sugar was 138. Insulin was administered. d. On 7/8/24, the blood sugar was 146. Insulin was administered. e. On 7/11/24, the blood sugar was 112. Insulin was administered. f. On 7/13/24, the blood sugar was 148. Insulin was administered. g. On 7/14/24, the blood sugar was 137. Insulin was administered. h. On 7/15/24, the blood sugar was 148. Insulin was administered. During an interview, on 4/18/24 at 10:47 a.m., the DHS (Director of Health Services) indicated they should not have administered the insulin. 5a. The clinical record for Resident 16 was reviewed on 4/17/24 at 9:42 a.m. The diagnoses included, but were not limited to, long term current use of insulin, bradycardia (slow heart rate), paroxysmal atrial fibrillation, ventricular premature depolarization, and type 2 diabetes mellitus. A physician's order, dated 7/9/21, indicated digoxin tablet (used to treat heart failure and heart rhythm problems), give 125 micrograms (mcg) every other day, with special instructions to hold the medication if her pulse was less than 60 and to notify the physician. The Medication Administration Record (MAR) indicated, on 3/19/24, Resident 16's pulse was 51 and the digoxin tablet was given. The MAR indicated, on 4/12/24, Resident 16's pulse was 56 and the digoxin tablet was given. The MAR indicated the digoxin was held due to a pulse rate less than 60 on 3/23/24, 3/31/24, and 4/14/24. The clinical record did not indicate the provider was notified of the pulse rate less than 60 or when the digoxin was given and not given according to the physician's order. During an interview, on 4/18/24 at 10:27 a.m., LPN 1 indicated staff would call or notify the physician in person for an abnormal vital sign, blood sugar, or if a medication was held. The staff should notify the provider as soon as they could. During an interview, on 4/18/24 at 1:30 p.m., the Clinical Support Nurse indicated the facility could not provide any documentation of the physician notification of the heart rate or the medication being held. 2b. A physician's order, dated 1/15/24, indicated insulin aspart U-100 insulin pen, give 5 units subcutaneous prior to meals, with special instructions to hold if the blood sugar was less than 110 mg/dL. The MAR, dated 3/19/24, indicated 5 units of insulin were given at breakfast with a blood sugar of 105 at 7:05 a.m. The MAR, dated 3/26/24, indicated 5 units of insulin were given at breakfast with a blood sugar of 83 at 7:17 a.m. The MAR, dated 3/27/24, indicated 5 units of insulin were given at breakfast with a blood sugar of 108 at 7:48 a.m. A current policy, titled Bruise, Rash, Lesion, Skin Tear, Laceration Assessment Guidelines, dated as revised on 5/10/16 and received from the Executive Director on 4/19/24 at 4:00 p.m., indicated .One weekly follow-up assessment may be completed to ensure rash/lesion is resolved, healing, or becomes a chronic skin condition. If further follow-up is needed, documentation may be placed in a progress note A current policy, titled Medication Administration- General Guidelines, dated as revised on 11/2018 and received from the Clinical Support Nurse on 4/18/24 at 1:30 p.m., indicated .Medications are administered in accordance with written orders of the prescriber A current policy, titled Physician-Provider Notification Guidelines, dated as reviewed on 12/31/23 and received from the Clinical Support Nurse on 4/18/24 at 1:30 p.m., indicated .To ensure the resident's physician or practitioner .is aware of all diagnostic testing results or change in condition in a timely manner to evaluate condition for need of provision of appropriate interventions for care Attempts to notify the physician/provider and their response should be documented in the resident electronic medical record 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure expired medications were removed from the medication cart and medications were labeled for 1 of 3 medication carts reviewed for medication storage. (500 back hall medication cart) Finding includes: During an observation, on 4/18/24 at 11:08 a.m., the 500 back hall medication cart had a partial bottle of Robitussin DM with an expiration date of 2/22/24, and a partial bottle of Geri tussin Liquid 100/5 with an expiration date of 3/18/24. The bottom drawer contained a partial bottle of Tums unlabeled, 2 tubes of Diclofenac sodium topical gel 1% unlabeled, and a partial bottle of Childrens Tylenol with a resident's name in marker and not labeled. During an interview, on 4/18/24 at 11:30 a.m., QMA 11 indicated she did not know what resident(s) were receiving the Tums and Diclofenac gel. The expired medications should have been removed. She took expired medications to the Director of Nursing Services for destruction. A current policy, titled Medication and Storage in the facility, received from the Clinical Support Nurse on 4/19/24 at 9:30 a.m., indicated .outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or with secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal A current policy, titled Medication Administration-General Guidelines, dated 11/2018 and received from the Clinical Support Nurse on 4/18/24 at 1:30 p.m., indicated .label, container and contents are checked for integrity, and compared against the medication administration record by reviewing the 5 rights .prior to administration of any medication, the medication and dosage schedule on the resident's medication administration record are compared with the medication label 3.1-25(l)(1) 3.1-25(o)

Based on interview and record review, the facility failed to ensure resident council concerns and grievances were addressed and the resolutions to the concerns/grievances were documented in the meeting minutes for 4 of 12 months reviewed for resident council meeting minutes. (July 2023, January 2024, February 2024, March 2024. Finding includes: During the resident council meeting, on 4/17/24 at 10:00 a.m., the residents indicated the call lights continued to be an ongoing concern. The resident council meeting minutes were reviewed and indicated the following: a. On 7/14/23, there were concerns voiced with the call light response times. The resident council meeting minutes, dated 8/14/23, did not indicate the call light concerns from 7/14/23 were discussed and no resolution was included in the meeting minutes. b. On 1/15/24, there were concerns voiced about the call light response times at night being extended. c. On 2/19/24, there were concerns voiced about the call lights in the evening. The minutes did not include the call light concerns from 1/15/24 were reviewed or resolved. d. On 3/18/24, 1 of 2 residents indicated there were still concerns about the call lights. The minutes did not include the call light concerns from 2/19/24 were reviewed or resolved. e. On 4/15/24, the minutes did not include the call light concerns from 3/18/24 were reviewed or resolved. During an interview, on 4/17/24 at 10:09 a.m., Resident 28 indicated she had to put her call light on several occasions for her roommate. The call light would stay on for an hour or more. The call lights have continued to be an ongoing issue. During an interview, on 4/17/24 at 10:11 a.m., Resident 41 indicated the call lights would stay on for 30 minutes to 1 hour before they were answered. There were times the lights were not answered, and she would provide her own care. During an interview, on 4/17/24 at 10:20 a.m., Resident 3 indicated during several resident council meetings the call lights concerns were discussed. The resident considered his call light as his lifeline and there were times the staff would exit the room without making sure the call light was within his reach. During an interview, on 4/18/24 at 10:39 a.m., the Activity Director indicated she helped the residents fill out the grievances when they had a concern, and she did not know why the call light concerns had not been addressed. During an interview, on 4/18/24 at 3:10 p.m., the Director of Nursing Services (DNS) indicated she did not have documentation call light audits were completed. A current policy, titled Resident Council, dated 6/2/16 and received from Executive Director on 4/19/24 at 4:53 p.m., indicated .Patients are informed of council meetings and are encouraged to utilize the complaint resolution process .The group facilitator will determine the pervious of the concerns/recommendations voiced to determine appropriate follow-up. The group's grievances and recommendations will be brought to the attention of the Executive Director who will forward the concerns to the appropriate department leader for attention and response. Responses regarding resolutions will be documented, reviewed by the Executive Director, and kept with Resident Council minutes .Actions taken and/or considerations given to issues will be reported back to the Resident Council at the next meeting. A current policy, titled Your Rights and Protections as a Nursing Home Resident, not dated and received from Executive Director at entrance indicated .Make Complaints: You have the right to make a complaint to the staff of the nursing home, or any other person, without fear of punishment. The nursing home must address the issue promptly A current policy, titled Resident Concern Process, dated 11/13/19 and received from Executive Director on 4/19/24 at 4:59 p.m., indicated .To provide a process of handling, tracking and resolving customer concerns to provide excellence in customer service .The facility staff will follow these basic steps in responding to a complaint: Listen to the concern without interruption .Take steps to correct the problem. Make the problem their own by following up to make sure it is resolved and stays resolved .Concerns are reviewed in morning meeting, noting new entries and assigning them for follow up and resolution .The Executive Director will review and manage the follow up of the concerns .The QAPI team will review the trends of the concerns and the action plans to resolve concerns on a monthly basis 3.1-3(l)

Based on observation, interview and record review, the facility failed to ensure resident rooms and hallways were in good repair and rooms were free of odors for 5 of 28 rooms observed for environment on the 500 hall. (room [ROOM NUMBER], 512, 517, 518 and 519). Findings include: 1. During an observation, on 4/15/24 at 11:20 a.m., the doorway of room [ROOM NUMBER] was missing approximately 18 inches of carpet. The hall between rooms [ROOM NUMBERS] had two gold floor plates which were missing pieces of carpet around them. During an interview, on 4/15/24 at 3:37 p.m., the Maintenance Director indicated there were no purchase orders for the carpet in room [ROOM NUMBER] or the 500 hall. 2 During an observation, on 4/15/24 at 3:37 p.m., room [ROOM NUMBER]'s bed was very loud when moving up and down. During an interview, on 4/15/24 at 3:38 p.m., the Maintenance Support and the Maintenance Director indicated there were approximately 50 beds like room [ROOM NUMBER]'s bed. The Maintenance Support indicated the bed sounded like it was getting ready for take-off. The reason the bed made loud noises was the grease on the bottom of the bed frame dried. They would spray WD 40 (a type of lubricant) on the bed frame to correct the loud noise. The beds were old. The company who manufactured the beds was no longer in business. 3. During an observation, on 4/15/24 at 12:27 p.m., room [ROOM NUMBER], 518 and 519 had a strong urine odor. The odor was carried out into the hallway. During an interview, on 4/15/24 at 12:30 p.m., Certified Nursing Assistant (CNA) 8 indicated the 500 hall always had a strong odor. room [ROOM NUMBER] had a really bad smell, and they did not know why. During an interview, on 4/15/24 at 12:50 p.m., the Assistant Director of Nursing Services (ADNS) indicated she did not know what was being done about the strong odors on the 500 Hall. During an interview, on 4/15/24 at 3:41 p.m., the Maintenance Support indicated the facility changed all the exhaust fans in room [ROOM NUMBER] and there was still an odor. room [ROOM NUMBER] had a strong urine odor, and the facility thought it was because a resident used a urinal and would spill urine on the carpet. At the time of the exit conference, the facility did not provide an environmental policy. A current policy, titled Resident Rights, dated as reviewed on 4/18/21 and received from the Executive Director (ED) on 1/4/23 at 1:00 p.m., indicated .The resident has a right to a safe, clean, comfortable and Homelike environment, including but not limited to receiving treatment and supports for daily living 3.1-19(f)(5)

Based on interview and record review, the facility failed to ensure the Notice of Medicare Non-Coverage was given 48 hours prior to the Medicare benefits ending date for 2 of 3 residents reviewed for beneficiary notices. (Resident 38 and 101) Findings include: 1. The Notice of Medicare Non-Coverage (NOMNC) for Resident 38 indicated the Medicare services would end on 3/13/24 and Medicare probably would not pay for Skilled Nursing and Therapy after 3/13/24. Resident 38 signed the NOMC on 3/12/24. This was only a 24-hour notice prior to the end of the Medicare covered services. 2. The NOMNC for Resident 101 indicated the Medicare services would end on 3/5/24 and Medicare would probably not pay for Skilled Nursing and Therapy after this date. Resident 101 signed the NOMNC on 3/4/24. This was only a 24-hour notice prior to the end of the Medicare covered services. During an interview, on 4/19/24 at 12:43 p.m., the Executive Director (ED) indicated the staff who completed the notices was out of the facility on leave and was not able to be interviewed. The ED did not know the reason the notices were only given with a 24-hour notice instead of the 48-hour notice required. A current policy, titled NOMNC Completion SOP [Standard Operating Procedure], dated last reviewed on 12/31/23 and received from the ED on 4/19/24, indicated .In order to streamline communication for completion of Notice of Medicare Non-Coverage [NOMNC] .this SOP outlines the expectations for completion .For residents being notified of discontinuation of their Medicare coverage, the NOMNC is required to be issued 2 calendar days prior to the actual discharge from Medicare 3.1-4(f)(3)

Based on interview and record review, the facility failed to ensure a revised Preadmission Screen and Resident Review (PASARR) level I was completed after psychotropic medications were prescribed for 1 of 5 residents reviewed for PASARR. (Resident 40) Finding includes: The clinical record for Resident 40 was reviewed on 4/16/24 at 4:39 p.m. The diagnoses included, but were not limited to, depression, anxiety disorder, dementia, congestive heart failure, and hypertension. A PASARR level I, dated 3/1/24, indicated the resident did not require a level II. The PASARR level I indicated the resident was not taking any mental health medications and did not have a mental health diagnosis. The level I screen indicated if changes occurred or new information refuted these findings a new screen must be submitted. A physician's order, dated 3/27/24, indicated duloxetine delayed release (an antidepressant) 30 milligram (mg), give one capsule twice a day for depression. A care plan, dated 3/27/24, indicated the resident was at risk for developing adverse effects from the use of antidepressant medications. The approaches included, but were not limited to, administering medication per the physician's order. During an interview, on 4/18/24 at 3:34 p.m., the Executive Director indicated the Social Service Director was on vacation and she would have to look at the resident's PASARR information. During an interview, on 4/18/24 at 4:57 p.m., the Clinical Support Nurse indicated the level I was completed on 3/1/24 and the medication was not started until 3/27/24. The facility policy indicated the facility had a total of 14 days to complete a new PASARR level I and they were beyond 14 days. A new PASARR level I should have been completed. The facility did not have a PASARR policy. The facility used the Indiana PASARR Standard Operating Procedure Revenue [NAME] & Collections. 3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

Based on interview and record review, the facility failed to ensure a resident with a diagnosis of dementia, who was at risk for elopement, was supervised when the resident left the facility through a door in the kitchen without staffs knowledge for 1 of 5 residents reviewed for accidents. (Resident J) The deficient practice was corrected by 03/5/2023, prior to the start of the survey, and was therefore past non compliance. The facility thoroughly investigated the elopement. Staff were educated on elopement policies and procedures, a facility elopement drill was conducted, and all residents were evaluated and assessments were updated for elopement risk. Finding includes: An incident report, dated 3/4/2023, indicated a resident was found outside the facility with no supervision. The record for Resident J was reviewed on 3/5/2023 at 2:58 p.m. Diagnoses included, but were not limited to, dementia with other behavioral disturbances, adult failure to thrive, hypertension, disorientation, and atrial fibrillation. A nursing note, dated 3/5/2023, indicated the resident was seen outside the facility near the dumpsters, on 3/4/2023 at 4:10 p.m. The resident was wearing a hat, long pants, socks and shoes, a t-shirt and a long sleeve shirt. The resident was oriented to himself, and had no shortness of breath or pain. His wanderguard bracelet was in place and in working condition. The resident indicated he was waiting for his girlfriend to pick him up at the facility. The physician and family was notified. Resident J was placed on 15 minute checks, from 3/4/2023 until 3/8/32023, with no exit seeking behavior noted. The resident had cognitive and memory impairment which effects his safety and judgement. A nursing note, dated 3/5/2023 at 12:41 p.m., indicated the resident had been evaluated and assessed by the facility physician and his medication had been adjusted. A witness statement, on 3/4/2023, CNA 2 indicated she was in another resident's room on 3/4/3034 at 4:10 p.m. She looked out the window and saw Resident J outside by the dumpsters. She grabbed another staff member and when outside and got the resident. The resident was in no distress and sitting in his wheelchair. A witness statement, on 3/4/2023, CNA 3 indicated she was going on a break outside in the parking lot area on 3/4/3034 at 4:10 p.m., she heard sounds from the dumpster area and saw resident J outside by the dumpsters. She saw CNA 2 and another staff member coming toward the dumpsters. The resident was in no distress and sitting in his wheelchair. The resident was returned to the facility through the facility front door when his alarm sounded and the doors were locked properly. A witness statement, on 3/4/2023, CNA 4 indicated she had seen Resident J in the activities room at 4:00 p.m. She saw Resident J heading to the dining room, when she assisted another resident to their room. She then was asked by CNA 2 to assist her in getting Resident J from outside near the dumpsters. The resident was in no distress and sitting in his wheelchair. An investigation report by the facility indicated the door behind the hot food serving area was left open and the kitchen door to the outside was left open and neither door was supervised by staff. An episodic event form, completed on 3/5/2023, indicated the resident was found outside on the property, the door was unlocked in the kitchen, and the outside kitchen door was opened. During an observation, on 7/13/2023 at 10:30 a.m., the distance from the facility building to the dumpsters was 50 feet. The dumpsters were on the facility property. The kitchen doors were locked. Resident J had a wanderguard in place and it was checked and activated on his right wrist. During an interview, on 7/12/2023 at 2:00 p.m., the Regional Clinical Support (RCS) indicated the doors should have been closed and locked. The doors were evaluated by the maintenance department and have been refurnished with new locks. The staff were in-serviced on locking the 2 doors and not leaving them open at any time without supervision. The quality control records for the observation and testing of the doors in the facility was ongoing and would continue on a monthly basis. During an interview, on 7/13/2023 at 10:45 a.m., Resident J oriented to himself. He did not know the date, day of week, or present time. He was confused as to his location and thought he was home and the staff were his housekeepers. A current facility policy, titled Guideline of Elopement/ Missing Resident, dated as revised on 12/31/2022 and provided by the RCS on 7/12/2023 at 4:40 p.m., indicated .Purpose: to establish guidelines to report and investigate all reports of elopement/missing persons. It is the responsibility of all personnel to report any residents attempting to leave the premises or suspected of being missing to the charge nurse as soon as possible 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure pain patches were monitored for placement and to change an order received from a hospital discharge for 1 of 5 residents reviewed for medication errors. (Resident E). Resident E was admitted to the hospital due to a change in mental condition. Finding includes: 1. A Facility Incident Report, dated 11/3/22 at 6:20 p.m., indicated the resident displayed a change in condition. When the nurse assessed Resident E, two fentanyl 37.5 mcg (microgram) patches (a pain patch apply to the skin) were discovered on the resident's chest. On the right side the patch was dated 10/30/22, and on the left side the patch was dated 11/2/22. The record for Resident E was reviewed on 1/9/23 at 4:21 p.m. Diagnoses included, but were not limited to, altered mental status, depressive disorder, anxiety disorder, nonpsychotic mental disorder, and cognitive communication deficit. A progress note, dated 11/3/22 at 6:20 p.m., indicated the nurse entered the room and noticed the resident had her eyes closed and was hard to arouse. An assessment was completed on the resident and two Fentanyl 37.5 mcg/hr patches were found on the resident's upper chest. The patches were dated 10/30/22 and 11/2/22. A progress note, dated 11/03/2022 at 8:00 p.m., indicated a new order for Narcan 0.4 mg (milligram) Intramuscular (IM) was administered and the resident was transferred to the Emergency Department. An Emergency Department report, dated 11/3/22, indicated the resident presented with respiratory distress. The resident was found with two fentanyl 37.5 mcg patches. During an interview, on 1/5/23 at 10:15 a.m., Resident E's family member indicated they received a call from the nurse informing them the resident was going to the hospital. The nurse thought the resident had too much Fentanyl. During an interview, on 1/10/23 at 11:06 a.m., the Administrator indicated the resident had two fentanyl patches. The nurse found the resident with her eyes closed and she was hard to arouse. The nurse completed an assessment on the resident. There were two fentanyl 35 mcg/hr patches on her chest. The nurse notified the physician and family. The nurse gave Narcan 0.4 mg IM and the resident was sent to the emergency room . During an interview, on 1/10/23 at 11:44 a.m., LPN 3 indicated the nurses were now supposed to double check the placement of a fentanyl patches and the site with two staff members. 2. The resident returned from the hospital on 11/4/22 with a new order to discontinue the current fentanyl 37.5 mcg/hr patch and start fentanyl 25 mcg/hr applied every 72 hours. A Medication Administration Record (MAR) indicated fentanyl 37.5 mcg/hr was given on 11/15, 11/18, 11/21, 11/24, 11/27, 11/30, 12/3, 12/6, 12/9, 12/12, 12/15, 12/18, 12/21, 12/24, 12/27, 12/30/22 and 1/2, 1/5, 1/8 and 1/11/23. The resident was administered the incorrect dosage of fentanyl 37.5 mcg for 10 weeks. During an interview, on 1/11/23 at 2:16 p.m., the Clinical Support Nurse indicated the resident's hospital discharge order from 11/4/22 was to discontinue previous order for fentanyl 37.5 mcg and replace it with 25 mcg/hr every 72 hours. The order was not put in correctly. A current policy, titled Specific Medication Administration Procedures, dated as revised 11/18 and received by the Administrator on 1/6/23 at 10:44 a.m., indicated .To administer medications in a safe and effective manner .After administration, return to cart, replace medication container .and document administration in the MAR or TAR, and controlled substance sign out record, if indicated. Monitor for side effects or adverse drug reactions immediately after administration and throughout each shift .Notification of Physician/Prescriber .Suspected adverse drug reactions A current policy, titled Guidelines for Medication Error Reporting. undated and received by the Clinical Support Nurse on 1/11/23 at 3:17 p.m., indicated .To identify medications given in error and expedite correction actions .In the event of a medication error, nursing personnel should first take whatever immediate action is necessary to protect the resident's safety and welfare. Notify the attending physician promptly of the error. Implement physician's orders. Notify the resident or responsible party. Initiate the appropriate Event form. Monitor the resident closely for 72 hours or as directed. Document the following in the resident's clinical record. A description of the error (brief). Name of physician and time notified. Physician's subsequent orders. Medication errors will be reviewed by the Quality Assurance Committee to identify trends and/or actions for implementations 3.1-48(c)(2)

Based on interview and record review, the facility failed to clarify a physician's order, failed to follow physicians' orders, failed to complete an accurate and thorough respiratory assessment and failed to notify the physician of the respiratory decline for 1 of 3 closed records reviewed (Resident B) which resulted in a hospitalization . Finding includes: The record for Resident B was reviewed on 10/27/2020 at 11:40 a.m. [DIAGNOSES REDACTED]. A care plan, dated 11/11/2019, indicated the resident had a potential for shortness of breath while lying flat related to [MEDICAL CONDITION]. The approaches included, but were not limited to, administer oxygen per physician's order and as needed. A care plan, dated 11/11/2019, indicated the resident had a potential for complications related to respiratory disease. The approaches included, but were not limited to, administer oxygen per orders, monitor oxygen saturation vial pulse oximetry as ordered, monitor lung sounds per orders or as needed, observe and report signs of respiratory distress including restless, wheezing, dyspnea, difficulty with expectoration, diaphoresis, crackles, [MEDICAL CONDITION] cyanosis and decreased breath sounds. A physician's order, dated 5/13/2020, indicated oxygen per nasal cannula as needed to keep the oxygen saturation greater than 92% or for shortness of breath. The facility did not clarify or specify the rate of flow for the oxygen. A physician's order, dated 5/13/2020, indicated to monitor O2 sats every shift. A Medication Administration Record, [REDACTED]. The Medication Administration Record, [REDACTED]. The Treatment Administration Record for August 2020, did not show the resident received oxygen on 8/1/2020 or 8/2/2020 as ordered by the physician. A progress note, dated 8/2/2020 at 3:39 p.m., indicated the resident's O2 sat was 80-82% on room air. The resident was placed on O2 at 3L (liters). The resident had no complaints of pain or respiratory issues. The progress note did not include the respiratory rate, the assessment of the lung sounds, the type of oxygen administration; such as nasal cannula or the notification of the physician of the drop in the oxygen saturation. A progress note, dated 8/3/2020 at 8:33 a.m., indicated the resident's oxygen saturation was 70%, and the resident was yelling out. The resident was placed on a non rebreather at 4L of oxygen and her oxygen saturation continued to fluctuate and dropped into the 70's. The resident was taking rapid shallow breaths. A progress note, dated 8/3/2020 at 8:50 a.m., indicated EMS (Emergency Medical Services) arrived and the resident was transported from the facility to the ambulance. A progress note, dated 8/3/2020 at 5:55 p.m., indicated the resident was currently in the intensive care unit. There were no progress notes, event notes or observation notes in the electronic record between 8/2/2020 at 3:39 p.m. and 8/3/2020 at 8:33 a.m. A (name of hospital) emergency department note, dated 8/3/2020, indicated the resident presented to the emergency department for respiratory distress which required oxygen by nasal cannula and quickly escalated to optiflow (a nasal high flow oxygen), then [MEDICAL CONDITION] was placed on the resident (a machine that supplies pressurized air into the lungs). The chest CT was negative for [MEDICAL CONDITION] embolism (PE) but revealed multifocal pneumonia. A hospital note, dated 8/25/2020, indicated the resident was admitted on [DATE] with [MEDICAL CONDITION], had bilateral [MEDICAL CONDITION] infiltrates with multifocal pneumonia and acute [MEDICAL CONDITION]. The resident remained in [MEDICAL CONDITION] on the ventilator throughout the hospital stay. During an interview, on 10/29/2020 at 3:11 p.m., the Campus Clinical Support staff member indicated the facility did not have any documentation of the resident's respiratory rate or lung sounds between the documentation on 8/2/2020 at 3:39 p.m., and 8/3/2020 at 8:33 a.m. There was no documentation of events or observations when the resident's O2 sats dropped into the 80's or between the time the resident's O2 sats dropped into the 70's. The facility could not provide any ongoing assessment of the resident's lungs or documentation in the electronic record of the resident's condition after the O2 was administered on 8/2/2020 at 3:39 p.m. A current policy, titled Guidelines for the Administration of Oxygen, dated 5/2018 and received on 10/29/2020 at 10:15 a.m., from the Campus Clinical Support staff member, indicated .Guidelines to properly Administering Oxygen and any Respiratory procedure .Verify physician's order for the procedure .Before administering emergency oxygen or oxygen for the first time assess for the following .Signs or symptoms of cyanosis (i.e , blue tone to the skin and mucous membranes) .Signs or symptoms of [MEDICAL CONDITION] (i.e., rapid breathing, rapid pulse rate, restlessness, confusion) .Vital signs .Lung sounds .Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated A current policy, titled Guidelines for Medication Orders, dated 5/2016 and received from the Campus Clinical Support staff member on 10/29/2020 at 10:15 a.m., indicated .To establish uniform guidelines in the receiving and recording of medication orders .A current list of orders will be maintained in the electronic clinical record of each resident .Oxygen orders .When recording oxygen orders specify .The rate of flow, route and rational (i.e., 2, 2L/min per nasal cannula PRN for SOB) A current policy, titled Lung Auscultation, dated 5/11/2016 and received from the Campus Clinical Support staff member on 10/29/2020 at 3:11 p.m., indicated .To evaluate the air flow through the lungs, presence of fluid or mucus and determine the condition of the lungs and surrounding pleural space .If the resident is able ask them to take deep breaths in and slowly exhale through their mouth. Let the resident pause as needed to avoid hyperventilation .Place the stethoscope on the chest wall and listen to a complete inspiration and expiration in all four quadrants of the lungs .A complete assessment should be performed both anteriorly and posteriorly .Diminished or absent sounds indicated inability to ventilate the lungs sufficiently to prevent atelactasis .Document the results of the lung assessment in the resident's medical record .Notify the physician and family of and (any) change in condition This Federal Tag relates to Complaint IN 971 and IN 572. 3.1-47(a)(6)

Based on observation, record review and interview, the facility failed to reassess interventions, implement new interventions and follow physician and registered dietitian recommendations which resulted in a significant weight loss for 2 of 3 residents reviewed for nutrition (Residents 38 and 77). Resident 38 had a 26 pound (lb) weight loss in 180 days, which is a significant weight loss. Findings include: 1. The record for Resident 38 was reviewed on 10/12/2017 at 10:22: a.m. [DIAGNOSES REDACTED]. On 10/16/2017 at 8:12 a.m., Resident 38 was observed in the restorative dining room eating biscuits and gravy on a regular plate with a small glass of milk. The resident was not observed to be cued to take a bite or swallow. The resident was not observed to have a fortified shake at breakfast. The following weights were recorded for Resident 38: 1) On 4/3/2017, the resident weighed 151 pounds (lbs). 2) On 5/5/2017, the resident weighed 148.7 lbs. 3) On 6/7/2017, the resident weighed 141.4 lbs. 4) On 7/7/2017, the resident weighed 136.2 lbs. 5) On 8/2/2017, the resident weighed 131.8 lbs. 6) On 9/6/2017, the resident weighed 128.6 lbs. 7) On 10/1/2017, the resident weighed 125.2 lbs. No other weights were located for the resident. A care plan, started 6/25/2016 and last reviewed/revised on 8/23/2017, identified Resident 38 had difficulty feeding herself related to her dementia and weakened physical condition. The goal was for the resident to have adequate nourishment at meals with our without assistance of staff. Approaches were to .provide meals and set up and assist as needed, may sit in restorative for additional assistance, therapy consult prn (as needed) ST (speech therapy) has recommended eating foods in separate bowls to help with self feeding A care plan, started 6/22/2016 and last reviewed/revised on 8/23/2017, identified Resident 38 had some swallowing deficits and took a long time to eat meals. The goal was for the resident to have the safest and least restrictive diet and not demonstrate any choking or aspiration. Two approaches were implemented. The most recent approach started 7/31/2017, indicated the resident was to, .sit in restorative dining for additional assist The second approach, started 6/22/2016, indicated the daughter had agreed to speech therapy, diet per speech therapy recommendations and provide food in separate bowls. If able keep distractions at a minimum while eating. Daughter is ok with her eating in room to take as long as she wants A care plan, started 5/13/2016 and last reviewed/revised on 8/11/2017, identified Resident 38 would like to meet her nutritional and hydration needs to support her overall metabolic demands. The identified goal was to .Maintain my weight at a healthy range .without any unwarranted significant weight changes, tolerate my physician ordered diet, have my personal food and dining preferences met; maintain my skin integrity Approaches were to obtain .weight as ordered/needed offer alternate food and beverage items as needed .assist with meals as needed .diet/supplements/medications as ordered A current physician order, dated 3/7/2017, indicated Resident 38 was to receive Med pass 120 milliliters (mLs) by mouth 3 times a day between meals to promote healing. A Resident Progress Note dated 5/2/2017 at 11:53 a.m., indicated, .Resident is taking hours to eat, seems distracted, chewing and chewing foods but forgetting to swallow A physician order, dated 5/3/2017 and discontinued 6/12/2017, indicated speech therapy for dysphagia (a swallowing problem) and cognitive linguistic evaluation was completed and the resident began speech therapy skilled services 3 times a week for 60 days to treat cognitive linguistic deficits including problem solving and recall and dysphagia deficits. The least restrictive diet level was to be determined during this therapy. A current physician order, dated 6/1/2017, indicated Resident 38 was to have pureed meat and a mechanical soft diet for all other foods. Each food item was to be served in an individual bowl. A Resident Progress Note written by the Registered Dietitian (RD) dated 6/09/2017 at 10:58 a.m., indicated .No [MEDICAL CONDITION] noted. Res (resident) on Mech (mechanical) soft diet with puree meat. Res on Med Pass 120 ml (milliliters) TID (three times a day). PO (by mouth) intake 35-55% which is decreased for res. Will add fortified shake with meals to help promote stable weight. A current physician order [REDACTED]. Review of the Therapist Progress and Discharge Summary, dated 6/12/2017, indicated the while chewing the resident had minimal impairment (10-25% impairment; risk for trace aspiration .) . and .mild impairment (25-50% impairment; risk for aspiration on liquids .) .SLP (speech language pathologist) recommends all puree foods, but POA (power of attorney) requests only puree meats and all other foods be served mechanical soft .The pt (patient) is very distracted in the dining room and requires max cues from SLP to take another bite, alternate solids and liquids, and to swallow .the pt demonstrates increased meal consumption provided assistance to feed and cues to consume solids A Resident Progress Note .Quarterly Progress Note written by the RD, dated 6/20/2017 at 8:31 a.m., indicated .Res feeds self in DR (dining room). No chewing or swallowing problems noted .Nutritional status is stable. Will continue to monitor A Resident Progress Note, regarding nutrition, dated 7/7/2017 at 5:23 p.m., indicated .Sig (significant) loss in 90d (90 days). Res on puree meat, other foods mech (mechanical) soft, fortified shakes with meals. Res does not like puree meat. PO intake 30-35%. Res on Med Pass 120 ml (milliliters) TID. Current interventions provide ample calories for wt (weight) support. Will inquire if diet consistency can be upgraded to increase intake. Will continue to monitor A Resident Progress Note written by the Social Services Director on 7/28/2017 at 10:34 a.m., indicated the resident's family was contacted regarding the residents decline in .being able to eat by herself and it is taking her longer to complete each meal. Often, resident doesn't eat much at all A Resident Progress Note-Sig (Significant) Change Nutrition Assessment written by the RD dated 8/4/2017 at 10:19 a.m., indicated .Res having increased difficulty with self feeding. Family agreed to RDR (restorative dining room) with increased assistance at meals. Res has had sig wt loss in 180d. Res has fort (fortified) shakes at meals and Med Pass between meals which provide ample calories for wt maintenance. Will monitor intakes in RDR and weights for weight improvement .Monitoring and Evaluation: Monitor weight, labs, and physical parameters to evaluate that diet and intake meet actual nutrition needs and resident goals On 8/7/2017 at 10:20 a.m., Resident 38 was identified to have a stage III (full thickness tissue loss) pressure ulcer to her left ankle. A Resident Progress Note dated 8/9/2017 at 11:30 a.m., indicated .Resident continues to loose (sic) weight r/t (related to) current intake less than 50% of meals .Resident does not like pureed meats. Resident has order for fortified shakes with meals and medpass (Med Pass) TID A Resident Progress Note- Nutrition- Sig Change assessment written by the RD dated 8/11/2017 at 1:13 p.m., indicated .Res on Mech soft diet with puree meat and fortified shakes with meals, po (by mouth) intake 40-60%. No chewing or swallowing problems noted. Res also on 2 cal supplement 120 ml TID-takes >75%. Res has Pressure area to ankle. Meds (medications) reviewed. Current interventions provide adequate protein for healing. Will monitor progress A Resident Progress Note dated 9/11/2017 at 2:51 p.m., indicated .Residents weight is down 3.2# (pounds)/30 days and 7.6#/60 days. Resident pureed diet started in 6/17. Resident already has orders for fortified shakes with meals A Resident Progress Note-Nutrition written by the RD on 9/13/2017 at 2:48 p.m., indicated .fortified shakes with meals .Will continue fortified foods and supplement and encourage po intake. Will continue to monitor A Resident Progress Note dated 9/21/2017 at 9:41 p.m., indicated .CRCA (Certified Resident Care Assistant) said res had dentures out, said res told her they don't fit A Resident Progress Note-Nutrition dated 10/6/2017 at 10:46 a.m., indicated .Res on puree meant, other foods mech soft, fortified shakes with meals. Res does not like puree meat. PO intake 40-70%. Res on Med Pass 120 ml TID. Current interventions provide ample calories for wt support. Will continue fortified foods and supplements and encourage po intake. Will continue to monitor The tray card on 10/16/2017 for Resident 38 indicated the resident should have been served in individual bowls. The diet was listed as regular, fortified, mechanical soft. There was no mention of fortified shakes with meals on the tray card. Review of the resident's profile indicated the resident was to be in the restorative dining room for .cues and encouragement Review of the Med Pass supplement intake report indicated from June 2017 through October 13, 2017 no supplement intake was recorded. Review of the Meals and Fluids Detailed Entry Report for Resident 38 from 3/17/2017 through 8/20/2017 indicated the following: 1) No dinner intake was recorded for 3/18/2017. 2) No lunch intake was recorded for 3/19/2017. 3) No dinner intake was recorded for 3/21/2017. 4) No lunch intake was recorded for 3/30/3017. 5) 2 different lunch intakes were recorded on 3/31/2017. 6) 2 different breakfast intakes were recorded on 4/14/2017. 7) No lunch intake was recorded for 4/15/2017. 8) No breakfast intake was recorded for 4/21/2017. 9) No dinner intake was recorded for 5/4/2017. 10) No dinner intake was recorded for 5/5/2017. 11) No dinner intake was recorded for 5/8/2017. 12) No lunch intake was recorded for 5/12/2017. 13) No dinner intake was recorded for 5/17/2107. 14) No lunch intake was recorded for 5/27/2017. 15) No breakfast or lunch intakes were recorded for 5/29/2017. 16) No breakfast intake was recorded for 6/6/2017. 17) No breakfast intake was recorded for 6/10/2017. 18) No lunch or dinner intakes were recorded for 6/16/2017. 19) 2 different dinner intakes were recorded for 7/4/2017. 20) No dinner intake was recorded for 7/10/2017. 21) 2 different breakfast intakes were recorded on 7/12/2017. 22) No lunch intake was recorded for 7/14/2017. 23) No breakfast intake was recorded and 2 different lunch intakes were recorded for 7/17/2017. 24) No lunch intake was recorded for 8/12/2017. 25) 2 different breakfast intakes were recorded for 8/16/2017. 26) No breakfast intake was recorded for 8/19/2017. During an interview on 10/13/2017 at 11:56 a.m., the SLP indicated she was unaware the resident was eating in the restorative dining room and that staff should have been trained on giving her cues, feeding techniques, and strategies to assist her. Additionally, the resident's food should be served in separate bowls. During an interview on 10/13/2017 at 1:55 p.m., the Social Services Director indicated she was unaware the resident was having problems with her dentures. During an interview on 10/13/2017 at 2:06 p.m., the Assistant Director of Health Services (ADHS) indicated the computer tracking software was a critical communication tool and nursing staff was trained on how to complete the documentation accurately and completely. During an interview on 10/13/2017 at 2:39 p.m., the RD indicated poorly fitting dentures should be considered as a reason the resident lost weight. The resident was getting Med Pass between meals and should have received fortified shakes and foods at meals. No additional interventions have been considered since those interventions should provide the needed calories for the resident. During an interview on 10/13/2017 at 2:44 p.m., LPN 3 indicated if the supplemental intake is blank the supplement was not charted as given. During an interview on 10/13/2017 at 2:46 p.m., the Assistant Director of Health Services indicated the CRCA's should have cued the resident to eat and at the time the resident moved to the restorative dining room, the staff was not trained on techniques to cue the resident. During an interview on 10/13/2017 at 3:29 p.m., the Director of Health Services indicated residents with nutritional problems should be weighed. During an interview on 10/16/2017 at 8:20 a.m., CRCA 1 indicated the resident was drinking regular milk and eating off a regular plate. 2. The record for Resident 77 was reviewed 10/12/2017 9:07:45 AM. [DIAGNOSES REDACTED]. The following weights were recorded for the resident: 1) On 8/1/2017, the resident weighed 82.8 pounds (lbs). 2) On 8/18/2017, the resident weighed 77 lbs (which is a 7.2% loss). 3) On 8/23/2017, the resident weighed 77.2 lbs. 4) On 8/28/2017, the resident weighed 75.6 lbs. Documentation was provided by the ADHS on 10/13/2017 at 3:03 p.m., the Assistant Director of Health Services (ADHS) indicated at that time the information was from a Weight Record and not from the resident's electronic medical chart. 5) On 9/6/2017, the resident weighed 74.8 lbs. 6) On 9/10/2017, the resident weighed 79.6 lbs. 7) On 10/1/2017, the resident weighed 79.8 lbs. A care plan dated 8/4/2017, indicated the resident had the potential for altered nutrition. Approaches included, but were not limited to .Obtain weight as ordered/needed A Resident Progress Note dated 8/7/2017 at 11:54 p.m., indicated a wound was found on the resident's buttocks, the medical doctor (MD) was notified and treatment orders were received. A Resident Progress Note dated 8/9/2017 at 12:03 p.m., indicated the wound is a stage II pressure ulcer. A Resident Progress Note dated 8/21/2017 at 5:26 p.m., indicated Resident weight down 5.8 (lbs)/2 weeks. Resident already has order for 90 ml med pass BID (twice a day). Will continue to monitor weekly A Resident Progress Note dated 8/23/2017 at 3:25 p.m., indicated Nutrition note: wt (weight): 77# (pounds) wt down since admission. although wt is stable with July wt at other facility 79#. Res eats ave (average) 82% at meals. 90 mL 2.0 cal supplement BID started. no new interventions. will ask for wkly (weekly) weights x4 or until stable No weekly weights were located for this resident. A physician's orders [REDACTED]. During an interview with the ADHS and RD on 10/13/2017 at 2:06 p.m., the RD indicated weekly weights should have been done for the resident. A current facility policy titled Guidelines for Weight Tracking dated 5/15/2016, received from Clinical Support on 10/12/2017 at 3:08 p.m., indicated the purpose of the policy was to .ensure resident weight is monitored for weight gain and/or loss to prevent complications arising from compromised nutrition/hydration .Procedures .2. Unless otherwise indicated or ordered by the physician the resident have their weight taken and recorded monthly .6. The weight should be recorded in the individual resident medical record A current facility policy titled, Nutrition Documentation dated 11/21/2016, received from the Executive Director on 10/12/2017 at 4:33 p.m., indicated .h. Indicate if diet and intake meet estimated and/or actual nutrition needs .i. Chewing/Swallowing issues .m. Information collected from the resident/resident's family/members of the IDT should be used to complete the assessment and writing a resident-driven plan of care 3.1-46(a)(1)

Based on record review and interview, the facility failed to ensure appropriate interventions were put in place to prevent a fall and a fall related injury for 2 of 5 residents reviewed for a fall related injury. Resident B had a fall that resulted in a Cervical fracture. (Residents B & E) Findings include: 1. The clinical record for Resident B was reviewed on 11/17/14 at 1:00 p.m. [DIAGNOSES REDACTED]. An ADL (Activities of Daily Living) care plan, dated 8/11/14, indicated the following: "I have had a general decline, weak and tired. ....At present I require assist with transfers. I am currently non-ambulatory. I rely on a wheelchair and staff for my locomotive needs." Nursing notes indicated the following: 9/29/14 nursing notes indicated, "Resident has a poor appetite, showing a decline in health. Res (resident) requires extensive assist of 2 with transfers, can bear weight with 2 persons but unstable. Leans to the left in her wheelchair and needs repositioned frequently. ...." Nursing notes indicated Resident B had a history, as well as a preference, of leaning forward while she was in a sitting position. 10/5/14 at 7:15 p.m. "Res (resident) tipped forward falling out of w/c (wheelchair) as CNA was pushing her down the hall. As smooth surface floor changed to carpet, the bump caused her feet to jerk the w/c forward throwing her out. She fell on her head. Several involuntary body movements with 2 episodes of vomiting. ...." 10/6/14 at 3:00 a.m. "(name of hospital) contacted facility. Informed writer Res has C1 cervical fracture ...." During an interview on 11/18/14 at 10:15 a.m., the DHS indicated she discussed the health decline of Resident B with family members on 9/29/14. Resident B was, increasingly, leaning forward while sitting. The discussion included the possibility of using a high back wheelchair with foot pedals to prevent an accident. The DHS indicated before staff put the new interventions/preventions in place, Resident B fell and fractured her neck. Resident B was a known fall risk and facility staff did not act on their own recommendations, fast enough. 2. The clinical record for Resident E was reviewed on 11/18/14 at 12:30 p.m. [DIAGNOSES REDACTED]. Nurses notes, dated 9/1/14 at 5:50 a.m., indicated Resident E was found on the floor, at the foot of her bed. She stated she was "going after my walker so I can go to the bathroom." Resident E was not able to move her right hip and right leg and yelled out in pain when the nurse attempted to move her right leg for assessment. Nurses notes indicated her right foot was slightly rotated, outward. A fall circumstance report, dated 9/1/14, indicated Resident E was found on the floor in her room, secondary to a fall, at 5:50 a.m. She was attempting to transfer without the use of an assistive device. "Walker was out of reach." Additionally, nursing assessment and fall report documentation, dated 9/1/14, indicated "Resident was attempting to take herself to the bathroom without assistance and fell reaching for her walker." On 9/1/14 at 9:30 p.m., nurses notes indicated the hospital reported Resident E had a right hip fracture. A care plan, facility review dated 5/20/14, indicated Resident E was at risk for a fall with injury. Prevention interventions included: - Provide/monitor the use of adaptive devices: walker, wheelchair. At 4:00 p.m., on 11/18/14, during an interview, the DHS and ADHS indicated staff failed to ensure Resident E's walker was within her reach. This Federal tag relates to Complaint #IN 616. 3.1-45(a)(2)