Every finding on record at St Mary Healthcare Center

Based on observation, interview and record review, the facility failed to ensure the food preparation area did not contain employee drinks and frozen food was sealed in 1 of 1 kitchen reviewed. This deficient practice had the potential to affect 65 of 65 residents who received food from the kitchen.Findings include:During the kitchen observation, on 3/24/26 at 9:36 a.m., with the Dietary Manager, the following were observed:a. The food preparation counter had two unopened cans of energy drinks and a white cup with a lid and straw stored next to a jar of peanut butter and loaf of bread.b. On the second shelf in the walk-in freezer, there was a large opened plastic bag containing one skinless chicken breast. The chicken breast had a small amount of ice buildup on the upper left corner.c. On the second shelf in the walk-in freezer, there was a large cardboard box of skinless chicken breasts. The chicken was left in an untied plastic bag, and the cardboard lid was left wide open. During an interview, on 3/24/26 at 9:45 a.m., the Dietary Manager indicated the drinks belonged to the staff and staff were not supposed to store any food or drinks in the food preparation area. During an interview, on 3/24/26 at 10:19 p.m., the Dietary Manager indicated the clear package of one skinless chicken breast was open and had ice on the edges of the chicken breast. The box of opened chicken should have been tied and not opened to air. During an interview, on 3/25/26 at 11:15 p.m. Dietary Staff 5 indicated staff should never leave their personal drinks or food in the kitchen. A current facility policy, titled Culinary Services, reviewed on 7/10/25 and received from the Executive Director 3/25/26 at 1:59 p.m., indicated .Food and supplies shall be properly stored to keep foods safe and preserve flavor, nutritive value, and appearance.All foods in the freezer are wrapped in moisture proof wrapping or placed in suitable containers, to prevent freezer burn. Items are labeled and dated.410 IAC (Indiana Administrative Code) 3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure a physician's orders were followed, a medication was administered according to the ordered parameters, and to obtain an admission weight for 3 of 3 residents reviewed for quality of care. (Resident 6, 17 and 44)Findings Include: 1. The clinical record for Resident 6 was reviewed on 3/25/26 at 10:59 a.m. The diagnoses included, but were not limited to, hypotension, vitamin deficiency, acute kidney failure, and iron deficiency anemia.A care plan, dated 3/19/26, indicated the resident had a potential for cardiovascular distress related to the diagnosis of hypotension. Interventions included, but were not limited to, administer medications as ordered. A physician's order, dated 3/11/26, indicated to administer midodrine (a medication for low blood pressure) 5 milligrams (mg), four times a day, and to hold the medication for a systolic blood pressure greater than 110. A medication administration record (MAR), dated 3/11/26 through 3/25/26, indicated midodrine was administered outside of the hold parameters on the following dates: On 3/12/26 at 4:00 p.m., with a systolic blood pressure of 167.On 3/15/26 at 4:00 a.m., with a systolic blood pressure of 129.On 3/17/26 at 8:00 a.m., with a systolic blood pressure of 112.On 3/23/26 at 12:00 p.m., with a systolic blood pressure of 114.On 3/24/26 at 4:00 a.m., with a systolic blood pressure of 111.On 3/25/26 at 8:00 a.m., with a systolic blood pressure of 127.A MAR, dated 3/11/26 through 3/25/26, indicated midodrine was held when it should have been administered on the following dates:On 3/11/26 at 12:00 p.m., with a systolic blood pressure of 102.On 3/11/26 at 4:00 p.m., with a systolic blood pressure of 110.On 3/12/26 at 8:00 a.m., with a systolic blood pressure of 101.On 3/12/26 at 12:00 p.m., with a systolic blood pressure of 101. On 3/16/26 at 4:00 a.m., with a systolic blood pressure of 104.On 3/17/26 at 4:00 p.m., with a systolic blood pressure of 109.On 3/18/26 at 4:00 a.m., with a systolic blood pressure of 100.On 3/18/26 at 8:00 a.m., with a systolic blood pressure of 104.On 3/18/26 at 12:00 p.m., with a systolic blood pressure of 104.On 3/18/26 at 4:00 p.m., with a systolic blood pressure of 102.On 3/19/26 at 8:00 a.m., with a systolic blood pressure of 105.On 3/19/26 at 12:00 p.m., with a systolic blood pressure of 108.On 3/19/26 at 4:00 p.m., with a systolic blood pressure of 101.On 3/22/26 at 4:00 a.m., with a systolic blood pressure of 105.On 3/23/26 at 4:00 a.m., with a systolic blood pressure of 106.On 3/23/26 at 8:00 a.m., with a systolic blood pressure of 106.During an interview, on 3/25/26 at 11:21 a.m., the Director of Nursing (DON) indicated medications should not be administered or held out of parameters. During an interview, on 3/25/26 at 11:32 a.m., LPN 2 indicated on the MAR, the nurse's initials would be in parenthesis if the medication was not given and a note would appear below with the reason it was held. Medications should not be administered outside of parameters. 2. The clinical record for Resident 17 was reviewed on 3/25/26 at 11:44 a.m. The diagnoses included, but were not limited to, diastolic (congestive) heart failure, dementia, type 2 diabetes mellitus, and anxiety disorder. A physician's order, dated 7/31/25, indicated an admission order was placed for a one-time weight with an end date of 7/31/25. There was no admission weight found during the clinical record review. During an interview, on 3/25/26 at 11:23 a.m., the Director of Nursing (DON) indicated the first weight for Resident 17 was obtained on 8/5/25. No other weight was documented prior to 8/5/25. 3. The clinical record for Resident 44 was reviewed on 3/25/26 at 10:53 a.m. The diagnoses included, but were not limited to, cellulitis of the right lower limb, pulmonary fibrosis, dementia, diabetes mellitus, and hypertension.The resident was admitted on [DATE] and the admission weight was not obtained until 1/23/26. During an interview, on 3/25/26 at 10:35 a.m., the Clinical Support Nurse indicated the policy did not specify when to obtain an admission weight. The weight in the computer was charted three days after the resident was admitted to the facility. During an interview, on 3/25/26 at 11:29 a.m., LPN 2 indicated admission weights were to be obtained at the time of admission. During an interview, on 3/25/26 at 11:39 a.m., LPN 3 indicated she would obtain admission weights on the day of admission before the end of her shift. During an interview, on 3/25/26 at 11:41 a.m., QMA 4 indicated an admission weight needed to be obtained within 24 hours of the resident's arrival. One of the first tasks she would complete with a new resident would be to obtain their weight. A current facility policy, titled Medication Administration General Guidelines, dated as revised on 11/2018 and received from the Executive Director on 3/24/26 at 1:59 p.m., indicated .Medications are administered as prescribed.FIVE RIGHTS - Right resident, right drug, right dose, right route and right time.A current facility policy, titled Guidelines for Weight Tracking, dated as reviewed on 5/22/18 and received from the Clinical Support Nurse on 3/24/26 at 1:59 p.m., indicated .Guidelines for Weight Tracking.Residents will have their weight taken and recorded upon admission to establish a baseline.410 IAC (Indiana Administrative Code) 3.1-37(a)

Based on interview and record review, the facility failed to ensure a resident's discharge paperwork provided to the receiving facility was accurate for 1 of 3 residents reviewed for discharge. (Resident C)Findings include: During an interview, on 8/20/25 at 2:09 p.m., an anonymous interviewee indicated Resident C was transferred, on 7/31/25, to their group home. She indicated Resident C came with discharge paperwork. The discharge assessment indicated Resident C required assistance with eating, hygiene, toileting, showers, lower body dressing, and putting on and taking off footwear. She indicated Resident C was independent and did not need assistance.The clinical record for Resident C was reviewed on 8/20/25 at 3:55 p.m. The diagnoses included, but were not limited to, asthma, tracheostomy status, and congenital malformation of the musculoskeletal system.The clinical record indicated Resident C was cognitively intact and was capable of making her own decisions.A nursing progress note, dated 7/29/25 at 12:23 p.m., indicated the resident's discharge plan was to discharge to a group home. A meeting was held with the family and Resident C.A nursing progress note, dated 7/31/25 at 4:11p.m., indicated Resident C was discharged from the facility. The discharge summery was signed. The resident was discharged with family and was taken by family car to a group home.A discharge narrative sent with Resident C indicated she needed assistance with eating, hygiene, toileting, showers, lower body dressing, and putting on and taking off her footwear.During an interview, on 8/21/25 at 1:04 p.m., the Director of Nursing (DON) indicated the discharge plan was incorrect. She was not aware the incorrect discharge assessment had been sent with Resident C. The resident was independent with care. A current facility policy, titled Guidelines for transfer and discharge (including AMA), dated as revised 12/17/24 and provided by DON on 8/21/25 at 4:30 p.m., indicated .Nursing will complete the Discharge Summary at the time of discharge 3.1-12(a)(3)

Based on observation, interview and record review, the facility failed to ensure residents were served their meals together, staff were seated while eating with the residents, and a resident was able to complete their meal before being removed from the dining room for 1 of 2 dining rooms reviewed for dignity. (the legacy dining room) Findings include: 1. During an observation, on 5/14/25 at 12:00 p.m., the residents were seated in the legacy dining room. CNA 15 took a resident's meal ticket, gave the ticket to Dining Assistant 12, and he prepared the resident's plate. The CNAs passed out plates to residents seated at different tables randomly until all residents were served. During an interview, on 5/14/25 at 11:54 a.m., CNA 11 indicated Dining Assistant 12 told her to take a resident's meal ticket and pass the food out in the order of the tickets. CNA 11 told Dining Assistant 12 they should serve one table at a time. During an interview, on 5/14/25 at 12:12 p.m., Activity Associate 13 indicated normally the trays were passed out one table at a time until all the residents had received their food. During an interview, on 5/14/25 at 12:26 p.m., Dining Assistant 12 indicated he was told to serve the residents by meal tickets and not one table at a time. 2. During an observation, on 5/14/25 at 12:24 p.m., CNA 11 was standing next to a table in the dining room talking with two residents. CNA 11 had a small bowl in her left hand and a fork in her right hand eating out of the bowl. During an interview, on 5/14/25 at 12:27 p.m., CNA 11 indicated she needed to sit down and not eat standing next to the residents. During an interview, on 5/14/25 at 1:15 p.m., the Director of Nursing (DON) indicated the staff should not stand and eat out of a bowl in the dining room. During an interview, on 5/15/25 at 3:03 p.m., the DON indicated the Legacy dining room was served family style and the staff were encouraged to eat with the residents. CNAs needed to sit down with the residents at the table and not stand. 52643 3. During an observation, on 5/12/25 at 12:06 p.m., Resident 58 was in his wheelchair in the legacy dining room and had just finished a bowl of soup. The hospice CNA entered the dining room and approached the resident. The resident was waiting for the main course when the hospice CNA pulled the resident away from his table. The hospice CNA was observed pushing the resident out of the dining room before he finished his meal and had told the resident she was going to give him a shower. During an observation, on 5/12/25 at 12:21 p.m., the hospice CNA returned the resident to the dining room. The resident was wearing clean clothes, and his hair was wet. The dining staff had served the other residents, and the hospice CNA had to retrieve the resident's food from the kitchen. During an interview, on 5/15/25 at 9:43 a.m., CNA 2 indicated showers were usually given before or after breakfast on the day shift. The showers were not to be given during mealtimes. During an interview, on 5/15/25 at 9:55 a.m., the DON indicated residents would be given showers during mealtime only in an extreme situation. A shower could be given when a resident was incontinent and covered with bowel movement. A hospice visit note, dated 5/12/25, indicated the hospice CNA provided activities of daily living (ADL) for Resident 58 from 12:04 p.m. to 12:38 p.m., and a shower was given. A current facility policy, titled Guidelines for Meal Service, dated as revised 5/22/18 and received from the DON on 5/14/25 at 12:22 p.m., indicated .To provide residents with a choice of food, dining times and fine dining experience .Lunch is generally served around noon .During meal service, staff members will make efforts to serve all the residents seated together at the same time. This is not always possible due to various reasons A current facility policy, titled Resident Rights-Life Enrichment, dated as revised 4/14/25 and received from the Executive Director on 5/12/25 at 10:40 a.m., indicated .The purpose of this policy is to ensure that the rights of each resident are consistently preserved and respected in the provision of Life Enrichment services. Special care must be taken to uphold and safeguard these rights while delivering programs that enhance the quality of life for residents .Residents' dignity and privacy will be respected during individual and group programs A current facility policy, titled Legacy Family Style Dining Standards, dated as revised 11/7/18 and received from the Clinical Support Nurse on 5/15/25 at 3:30 p.m., indicated .Serve residents from the LEFT, following the THS Standards: Each dish or meal item is owned by the team member throughout the meal service to ensure everyone is offered the items, and to ensure the dish/bowl is refilled and served again when requested .Approach each resident and offer the assigned item to each resident, using a verbal prompt .After everyone at the table is served, move to the next table to repeat the process until every resident has been served .Eat with residents and carry on pleasant conversation: Place a small amount of food on a COLORED plate and sit among the residents, at the corner of table 3.1-3(t)

Based on interview and record review, the facility failed to ensure a do not resuscitate (DNR) order was updated when received for 1 of 1 resident reviewed for advanced directives. (Resident 21) The deficient practice was corrected on 4/28/25, prior to the start of the survey, and therefore was past noncompliance. Findings include: The clinical record for Resident 21 was reviewed on 5/16/25 at 11:34 a.m. The diagnoses included, but were not limited to, adult failure to thrive, heart failure, coronary artery disease, hypertension, Parkinson's disease, type 2 diabetes, obesity, schizophrenia, iron deficiency anemia, and hypothyroidism. A physician's order dated 3/25/25 indicated full code status. A State of Indiana Out of Hospital Do Not Resuscitate Declaration and Order form indicated the resident was to be a DNR. The form was signed by the resident representative and witness on 4/1/25. The form was signed by the physician on 4/14/25. A physician's order, dated 4/22/25, indicated DNR code status. During an interview, on 5/19/25 at 10:19 a.m., LPN 10 indicated that when she received a signed DNR order, she entered the order and scanned the form into the resident's electronic chart. During an interview, on 5/19/25 at 12:13 p.m., the DON indicated once the form was completed, it was uploaded into the residents' chart and the orders were updated to match the form. The DON indicated there were times the form was uploaded into the chart and the orders did not get updated. She began an audit with a plan of correction in April. A current facility policy, titled Guidelines for Advanced Directives, dated 9/26/24 and received from the Clinical Support Nurse on 5/16/25 at 2:25 p.m., indicated .Advanced Directives will be reviewed with resident and/or resident representative .The resident or representative will advise .regarding wishes for end of life directives and code status .The nursing staff will confirm the desired code status and obtain an order from the physician The deficient practice was corrected by 4/28/25, after the facility implemented a systemic plan which included audits and conducting staff training on advanced directives. 3.1-4(f)(5)

Based on record review and interview, the facility failed to ensure the residents were issued SNF ABN's (Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage) for 2 of 3 residents reviewed for beneficiary notification. (Resident 1 and 20) The deficient practice was corrected on 2/13/25, prior to the start of the survey, and therefore was past noncompliance. Findings include: 1. Resident 1 started on Medicare Part A services on 11/3/24. The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted. The last covered day of Part A Service was 12/13/24. There was no SNF ABN or NOMNC provided to Resident 1. 2. Resident 20 started on Medicare Part A services on 10/22/24. The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted. The last covered day of Part A Service was 12/23/24. There was no SNF ABN or NOMNC provided to Resident 20. During an interview, on 5/15/25 at 11:22 a.m., the DON (Director of Nursing) indicated the beneficiary notices were not being completed prior to February this year and a plan of correction was now in place. A current facility policy, titled NOMNC Completion SOP, reviewed on 10/24/22 and provided by the Clinical Support on 5/19/25 10:00 a.m., indicated .For residents receiving therapy under Medicare Part A, social services will issue NOMNC prior to therapy discharge. If the resident has Medicare days remaining and is staying at the campus after therapy discharge social services will the SNF ABN form in addition to the NOMNC The deficient practice was corrected by 2/13/25, after the facility implemented a systemic plan which included audits and conducting staff training on following the standard operating procedure for completing NOMNCs. 3.1-4(f)(3)

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was correctly coded for 1 of 1 resident reviewed for resident assessments. (Resident 49) Findings include: The clinical record for Resident 49 was reviewed on 5/14/25 at 3:56 p.m. The diagnoses included, but were not limited to, schizophrenia, bipolar disorder, and cognitive communication deficit. A Preadmission Screening and Resident Review (PASARR), dated 12/18/24, indicated the resident did not have any known recent or current mental health conditions. An admission minimum data set (MDS) assessment, dated 12/24/24, indicated the resident did not have a diagnosis of schizophrenia. A resident information sheet, last reviewed by the physician on 3/13/25, indicated the resident had a diagnosis of schizophrenia and bipolar disorder. A significant change in status MDS assessment, dated 3/26/25, indicated Resident 49 had a diagnosis of schizophrenia. Resident 49's physician's orders did not include any antipsychotic medications for the treatment of schizophrenia or bipolar disorder. During an interview, on 5/16/25 at 2:00 p.m., the Director of Nursing (DON) indicated Resident 49 did not have a schizophrenia or bipolar diagnosis, but his roommate did. During an interview, on 5/19/25 at 11:09 a.m., the DON indicated the incorrect diagnoses had been removed from Resident 49's chart. During an interview, on 5/19/25 at 11:11 a.m., the MDS Coordinator indicated that the schizophrenia and bipolar disorder diagnoses were inputted incorrectly onto the MDS assessment. They should not have been listed. During an interview, on 5/19/25 at 12:27 p.m., the MDS corporate support indicated the facility did not have an MDS policy. They followed the RAI (resident assessment instrument) guidelines. 3.1-31(c)(1) 3.1-31(i)

Based on interview and record review, the facility failed to ensure vital signs and neurological assessments were documented for 1 of 1 resident reviewed for assessments. (Resident 70) The deficient practice was corrected on 5/10/25, prior to the start of the survey, and therefore was past noncompliance. Findings include: The clinical record for Resident 70 was reviewed on 5/15/25 at 1:37 p.m. The diagnoses included, but were not limited to, hypertension, chronic kidney disease, type 2 diabetes mellitus, and retention of urine, A facility event and incident report, dated 12/13/24 at 6:41 p.m., indicated the resident had an unwitnessed fall. The report did not include documentation for the 72-hour follow-up vital signs or neurological assessments. A facility event and incident report, dated 4/1/25 at 10:20 a.m., indicated the resident had an unwitnessed fall. The report did not include documentation for the 72-hour follow-up vital signs or neurological assessments. During an interview, on 5/15/25 at 9:48 a.m., the Director of Nursing (DON) indicated neurological assessments were not initiated on 4/1/25. The nurse took the first set of vital signs and did not initiate the documentation needed to complete the required documentation. During an interview, on 5/19/25 at 11:33 a.m., the DON indicated documentation for the unwitnessed fall on 4/1/25 was not started. The nurse was new and did not initiate the required records. The unwitnessed fall, dated 12/13/24, did not have documentation of the 72-hour vital signs. During an interview, on 5/19/22 at 11:30 a.m., LPN 14 indicated that when a resident had an unwitnessed fall the resident would be assessed for injuries. Vital signs and neurological assessments would be completed every shift for 72 hours. The nurse would chart the information in the residents' Electric Health Records (EHR) During an interview, on 5/19/25 at 3:25 p.m., the DON indicated the facility had no further documentation to provide. A facility falls management program guideline indicated the nursing staff would monitor and document the continued resident response and effectiveness of interventions for 72 hours. The neurological assessments would be completed and documented on the fall event form. A current facility policy, titled Fall Management Program Guideline, dated as reviewed 12/17/24 and received from the DON on 5/19/25 at 11:45 a.m., indicated .The attending physician or medical director in the absence of the attending physician and the responsible party should be notified .Any orders received from the physician should be noted and carried out .Nursing staff will monitor and document continued resident response and effectiveness of interventions for 72 hours .communicate Interventions during shift report A current facility policy, titled Guidelines for Neurological Checks, dated as reviewed 12/17/24 and received from the DON on 5/15/25 at 10:30 a.m., indicated .To evaluate the level of consciousness, evaluate pupil response, motor function, and vital signs that may alert staff for potential for head injury or seizure activity .Neuro-checks for 24 hours should be completed within the Fall Event Form .Obtain vital signs with each assessment A current facility policy, titled Quick Guide to Matrix Documentation Guidelines, dated as revised on 2/20/18 and received from the DON on 5/19/25 at 11:45 a.m., indicated .Post event .progress notes, vital signs q shift for 72 hours The deficient practice was corrected by 5/10/25, after the facility implemented a systemic plan which included audits, conducting staff education for falls and neuro checks. 3.1-37(a)

Based on interview and record review, the facility failed to ensure a resident's diagnoses in the medical record were accurate and correct for 1 of 1 resident reviewed for documentation. (Residents 49) Findings include: The clinical record for Resident 49 was reviewed on 5/14/25 at 3:56 p.m. The diagnoses included, but were not limited to, schizophrenia, bipolar disorder, and cognitive communication deficit. A facility resident information sheet, last reviewed by the physician on 3/13/25, indicated the resident had a diagnosis of schizophrenia and bipolar disorder. The physician's orders did not include any antipsychotic medications for the treatment of schizophrenia or bipolar disorder. During an interview, on 5/16/25 at 2:00 p.m., the Director of Nursing (DON) indicated Resident 49 did not have schizophrenia or a bipolar diagnosis. During an interview, on 5/19/25 at 11:09 a.m., the DON indicated the incorrect diagnoses were incorrect and should not have been listed on the diagnoses list. Upon exit, the facility was unable to provide an accurate records policy. 3.1-50(a)(2)

Based on interview and record review, the facility failed to ensure the policy and procedure related to administering two (2) step Mantoux skin tests for tuberculosis were followed for 4 of 5 employees reviewed for infection control. (QMA 6, QMA 7, CNA 8 and CNA 9) Findings include: 1. A facility tuberculin testing for employees' form, dated 9/25/24, indicated QMA 6 was given the first step tuberculosis (TB) test on 9/25/24 and was read on 9/28/24. The second step was given on 10/10/24 and read on 10/12/24. There was no documentation indicating the time the first and second step tests were read. 2. A facility tuberculin testing for employees' form, dated 8/14/24, indicated QMA 7 was given the first step TB test on 8/14/24 and was read on 8/16/24. The second step was given on 8/30/24 and read on 9/1/24. There was no documentation indicating the time the first and second step test was read. 3. A facility tuberculin testing for employees' form, dated 1/19/25, indicated CNA 8 was given the first step TB test on 1/19/25 and was read on 1/21/25. The second step was given on 2/1/25 and read on 2/3/25. There was no documentation indicating the time the first and second step test was read. 4. A facility tuberculin testing for employees' form, dated 11/8/24, indicated CNA 9 was given the second step TB test on 11/18/24 and was read on 11/20/24. There was no documentation indicating the time the second step test was read. During an interview, on 5/19/25 at 10:28 a.m., LPN 10 indicated when a TB test was administered all the information including the lot number, date, time, and initials should be documented. The test would be read in 48-72 hours. It would be the same process when reading the test. A current facility policy, titled Mantoux Test Procedure, dated as reviewed on 12/16/24 and provided by the DON on 5/19/25 at 9:49 a.m., indicated .Record administration of Mantoux Test (date, time .) .Read the Mantoux Test results in 48-72 hours 3.1-18(e)

Based on interview and record review, the facility failed to ensure a resident received medications per the physician's order for 1 of 1 resident reviewed for quality of care. (Resident H) This deficient practice was corrected on 6/10/24, prior to the start of the survey, and was therefore past noncompliance. Finding includes: The clinical record for Resident H was reviewed on 11/14/24 at 12:30 p.m. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, chronic kidney disease, and anxiety. The resident had a severe cognitive deficit and was receiving hospice care. A review of the Medication Administration Record (MAR) indicated the resident did not receive her ordered dose of Morphine concentrate (a pain medication) every 6 hours on 5/25/24 at 10:00 p.m., 5/26/24 at 4:00 a.m., 10:00 a.m., 4:00 p.m., 10:00 p.m., and on 5/27/24 at 4:00 a.m., 10:00 a.m., 4:00 p.m., 10:00 p.m. The MAR indicated the medication was not available for administration. The nursing notes did not indicate the resident had been assessed for pain on 5/25, 5/26, and 5/27/24. The physician had been notified. Family had not been notified. Hospice had not been notified. The Emergency Drug Kit (EDK) medication box had not been utilized. During an interview, on 11/13/24 at 3:39 p.m., Resident H could not answer questions other than yes or no questions. The resident did indicate she had no pain. During an interview, on 11/13/24 at 2:10 p.m., the Regional Clinical Support nurse indicated the errors were made by the facility staff and two (2) staff members had been terminated for not following the policies and procedures of the facility. During an interview, on 11/13/24 at 4:15 p.m., the Regional Clinical Support nurse indicated there was no pain assessment documented for the resident on 5/25, 5/26 and 5/27/24. The MAR indicated the resident was given routine Tylenol three times daily on 5/25, 5/26 and 5/27/24. A current facility policy, titled Preparation and General Guidelines, revised 11/2018 and provided by the Regional Clinical Support nurse on 11/14/24 at 11:13 a.m., indicated .The individual who administers the medication dose records the administration on the resident's MAR directly after medication is given A current facility policy, titled Guidelines for Narcotic Count, revised 8/2016 and provided by the Regional Clinical Support nurse on 11/14/24 at 11:11 a.m., indicated .Each controlled drug shall have a corresponding count sheet to track distribution. 2. The narcotic book shall contain a sheet providing space for the off going and oncoming nursing staff to record their signatures indicating the narcotics has been reviewed .Both staff members shall sign that the narcotic count is accurately reconciled The deficient practice was corrected by 6/10/24 after the facility implemented a systemic plan which included a thorough investigation, staff education, and audits of the shift-to-shift controlled substance counting, disposal of controlled substances, and controlled substance documentation. This citation relates to Complaint IN00436486. 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure medications were documented as given, medications were disposed of properly, narcotic medication logbooks reflected the medication given to residents and medication records were reconciled for 3 of 5 medication carts reviewed. This deficient practice was corrected on 6/10/2024, prior to the start of the survey, and was therefore past noncompliance. Finding includes: 1. The narcotic sign-in and sign-out record book, from 5/1/24 thru 6/9/24 was missing 66 nursing staff signatures. 2. The medication destruction logbook, from 4/14/24 thru 6/15/24, had 24 errors. There were 7 dates missing, 11 resident names missing, 3 quantity amounts missing, 2 nursing signatures missing, and one entry was not log into the book. 3. The narcotic logbook entries did not match the resident Medication Administration Record (MAR) for 14 residents. The number of errors was 61 for the period of 4/4/24 thru 6/6/24. The narcotic book indicated 32 medications were withdrawn. The MAR did not reflect the administration of the medications. The MAR indicated 29 medications were administered. The narcotic record logs did not indicate the medications were withdrawn for the medication administration. During an interview, on 11/13/24 at 2:10 p.m., the Regional Clinical Support nurse indicated the documentation errors were made by the staff. She indicated two (2) staff members had been terminated for not following policies and procedures of the facility. A current facility policy, titled Disposal of Medications and Medication - Related Supplies, revised 11/2018 and provided by Regional Clinical Support nurse on 11/14/24 at 11:11 a.m., indicated .The person witnessing the destruction ensures that the following information is entered on the individual controlled substance accountability record/book: 1) Date of destruction. 2) Resident's name. 3) Name and strength of medication. 4) Prescription number. 5) Amount of medication destroyed. 6) signature of witnesses A current facility policy, titled Preparation and General Guidelines, revised 11/2018 and provided by Regional Clinical Support nurse on 11/14/2024 at 11:13 a.m., indicated .The individual who administers the medication dose records the administration on the resident's MAR directly after medication is given A current policy, titled Guidelines for Narcotic Count, revised 8/2016 and provided by Regional Clinical Support nurse on 11/14/2024 at 11:11 a.m., indicated .Each controlled drug shall have a corresponding count sheet to track distribution. 2. The narcotic book shall contain a sheet providing space for the off going and oncoming nursing staff to record their signatures indicating the narcotics has been reviewed .Both staff members shall sign that the narcotic count is accurately reconciled The deficient practice was corrected by 6/10/2024, after the facility implemented a systemic plan which included a thorough investigation, staff education, and audits of the shift-to-shift controlled substance counting, disposal of controlled substances, and controlled substance documentation. This citation relates to Complaint IN00436486. 3.1-25(b)

Based on observation, interview and record review, the facility failed to administer medications within the ordered time frame, assess and accurately document a resident's dental status and communicate with hospice and provide a positioning chair to meet the residents care planned needs for 6 of 6 residents reviewed for quality of care. (Residents 40, 47, 1, 20, 46 and 27) Findings include: 1. The clinical record for Resident 40 was reviewed on 4/24/24 at 3:45 p.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus with diabetic neuropathy, heart failure, edema, and chronic kidney disease stage 3. A current physician's order, with a start date of 12/21/23, indicated the resident was to take buspirone (an antianxiety medication) 5 milligrams (mg) 3 times per day. Administer the first dose from 6:00 a.m. to 10:00 a.m., administer the second dose from 11:00 a.m. to 1:30 p.m., and administer the third dose from 6:00 p.m. to 10:00 p.m. A medication administration record (MAR) indicated the following administration times for buspirone: a. On 4/1/24 at 3:07 a.m. b. On 4/6/24 at 3:02 a.m. c. On 4/7/24 at 3:00 a.m. d. On 4/8/24 at 3:01 a.m. e. On 4/13/24 at 3:06 a.m. f. On 4/14/24 at 3:01 a.m. g. On 4/17/24 at 4:36 a.m. h. On 4/20/24 at 3:10 a.m. i. On 4/21/24 at 3:00 a.m. j. On 4/22/24 at 3:20 a.m. There was no documentation to show the physician was notified about administering the medications early. During an interview, on 4/26/24 at 11:57 a.m., the DON (Director of Nursing) indicated she was not sure why the medications were given outside of the ordered times. 2. The clinical record for Resident 47 was reviewed on 4/24/24 at 3:54 p.m. The diagnoses included, but were not limited to, dependence on renal dialysis, diabetes mellitus, depression, and end stage renal disease. A physician's order, dated 1/18/24, indicated to give Eliquis (an anticoagulant) 2.5 mg tablet twice a day. Administer the first dose from 6:00 a.m. to 10:00 a.m., and the second dose from 7:00 p.m. to 10:00 p.m. A MAR indicated the following administration times for Eliquis: a. On 4/1/24 at 3:07 a.m. b. On 4/6/24 at 3:02 a.m. c. On 4/7/24 at 3:00 a.m. e. On 4/8/24 at 3:01 a.m. f. On 4/13/24 at 3:07 a.m. g. On 4/14/24 at 3:02 a.m. h. On 4/17/24 at 4:46 a.m. i. On 4/20/24 at 3:10 a.m. j. On 4/21/24 at 3:01 a.m. k. On 4/22/24 at 3:21 a.m. There was no documentation to show the physician was notified of the early medication administration. During an interview, on 4/24/24 at 11:15 p.m., QMA 6 indicated the time she checked medications off in the computer was the time she gave the medication. 3. The clinical record for Resident 1 was reviewed on 4/24/24 at 3:57 p.m. The diagnoses included, but were not limited to, cerebral palsy, diabetes mellitus, depressive disorder, and anxiety disorder. A physician's order, dated 2/15/24, indicated to give baclofen (a muscle relaxant medication) 10 mg tablet three times a day. Administer the first dose from 6:00 a.m. to 10:00 a.m., the second dose from 11:00 a.m. to 1:30 p.m., and the last dose from 6:00 p.m., to 10:00 p.m. A MAR indicated the following administration times for baclofen: a. On 4/1/24 at 3:08 a.m. b. On 4/6/24 at 3:09 a.m. c. On 4/7/24 at 3:01 a.m. d. On 4/8/24 at 3:02 a.m. e. On 4/14/24 at 3:05 a.m. f. On 4/20/24 at 312 a.m. g. On 4/21/24 at 3:03 a.m. h. On 4/22/24 at 3:23 a.m. There was no documentation to show the physician was notified of the early medication administration. 4. The clinical record for Resident 20 was reviewed on 4/26/24 at 9:44 a.m. The diagnoses included, but were not limited to, dysphagia (difficulty swallowing), chronic kidney disease, anxiety disorder, and major depressive disorder. A physician's order, dated 12/28/23, indicated to give lansoprazole oral suspension liquid (a medication used to treat indigestion, acid reflux, heartburn, and other stomach issues) 3 mg/ml, take 10 ml's by gastric tube twice a day. Administer the first dose from 6:00 a.m. to 12:00 p.m., and the second dose from 6:00 p.m. to 10:00 p.m. The MAR indicated the following administration times for lansoprazole: a. On 4/6/24 at 3:05 a.m. b. On 4/7/24 at 3:02 a.m. c. On 4/8/24 at 3:03 a.m. d. On 4/13/24 at 3:12 a.m. e. On 4/14/24 at 3:07 a.m. f. On 4/20/24 at 3:14 a.m. g. On 4/21/24 at 3:05 a.m. h. On 4/22/24 at 3:25 a.m. There was no documentation to show the physician was notified of the early medication administration. During an interview, on 4/25/24 at 11:18 a.m., the DON indicated the facility had extended medication times. The nurses had one hour before and one hour after the scheduled times to pass the medication. During an interview, on 4/26/24 at 11:57 a.m., the DON indicated the time the medications were charted was most likely the time the nurse gave the medications. She did not know why the nurses gave the medication early. 36454 5. During an observation, on 4/23/24 at 12:46 p.m., Resident 46 was sitting up in a chair in the dining room. The resident did not look like she had any teeth as her mouth and cheeks were sunk in. During an observation, on 4/23/24 at 1:18 p.m., Resident 46 was standing in the dining room, she had no top teeth and had several natural teeth on the bottom which were observed while the resident was talking and smiling. The clinical record for Resident 46 was reviewed on 4/25/24 at 9:51 a.m. The diagnoses included, but were not limited to, unspecified dementia with behavioral disturbance, osteoarthritis, anxiety disorder, and depression. A Minimum Data Set (MDS) assessment, dated 8/23/23, indicated the resident was edentulous (had no teeth). A Personal Inventory Form, dated 8/21/23, was blank. A care plan profile guide, dated 8/22/23, indicated the resident was edentulous. A care plan, dated 8/29/23, indicated the resident was at risk for mouth pain related to the edentulous status. The approaches included, but were not limited to, assessing the condition of the oral cavity as needed and a dental evaluation and interventions as needed. A Nutrition note, dated 2/22/24, indicated the resident had upper and lower dentures. A Dental Note, dated 4/9/24, indicated the resident had a full removable upper appliance. The upper denture was cleaned and inspected and appeared to be okay. The resident had 9 natural teeth on the bottom. During an interview, on 4/25/24 at 11:49 a.m., QMA 2 indicated the resident would not put in her upper dentures. QMA 2 was not sure if the resident had natural bottom teeth. There was a denture cup in the resident's room and no dentures. During an interview, on 4/25/24 at 3:03 p.m., the Unit Director observed a denture cup in the resident's room, and it was empty. The resident had lost her dentures at the previous facility and the Unit Director did not know why the dentures had not been replaced. During an interview, on 4/25/24 at 3:50 p.m., the Clinical Support Nurse did not know if the resident had dentures when she arrived at the facility. During an interview, on 4/26/24 at 11:00 a.m., the Clinical Support Nurse indicated there was conflicting information in the resident's record about her teeth. The Registered Dietitian had reported the resident had upper and lower dentures and the MDS indicated the resident was edentulous. During an interview, on 4/26/24 at 11:56 a.m., the DON indicated there was a note from the previous facility which indicated the resident's upper dentures were missing. The resident's admission inventory list was not in the electronic health record, and she did not know if dentures were checked on the admission inventory. During an interview, on 4/29/24 at 3:19 p.m., the DON indicated the notes from the dentist could have been copied and pasted from dental notes at the previous facility. The resident did have natural lower teeth and no dentures. The resident had been non-compliant with wearing the upper dentures previously although this was not documented. There was conflicting information in the electronic health record about the resident's dental status. 6. During an observation, on 4/23/24 beginning at 12:17 p.m., Resident 27 was sitting up in a short Broda chair (a chair for positioning) with no leg rests or foot supports. Her head was even with the table and not at the normal height for eating. The resident was using her fingers to eat and had to reach up to the table. When she tried to pick up her silverware her hands would shake and then she would put the silverware down and use her fingers again. Her legs were dangling, and her feet were touching the floor. During an observation, on 4/23/24 at 1:01 p.m., Resident 27 was sitting up in a Broda chair in her room. Her legs were dangling, and her feet were touching the floor. During an observation, on 4/25/24 at 2:52 p.m., the resident was sitting up in a Broda chair in the dining area. Her legs were dangling, and her feet were touching the floor. During an observation, on 4/26/24 at 12:30 p.m., the resident was in the dining room in a different Broda chair with her feet on the foot rests of the chair. The chair was at a regular height for sitting at a dining table. The staff were cueing the resident, and she was eating the French fries and chicken with her fingers. The clinical record for Resident 27 was reviewed on 4/24/24 at 4:40 p.m. The diagnoses included, but were not limited to, Alzheimer's disease with late onset, adult failure to thrive, generalized anxiety disorder, and low back pain. A physician's order, dated 11/25/23, indicated to admit to hospice with a diagnosis of chronic kidney disease stage 3, dementia, failure to thrive, and hypertension. A hospice progress note, dated 4/10/24 at 9:28 p.m., indicated the resident was seated in a wheelchair. The hospice staff talked to the facility about this and even among the staff, they did not know why the resident was in a wheelchair. The resident could still walk although had been voluntarily sitting in the wheelchair more often. A hospice progress note, dated 4/17/24 at 11:44 a.m., indicated the resident was seen sitting in a Broda chair in the common area. The resident was no longer able to ambulate independently. The facility was using the resident's wheelchair for another resident, so they had the resident in a broken Broda chair. The hospice staff placed an order for a Broda chair. A care plan profile guide indicated to encourage the resident to elevate her legs when sitting up. There was no care plan for a Broda chair and no physician's order for the Broda chair. During an interview, on 4/25/24 at 3:06 p.m., Qualified Medication Aide (QMA) 2 indicated the Broda chair was ordered for the resident by hospice. During an interview, on 4/26/24, the Clinical Support Nurse indicated a Broda chair was ordered by hospice. The short Broda chair was from the facility since the Broda chair from hospice had not arrived yet. The care planned profile guide which indicated the resident was to be encouraged to keep her legs elevated when up was old and not a current concern for the resident. The Profile Guide has not been updated. During an interview, on 4/29/24 at 3:01 p.m., the Director of Nursing (DON) indicated the facility tried to get hospice to order a Broda chair and the chairs were on back order. The facility had plenty of wheelchairs. During an interview, on 4/30/24 at 10:18 a.m., the hospice Registered Nurse (RN) 3 indicated the facility had not communicated with the hospice the resident was no longer ambulatory. The resident was sitting in a Broda chair with the armrest on the left side broken. The staff told RN 3 the resident's wheelchair was needed for another resident, so they put the resident in the Broda chair. The resident was comfortable in the Broda chair, so the hospice staff ordered one for the resident on 4/17/24 and it was on back order until 4/26/24. The resident was still able to stand and transfer and physically had the ability to walk although with her dementia her mind was not letting her walk. The Broda chair ordered by hospice had leg and footrests for positioning. 44598 A current hospice contract, received at entrance, indicated .subsequent to the initial assessment, a plan of care is developed together with the primary physician, facility professionals and the patient and family A current policy, titled Medication Administration Times Procedural Guidelines, dated as revised on 12/1/21 and received from the Director of Nursing Services on 4/26/24 at 9:11 a.m., indicated .To ensure medication is administered in resident centered fashion and documented in medical records A current policy, titled Admission Policy, dated as revised on 1/19/17 and received from the Clinical Support Nurse on 4/26/24 at 4:30 p.m., indicated .The facility will not request or require residents or potential residents to waive potential facility liability or losses of personal property A current policy, titled Program Guidelines: Restorative Mobility Program, dated as revised on 12/31/22 and received from the Clinical Support Nurse on 4/26/24 at 4:30 p.m., indicated .To encourage increased independence and maintain mobility through services that promotes circulation stimulates and strengthens muscle, reduces the potential of falls and increases self-esteem .Analyze interdisciplinary assessments to determine need for restorative mobility interventions. Assessments may include but are not limited to: MDS .Nursing Assessments .Therapy screens and/or evaluations .Fall Event .Determine resident specific needs to enhance mobility by analyzing the assessments and communication .Determine the type of mobility program required and establish a baseline through the assessment. Mobility interventions include but are not limited to .Wheelchair mobility: using a wheelchair for independent mobility A current policy, titled Dental Services Including Repair, Replacement, dated as revised on 11/8/17 and received from the Clinical Support Nurse on 4/26/24 at 4:30 p.m., indicated .Clinical staff will assess teeth and gums upon admission, with each comprehensive assessment and as needed to identify pain, lost or broken teeth, visible signs of tooth decay and other chewing and swallowing problems .The facility will ensure the delivery of emergency dental services to meet the resident needs .The Admissions team (CSR, CSS or Guest Relations) will be responsible for getting the Dental consent form signed upon admission, if the resident chooses to us the contracted dental service 3.1-37(a)

Based on interview and record review, the facility failed to include a seizure disorder diagnosis or monitoring for seizure medication side effects in the care plan for 1 of 1 resident reviewed for comprehensive care plans. (Resident 29). Finding includes: The clinical record for Resident 29 was reviewed on 4/25/24 at 11:40 a.m. The diagnoses included, but were not limited to, epilepsy without status epilepticus, dementia with other behavioral disturbance, delusions disorder, depression, anxiety disorder, and insomnia. A physician's order, dated 2/20/24, indicated to give lamotrigine (an anticonvulsant) 100 milligrams (mg) twice a day for epilepsy. A care plan, dated 3/15/24, did not include the risk for seizures with an epilepsy diagnosis. There were no approaches for monitoring seizure activity or safety measures for seizures. A care plan, dated 3/15/24, did not include the resident receiving an anticonvulsant medication for epilepsy. There were no approaches for monitoring for seizure medication side effects. During an interview, on 4/26/24 at 2:35 p.m., the Clinical Support Nurse indicated the Nurse Practitioner included a history of seizures for Resident 29. During an interview, on 4/29/24 at 3:09 p.m., the Director of Nursing (DON) indicated the facility had not included monitoring for seizures in the care plan for Resident 29. A current policy, titled Comprehensive Care Plan Guideline, dated as reviewed on 12/31/23 and received from the Clinical Support Nurse on 4/26/24 at 4:30 p.m., indicated .Care plan interventions should be reflective of risk area(s) or disease processes that impact the individual resident .The comprehensive care plan should be .revised to reflect changes in the resident's condition as they occur .Comprehensive care plans need to remain accurate and current 3.1-35(a) 3.1-35(b)(1)

Based on interview and record review, the facility failed to ensure post fall interventions were evaluated for effectiveness and a rationale was documented prior to removing the interventions from the comprehensive care plan for 2 of 3 residents reviewed for accidents. (Resident 23 and 54) Findings include: 1. The clinical record for Resident 23 was reviewed on 4/25/24 at 3:42 p.m. The diagnoses included, but were not limited to, malignant neoplasm of the pancreas, unspecified dementia with other behavioral disturbance, and chronic kidney disease stage 3. A fall event, dated 9/24/23 at 5:53 p.m., indicated the resident was ambulating back from the dining room toward her room using a walker. The resident's legs became weak, and she was lowered to the ground. An interdisciplinary team (IDT) note, dated 9/25/23 at 9:46 a.m., indicated the new intervention was for hospice to re-evaluate the use of ambulatory device and weakness. The intervention for hospice to re-evaluate the use of ambulatory device and weakness was not on the current care plan and the progress notes did not include a resolution of this intervention. A Facility Reported Incident (FRI), dated 12/27/23, indicated Resident 23 was attempting to ambulate and fell . The injury was an acute metatarsal (a bone of the foot). The care plan was reviewed and updated accordingly. The new intervention was for staff to toilet the resident in the morning between 6:00 a.m. and 8:00 a.m. The new intervention for the staff to toilet the resident in the morning between 6:00 a.m. and 8:00 a.m., was not on the current fall care plan. 2. The clinical record for Resident 54 was reviewed on 4/24/24 at 2:59 p.m. The diagnoses included, but were not limited to, unspecified dementia with anxiety, heart failure, type 2 diabetes mellitus, chronic kidney disease stage 3, repeated falls, and difficulty in walking. A Fall Event, dated 2/27/24 at 2:39 p.m., indicated the resident was found on the floor in his room between beds. The IDT indicated the new intervention was to encourage and offer activities after lunch. The fall care plan, dated 6/1/23 and last updated on 4/24/24, did not include the intervention to offer activities after lunch. The electronic record did not include a resolution of this intervention. During an interview, on 4/29/24 at 3:22 p.m., the Director of Nursing (DON) indicated if the root cause of the fall changed then the intervention implemented from the IDT would be removed. The progress notes did not indicate if hospice had evaluated Resident 23 for the use of ambulatory devices. Both interventions were removed from the care plan and there was no documentation to indicate if the intervention was effective or no longer applied to the resident. The documentation for Resident 54 did not include if the intervention for offering activities was effective or no longer applied to the resident. A current policy, titled Fall Management Program Guidelines, dated as reviewed 12/31/23 and received from the Clinical Support Nurse on 4/26/24 at 4:30 p.m., indicated .strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures .The fall risk assessment is included as part of the Admission and Quarterly Nursing Observation and other Events/Observation in EHR [electronic health record] .Should the resident experience a fall the attending nurse shall complete the 'Fall Event. This includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode and a review by the IDT to evaluate thoroughness of the investigation and appropriateness of the interventions .The resident care plan should be updated to reflect any new or change in interventions .Discuss risks and interventions with resident and/or responsible party and communicate interventions during shift report 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a resident on a fluid restriction was monitored for 1 of 1 resident reviewed for a fluid restriction related to dialysis. (Resident 47) Finding includes: The clinical record for Resident 47 was reviewed on 4/24/24 at 3:54 p.m. The diagnoses included, but were not limited to, dependence on renal dialysis, diabetes mellitus, depression, and end stage renal disease. A care plan, dated 10/27/21, indicated the resident had a potential for weight fluctuations and alterations in labs due to receiving dialysis treatments. The interventions included, but were not limited to, limit fluid intake if a fluid restriction was ordered. A care plan, dated 10/27/21, indicated the resident had a diagnosis of renal failure. The interventions included, but were not limited to, treatment to dialysis site per physician's order, observe catheter site per orders, and fluid restriction per orders. A physician's order, dated 12/28/23, indicated to encourage a 1200 milliliters (ml's) daily fluid restriction. The order indicated to give 240 ml's with meals and nursing was to provide 240 ml's every dayshift, and 120 ml's on the evening and nightshift. A facility vitals report, from 4/1/24 to 4/25/24, indicated 17 out of 25 days the resident went over her daily fluid restriction. During an interview, on 4/29/24 at 10:44 a.m., CNA 4 indicated she was not aware the resident was on a fluid restriction. The information would be on the resident's care plan, and she had not recently looked at the care plan. During an interview, on 4/29/24 at 10:54 a.m., the Director of Nursing (DON) indicated the resident was on a fluid restriction. When the order said to encourage a fluid restriction, the facility would like to see the resident stay around the 1200 ml's a day. During an interview, on 4/29/24 at 10:58 a.m., Resident 47 indicated she was on dialysis and was not supposed to drink a lot. During an interview, on 4/29/24 at 11:17 a.m., the DON indicated the resident did not have a care plan for being noncompliant with fluids. A current policy, titled Guidelines for Fluid Restrictions, dated as revised 12/1/21 and received from the DON on 4/29/24 at 11:55 a.m., indicated .To ensure fluids are provided within the physician order guidelines .Upon receipt of a physician's order for fluid restriction the Director of Health Services and Director of Food Services shall be notified of the order. Intake monitoring shall be initiated up receipt of the order .The Dietary Department shall record established breakdown by meal on tray card. The Nursing Department shall record established breakdown by shift and document in the EHR. Fluid consumption shall be reviewed by shift to determine adjustments necessary in the fluid intake of the resident on the restriction in order to meet their established fluids needs .Should the resident .chose not to comply with the recommended fluid restriction a Self Determination of Care or Informal Refusal and Non-Compliance observation should be completed explaining the risk(s) of noncompliance .The resident should be periodically assessed for appropriateness and continued need for fluid restriction 3.1-37(a)

Based on interview and record review, the facility failed to include monitoring for seizure medication side effects and seizure activity and to review a resident's history for 1 of 5 residents reviewed for unnecessary medications. (Resident 29). Finding includes: The clinical record for Resident 29 was reviewed on 4/25/24 at 11:40 a.m. The diagnoses included, but were not limited to, epilepsy without status epilepticus, dementia with other behavioral disturbance, delusions disorder, depression, anxiety disorder, hyperlipidemia, insomnia, and deficiency of other specified B group vitamins. A psychiatric unit after visit care note, dated 12/14/23, indicated lamotrigine was for mood stabilization related to diagnoses of dementia with behavior disturbance, major depressive disorder, and anxiety disorder. A physician's order, dated 2/20/24, indicated to give lamotrigine (an anticonvulsant) 100 milligrams (mg) twice a day for epilepsy. The original physician's order indicated related diagnosis dementia, seizures? A care plan, dated 3/15/24, did not include risk for seizures with an epilepsy diagnosis. There were no approaches for monitoring seizure activity or safety measures for seizures. A care plan, dated 3/15/24, did not include the resident receiving an anticonvulsant medication for epilepsy. There were no approaches for monitoring for seizure medication side effects. The clinical record did not include order sets for seizures, monitoring for seizure activity, or for monitoring for side effects of anticonvulsant medication. During an interview, on 4/26/24 at 2:35 p.m., the Clinical Support Nurse indicated the Nurse Practitioner included a history of seizures for Resident 29. During an interview, on 4/26/24 at 3:35 p.m., the DON (Director of Nursing) indicated the diagnoses are not added by this facility, rather a Louisville home office coder provided this service. She indicated the facility would need to determine which diagnosis the lamotrigine was being given for and if the resident had a seizure disorder diagnosis. During an interview, on 4/29/24 at 3:09 p.m., the DON indicated the facility had not included monitoring for seizures in the care plan for Resident 29. She indicated there was not a clear reason for the lamotrigine prescription according to the facility documentation. She indicated she was trying to call the family to confirm the seizure diagnosis. She indicated a question mark should not be on the physician orders. During an interview, on 4/29/24 at 4:18 p.m., the DON indicated she had concluded the resident did not have a diagnoses of seizure disorder. She indicated she went back through all the records and decided Resident 29 did not have a seizure disorder. The clinical record did not include any gradual dose reduction attempt for the lamotrigine when given for mood disorder rather than seizure disorder. A current policy, titled Psychotropic Medication Usage and Gradual Dose Reductions, dated as reviewed on 12/31/23 and received from the Clinical Support Nurse on 4/29/24 at 4:00 p.m., indicated .To ensure every effort is made for residents receiving psychoactive medications to obtain the maximum benefit with minimal unwanted side effects through appropriate use, evaluation and monitoring by the interdisciplinary team .Regular monthly review of antipsychotics in CAR [clinically at risk] for continued need, appropriate dosage, side effects, risks and/or benefits will be conducted 3.1-48(a)(3) 3.1-48(a)(4)

Based on interview and record review, the facility failed to ensure the assessments for side effects for antipsychotic medications were completed timely for 1 of 5 residents reviewed for unnecessary medications. (Resident 54) Finding includes: The clinical record for Resident 54 was reviewed on 4/24/24 at 2:59 p.m. The diagnoses included, but were not limited to, unspecified dementia with anxiety, major depressive disorder, anxiety disorder, and a cognitive communication deficit. A physician's order, dated 5/25/23 through 10/27/24, indicated to give olanzapine (an antipsychotic) 5 milligram (mg) at bedtime. There was no diagnosis with the order. A physician's order, dated 10/27/23 through 1/13/23, indicated to give olanzapine 2.5 mg at bedtime. There was no diagnosis with the order. An Abnormal Involuntary Movement Scale (AIMS) was completed on 6/21/23. This was 27 days after the medication was ordered. A physician's order, dated 1/25/24 and open ended, indicated to give Risperdal (an antipsychotic) 0.5 mg once a day. An AIMS assessment was completed on 1/25/24. This was 7 months and 4 days after the initial AIMS assessment was completed on 6/21/24. A care plan, dated 1/30/24, indicated the resident was at risk for adverse reactions related to receiving an antipsychotic medication. The approaches included, but were not limited to, AIMS test according to guidelines. During an interview, on 4/29/24 at 2:53 p.m., the Director of Nursing (DON) indicated the AIMS was not completed initially and every 6 months according to the facility policy. A current Nursing Drug Handbook indicated the adverse reactions for olanzapine and Risperdal included, but were not limited to, extrapyramidal events (involuntary movements including tremors, facial movements which are caused by antipsychotic medication) and tardive dyskinesia (a feeling of restlessness and not being able to sit still with the urge to tap fingers, fidget or jiggle the legs). A current policy, titled Guidelines for: Abnormal Involuntary Movement Scale [AIMS], dated as reviewed on 12/31/23 and received from the DON on 4/29/24 at 10:20 a.m., indicated .Guidelines for: Abnormal Involuntary Movement Scale .To assess residents that have prescribed antipsychotic medications to identify symptoms that may indicate the presence of Tardive Dyskinesia; a neurologic disorder characterized by abnormal involuntary movements which may occur as an undesired effect of dopamine blocking medications .A licensed nurse will complete an AIMS scale assessment on all residents on antipsychotic medications and or other medications known to cause Tardive Dyskinesia .The AIMS assessment will be completed if possible, prior to the resident beginning this type of medication, or at the earliest possible time, either after admission; after medications listed above are prescribed; and with dosage changes .The AIMS assessment will be repeated for residents taking antipsychotic medications every six [6] months A current policy, titled Psychotropic Medication Usage and Gradual Dose Reductions, dated as reviewed on 12/31/23 and received from the Clinical Support Nurse on 4/29/24 at 4:00 p.m., indicated .To ensure every effort is made for residents receiving psychoactive medications to obtain the maximum benefit with minimal unwanted side effects through appropriate use, evaluation and monitoring by the interdisciplinary team .Regular monthly review of antipsychotics in CAR [clinically at risk] for continued need, appropriate dosage, side effects, risks and/or benefits will be conducted 3.1-48(a)(3)

Based on observation, interview and record review, the facility failed to ensure the facility was free of strong odors, the walls, doors, and carpet were maintained, and the trash was disposed of in 2 of 3 units observed for environment. (200 hall and 100 hall) Finding includes: During an observation, on 4/23/24 at 11:00 a.m., the back hallway had a strong odor. The odor was stronger near the riser room. During an observation, on 4/23/24 at 12:07p.m., the lower portion of the walls in the dementia unit dining room had brown paint with gouges in the corners and white paint showing through. The lower half of the doors throughout the hallway had black marks. The carpet in the hallways had faded areas and dark stains. During an observation, on 4/23/24 at 2:44 p.m., an odor of urine was noted in the bathroom of room [ROOM NUMBER]. A urine-soaked brief was observed in the trash can. During an observation, on 4/23/24 at 1:27 p.m., the carpet in room [ROOM NUMBER] was very wet and slick. A resident was walking on the wet carpet with nonskid socks and the socks were wet. During an observation, on 4/24/24 at 10:30 a.m., the back hallway had a strong odor. The odor was stronger near the riser room. During an observation, on 4/24/24 at 4:38 p.m., the front hallway had a strong odor noted. During an observation, on 4/25/24 at 2:01 p.m., with the Plant Operations Director, room [ROOM NUMBER] was observed to have black marks on the room entry door. room [ROOM NUMBER] had paint missing around the bathroom sink. The bathroom wall was yellow with white gouging around the wall by the sink. room [ROOM NUMBER] had two gouges on the right side of the bathroom wall the size of baseballs. There were paint chips all over linoleum towards the right side of the bathroom. room [ROOM NUMBER] had paint peeled around the sink. During an observation, on 4/26/24 at 2:29 p.m., a very strong odor was noted in the back hallway towards the chapel, the chapel had a very strong smell. During an observation, on 4/29/24 at 1:54 p.m., the front hallway had a very foul unidentifiable odor. The odor was not urine or bowel movement. During an interview, on 4/29/24 at 2:30 p.m., the Maintenance Director indicated the areas around the sinks were due to someone repairing the counter tops around the sinks and putting painters tape up. When the tape was removed, it peeled the paint. During an interview, on 4/25/24 at 11:20 a.m., the Maintenance Director indicated there have been problems with the sewage system. They had a quote and would have to bust concrete to replace some sewer lines, and quotes to fix the main water lines. There was a pipe rebuilt which was back in the riser room, the drain line had to be rebuilt, they saddled on to a different drain line, it drained from the water heater, water softeners and laundry room, they had to seal it up. The facility had a sewer gas smell usually in the shop or laundry room. There were multiple sewer lines, it was wet but not an active leak. The problem was in the shop, the water was not draining. He worked at the facility 2 and 1/2 years and they have had problems with the sewer line off and on the whole time. They are getting money to get some things updated. During an interview, on 4/26/24 at 10:00 a.m., the Executive Director indicated the wet carpet was extracted again and walk off mats (absorbs water from feet) were placed on the linoleum floors. The smells in the front hall and back hall were probably sewer, the back hall especially. The clean-out drain was located at the back of the building. When it rained, it could smell more. A current policy, titled Walls Preventative Maintenance, dated 2/18/2018 and received from the Executive Director, on 4/29/24 at 3:20 p.m., indicated . it is the policy to inspect common area and corridor walls monthly resident room walls are inspected during routine semi-annual preventative maintenance .survey the wall for any pain or wallcovering that needs repair .protect floor with a drop cloth while painting, touch up painting requires painting walls from break point to break point . Touching up spots on the walls is not an acceptable practice .glue lose vinyl wallcovering seams .inspect handrails for splintering and make sure they are tightly secured 3.1-19(f)(5)

Based on interview and record review, the facility failed to protect a resident from misappropriation of medication when a medication card for narcotics (30 tablets) was discovered to be missing from the facility's double locked medication cart for 1 of 1 resident reviewed for misappropriation of property. (Resident G) The deficient practice was corrected on 9/21/23, prior to the start of the survey, and was therefore past noncompliance. Finding includes: The record for Resident G was reviewed on 10/5/2023 at 1:10 p.m. Diagnoses included, but were not limited to, dementia, chronic kidney disease, anxiety, chronic pain, and anemia. An incident report to the Indiana Department of Health, on 8/30/2023, indicated it was reported Resident G's narcotic medication card was missing from the narcotic locked box. A search and investigation did not find the narcotic card with 30 hydroco/APAP 5-325 tablets. The physician and police were notified. A packing slip, dated 8/24/2023, from the pharmacy indicated the medication hydroco/APAP tab 5-325 mg 30 tablets for Resident G was delivered to the facility on [DATE] at 1:23 a.m. The medication was signed as received by RN 3. A scheduled record for narcotic reconciliation indicated the medication was entered in to the 200-memory car front cart on 8/25/2023. A nursing schedule for the memory care unit 200 front cart, on 8/28/2023 through 8/30/2023, indicated staff member 4 was on duty from 8/28/2023 at 2:00 p.m., until 8/29/2023 at 2:00 a.m. LPN 6 was on duty from 8/29/2023 at 2:00 a.m., until 8/29/2023 at 2:00 p.m. QMA 5 was on duty from 8/29/2023 at 2:00 p.m., until 8/29/2023 at 10:00 p.m. RN 3 was on duty from 8/29/2023 at 10:00 p.m., until 8/30/2023 at 6:00 a.m. QMA 2 came on duty on 8/30/2023 at 6:00 a.m. The facility investigation indicated during reconciliation of the narcotics on the day shift, on 8/30/2023, by staff members QMA 2 and RN 3, it was observed Resident G had a narcotic medication card missing. The facility Executive Director (ED) was notified, and all medication carts were checked for the missing card and corresponding documentation sheet. No card and sheet were found in any cart. The police were notified, and the investigation continued. All staff were interviewed. The staff sign on and off narcotic reconciliation records indicated no missing medications. The missing medications were replaced by the facility with no cost to the resident. The resident received the medication when she needed it. There was no break in care. The resident did not have any harm associated with the missing mediations. The staff were in serviced on narcotic reconciliation. The narcotic records have an ongoing audit system in place. During an interview, on 10/5/2023 at 1:19 p.m., the Executive Director (ED) indicated QMA 2 notified her of a medication issue. QMA 2 indicated the narcotic card and documentation sheet were noted to be missing on 8/30/2023 during the 6:00 a.m., narcotic reconciliation. QMA 2 indicated she saw the missing narcotic card and sheet, on 8/27/2023, in the narcotic box. An audit of all carts was initiate. The missing card and sheet were not found. The documentation for the pharmacy receipt of the medication was found signed by RN 3, on 8/25/2023 at 1:23 a.m. The medication card was added to the locked narcotic box in the front memory care medication cart. QMA 2 indicated she had seen the medication card in the locked narcotic box, on 8/27/2023. QMA 4 saw the narcotic card, on 8/29/2023 at 2:00 a.m. The narcotic card and documentation sheet were both discovered missing. The ED interviewed QMA 4 who indicated the card was in the locked box and counted with LPN 5, on 8/29/2023 at 2:00 a.m. The ED indicated staff could not remember whether the medication and sign out sheet was available for reconciliation from 2:00 a.m., on 8/29/2023 until 8/30/2023 at 6:00 a.m. During an interview, on 10/5/2023 at 2:47 p.m., LPN 6 indicated when she counted the narcotics at 2:00 a.m., on 8/29/2023 with QMA 4, who was the outgoing staff member, she did not remember seeing or counting the medication card or sheet for Resident G. She completed a narcotic reconciliation with QMA 5 at 2:00 p.m., on 8/29/2023, and did not remember seeing or counting the medication for Resident G. During an interview, on 10/5/2023 at 2:39 p.m., QMA 4 indicated when she counted the narcotics at 2:00 a.m., on 8/29/2023 with LPN 6, she did remember seeing and counting the medication card for Resident G. The card was the first card in the rack, and it was full. She did not see the documentation sheet; LPN 6 was doing that part of the narcotic reconciliation. She was not aware the card and sheet had gone missing until she was interviewed by the ED regarding the missing mediations on 8/30/2023. During an interview, on 10/5/2023 at 3:04 p.m., with QMA 2, via a phone conversation, she indicated when she counted the narcotics at 6:00 a.m., on 8/30/2023 with RN 3, who was the outgoing staff member, she did not see the medication card for Resident G. She remembered the card to be in the narcotic box a few days earlier. The documentation sheet was also noted to be missing. She notified the ED and a search for the medications and documentation sheet was started. During an interview, on 10/5/2023 at 3:11 p.m., QMA 5 indicated when she counted the narcotics at 2:00 p.m., on 8/29/2023 with LPN 6, who was the outgoing staff member, she did not remember seeing or counting the medication card or sheet for Resident G. The card was the first card in the rack, and it had been full, she saw the card when she worked on Sunday, 8/27/2023. She did not see it on 8/29/2023. She thought the medication had been discontinued. She did not think it was missing or stolen. During an interview, on 10/5/2023 at 4:55 p.m., the Clinical Support Staff indicated the staff had all been in serviced on narcotic reconciliation. The last date was 9/21/2023. She indicated an audit of staff narcotic reconciliation was on going. A current policy, titled Guidelines for Narcotic Count, dated as last reviewed on 12/31/2022 and received from the Regional Support Staff on 10/5/2023 at 1:52 p.m., indicated .1. Each controlled drug shall have a corresponding count sheet to track distribution .At the time one nurse or other staff qualified to pass medications relinquishes the keys to the medication cart to another staff member the narcotics shall be reconciled by comparing the medications in the cart to the count sheets. 5. Both staff members shall sign that the narcotic count is accurately reconciled The deficient practice was corrected by 9/21/23 after the facility implemented a systemic plan which included the following actions: The facility investigated the incident involving Resident G missing medications, educated the staff on narcotic reconciliation, reimbursed the resident, and began audits on narcotic reconciliation documentation. 3.1-28(a)

Based on interview and record review, the facility failed to ensure 100% of their staff were fully vaccinated, when 4 of 5 partially vaccinated staff members did not complete their second Covid-19 vaccination as required for the vaccine mandate. (CRCA 1, RCA 2, CRCA 3 and Payroll staff 4). In the last 4 weeks, the facility had 26 positive residents, three hospitalized and four deaths. (Residents E, F, G and H). The immediate jeopardy began on [DATE], when Resident Care Assistant (RCA 2) should have received the second Covid-19 vaccination after having the first Covid-19 vaccination on [DATE]. Certified Resident Care Assistant (CRCA) 1 received the first Covid-19 vaccination on [DATE] and was due for the second vaccine on [DATE]. CRCA 3 received the first Covid-19 vaccine on [DATE] and was due for the second vaccine on [DATE]. Payroll staff 4 had received the first Covid-19 vaccine on [DATE] and was due for the second vaccine on [DATE]. The facility had a Covid-19 outbreak which started on [DATE] with a total of 26 residents who tested positive. Three residents were hospitalized (Residents E, F and G) and four resident died (Resident E, F, G and H). Finding includes: A review of staff vaccination records, indicated the following: 1. A CHIRP (Children and [NAME] Immunization and Registry Program) Vaccination detail, dated [DATE], indicated RCA 2 had received the Pfizer Covid-19 vaccination on [DATE]. This was the only Covid-19 vaccine recorded. 2. A CHIRP Vaccination detail, dated [DATE], indicated CRCA 1 had received the Pfizer Covid-19 vaccination on [DATE]. This was the only Covid-19 vaccine recorded. 3. A CHIRP Vaccination detail, dated [DATE], indicated CRCA 3 had received the Pfizer Covid-19 vaccination on [DATE]. This was the only Covid-19 vaccine recorded. 4. A CHIRP Vaccination detail, dated [DATE], indicated Payroll staff 4 had received the first Covid-19 vaccine on [DATE]. This was the only Covid-19 vaccine recorded. A Trilogy Health Services Statement of Witness Form, dated [DATE], indicated RCA 2 was interviewed and verified she had not received the second Covid vaccine. A Trilogy Health Services Statement of Witness Form, dated [DATE], indicated CRCA 1 was interviewed and verified she had not received the second Covid Vaccine. A Trilogy Health Services Statement of Witness Form, dated [DATE], indicated CRCA 3 was interviewed and verified she had not received the second Covid Vaccine. A Trilogy Health Services Statement of Witness Form, dated [DATE], indicated Payroll 4 was interviewed and verified she had not received the second Covid vaccine. A review of resident records, indicated the following: 1. The record for Resident E was reviewed on [DATE] at 10:30 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's progress notes indicated the resident was admitted to the hospital on [DATE] and returned to the facility [DATE]. The facility's LTC Respiratory Surveillance Line List indicated Resident E tested positive for Covid [DATE] and died on [DATE]. 2. The record for Resident F was reviewed on [DATE] at 10:40 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's progress notes indicated the resident was admitted to the hospital on [DATE] and returned to the facility [DATE]. The facility's LTC Respiratory Surveillance Line List indicated Resident E tested positive for Covid [DATE] and died on [DATE]. 3. The record for Resident G was reviewed on [DATE] at 10:50 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's progress notes indicated the resident was admitted to the hospital on [DATE]. The facility's LTC Respiratory Surveillance Line List indicated Resident E tested positive for Covid [DATE] and died on [DATE]. 4. The record for Resident H was reviewed on [DATE] at 12:43 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's LTC Respiratory Surveillance Line List indicated Resident H tested positive for Covid on [DATE] and died on [DATE]. He was not hospitalized . During an interview, on [DATE] at 2:53 p.m., Clinical Support staff indicated the facility did not have the Pfizer vaccine until recently and would hold a vaccination clinic this week. The staff could have gone to other places in the community to get the second vaccine. The Director of Health Services (DHS) was responsible for the vaccination effort for the facility. During an interview, on [DATE] at 10:15 a.m., Clinical Support staff indicated RCA 2 and CRCA 1 had only received one Covid-19 vaccine and should have received the second dose in March of 2022 so they were a couple of months past due in getting the second Covid-19 vaccine. CRCA 3 and Payroll staff 4 also only received the first Covid-19 vaccine and should have received the second vaccine in March and [DATE]. A current policy, titled COVID-19 Health Care Staff Vaccination, dated [DATE] and received from the DHS upon entrance, indicated .This policy sets forth vaccination requirements for all employees of Trilogy Management Services .This policy is intended to comply with applicable federal, state, and local laws and regulations, as well as guidance from the Centers for Disease Control and Prevention .As a condition of employment, each current employee shall receive the vaccinations required under this policy or obtain an approved accommodation and will comply with the following on an annual basis .Provide proof of vaccination for Influenza and COVID .or .Obtain an approved accommodation .due to employee's inability to receive the vaccination because such employee is disabled or has a qualifying medical condition that contraindicates the vaccination .or Due to the employee's sincerely held religious practice of belief .All facility staff shall complete and maintain COVID-19 vaccination unless granted an exemption/accommodation to the vaccination requirements or those whose vaccination has been temporarily delayed, as recommended by the CDC, due to clinical precautions and consideration. All facility staff as specified above shall follow the Trilogy Employee and Other Vaccination Policy regarding obtaining COVID-19 vaccination and the process for obtaining an exemption .After the hiring decision and before the first day of work the new hire must provide proof of COVID vaccination [at least one dose completed] or indicated the need for an accommodation .An employee who fails to comply with any of the provisions of this policy is subject to appropriate corrective action up to and including, without limitation, suspension .or termination of employment .An employee who is disabled, has a qualifying medical condition that is a contraindication to the vaccination or who objects based on sincerely held religious beliefs and practices may request a reasonable accommodation with respect to the vaccine requirements under this policy .The facility must develop and maintain a tracking system for facility staff regarding COVID-19 vaccination .Tracking system to include .Facility staff member .Specific vaccine received including manufacturer and date of each dose or date off next scheduled dose .Booster information including date of booster and manufacturer .If granted an exemption, include the type of exemption .List any temporary delays in vaccination and include when the staff member can safely resume the vaccination The immediate jeopardy, that began on [DATE], was removed on [DATE] when the facility completed the following: All staff were educated on vaccine requirements for employment, the hiring managers were educated on vaccine requirements for employment, all residents were assessed for Covid-19 signs and symptoms and staff members were removed from the schedule until back in compliance with vaccination status. This Federal Tag relates to Complaints IN 437 and IN 664. 3.,d+[DATE](a)

Based on interview and record review, the facility failed to timely identify a significant weight loss, to timely implement interventions for the significant weight loss and to prevent further weight loss for a cognitively impaired resident for 1 of 3 residents reviewed for nutrition (Resident E). Resident E had a significant weight loss of 11.01% in 31 days. Finding includes: During a dining observation, on 1/21/2022 at 5:17 p.m., 21 residents were in the dementia dining room. Resident E was in her room, laying on the bed with her eyes closed and the room darkened. There was a tray on the bedside table across the room and the food had not been unwrapped yet. During an observation, on 1/21/2022 at 5:31 p.m., Resident E was still laying in her bed and the room was darkened. The food tray still was across the room, on the bedside table, and the food was not unwrapped. During an interview, on 1/21/2022 at 5:45 p.m., QMA 10 indicated Resident E would come out of her room occasionally for supper and the resident was a light eater. She usually wanted peanut butter and jelly, soup or something light for supper. The record for Resident E was reviewed on 1/21/2022 at 3:50 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 10/14/2019, indicated the resident had the potential for alteration in her nutritional status related to her diagnosis, medications, diet, intake and physical activity. The long term goal was to maintain a healthy weight range without any unwarranted significant weight changes. The approaches included, but were not limited to, assist with meals as needed and to obtain weight as ordered/needed. The resident had the following weights: a. On 11/28/21, the weight was 109 pounds. b. On 12/2/21, the weight was 101.4 pounds which was a significant weight loss of 6.97% in 4 days. c. On 1/2/22, the weight was 97 pounds which was a significant weight loss of 11.01% in 31 days. A nutrition progress note, dated 12/18/21 at 1:50 p.m., indicated the resident had a weight loss of 5.2% in 30 days which was significant. The resident intakes were less than noted in prior reviews and she may benefit from additional supplement with Med Pass. An event report, dated 12/18/21 at 1:53 p.m., indicated the RD (registered dietician) recommendation was for Med Pass 120 ml (milliliter) once daily. The resident had experienced a significant weight loss and also a decline in meal intakes. The progress note and event report were entered 16 days after the significant weight loss occurred. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An Event Report, dated 1/5/22, indicated the RD had recommended fortified foods or shakes with meals. The resident had experienced a significant weight loss and the RD recommended adjustments to the oral supplements. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview, on 1/24/22 at 2:33 p.m., the DHS indicated the resident's significant weight loss occurred on 12/2/21. The first documentation of the significant weight loss was when the RD entered the note on 12/18/21. She indicated the physician was not notified of the recommendation for the Med Pass supplement until 12/26/21 which was 8 days after the RD made the recommendation. The physician was not notified of the RD recommendation for the fortified shakes until 1/17/22 which was 12 days after the RD made the recommendation. The DHS was responsible for sending the RD recommendations to the physician. A current facility policy, titled Guidelines for Weight Tracking, dated 5/22/2018 and received from the clinical support on 1/24/2022 at 3:30 p.m., indicated .To ensure resident weight is monitored for weight gain and/or loss to prevent complications arising from compromised nutrition/hydration .The facility dietician or representative will review the resident's nutritional status, usual body weight and current weight to implement a nutritional program when warranted .The physician, responsible party and dietician shall be notified of the a weight variance of >5% [unless on a planned weight loss or gain program] This Federal Tag relates to Complaint IN 573. 3.2-46(a)(1)

Based on record review and interview, the facility failed to administer an anticoagulant as ordered and failed to hold an anticoagulant as ordered for 1 of 3 residents reviewed for unnecessary medication (Resident D). Resident D had to receive an antidote of vitamin K due to elevated lab results and increased bruising. Finding includes: 1. The record for Resident D was reviewed on 1/21/22 at 2:53 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 12/14/21, indicated the resident was at a risk for excessive bleeding and bruising related to medication. The approaches included, but were not limited to, administer medication as per physicians orders, labs as ordered and notify the physician of abnormal labs and notify the physician of abnormal bruising and or bleeding. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note, dated 12/21/21 at 11:52 a.m., indicated the nurse found a fax from 12/17/21 with new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An Event Report, dated 12/21/21, indicated the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The missing doses were on 12/17/21, 12/18/21, 12/19/21 and 12/20/21. During an interview, on 1/24/22 at 3:48 p.m., the clinical support indicated the paperwork found on 12/17/21 was not followed. The resident was not given any [MEDICATION(S)] between 12/17/21 and 12/20/21 and should have received the medication. 2. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An Event Report, dated 1/17/22, indicated the [MEDICATION(S)] order was not taken off the MAR (Medication Administration Record) when ordered to be on hold for (1/15/22 and 1/16/22). A progress note, dated 1/17/22 at 10:52 a.m., indicated the PT/INR was taken. The INR increased to 8 (critical which indicated an increased risk for bleeding). A progress note, dated 1/17/21 at 2:15 p.m., indicated a new order to recheck INR on 1/18/21 and to monitor for blood in the urine or stools, bleeding gums, severe headache or petechia (tiny brown/purple spots due to bleeding under the skin). A progress note, dated 1/18/22 at 9:16 a.m., indicated the resident had a 17 cm (centimeter) by 14 cm dark purple and black bruise on the right thigh. A progress note, dated 1/21/22 at 3:48 p.m., indicated a new order was received for a 1 time dose of Vitamin K 10 mg injection due to increased bruising. During an interview, on 1/24/21 at 3:48 p.m., the clinical support indicated she believed the resident received two doses of the [MEDICATION(S)] and she should not have. The resident received a one-time order for Vitamin K on Friday due to the bruising and the PT/INR lab results being over 8. A current facility policy, titled Guidelines for Medication Error Reporting, dated as revised on 5/10/16 and received from the Director of Health Services (DHS) on 1/24/22 at 4:23 p.m., indicated .In the event of a medication error, nursing personnel should first take whatever immediate action is necessary to protect he resident's safety and welfare .Notify the attending physician promptly of the error .Initiate the appropriate Event form. Monitor the resident closely for 72 hours or as directed A current facility policy, titled Provider Notification Guidelines, dated as revised on 9/12/17 and received from the DHS on 1/24/22 at 4:23 p.m., indicated .The provider should be notified of critical lab results or an immediate need by phone as soon as the results are known with a response received before the call is completed if possible .During non-office hour times the nurse should notify the physician/provider by phone of abnormal lab results or the need for physician/provider intervention .The physician/provider may return his/her response to the facility by fax or phone .If the facility has not had a response to abnormal test results or request for physician/provider intervention within 12 hours or normal test results within 72 hours, the nurse on duty will call the physician to obtain further instructions .The 24 Hour report shall be utilized for the nurse to nurse communication regarding the status of notification and response back This Federal Tag relates to Complaint IN 573. 3.1-48(c)(2)

Based on interview and record review, the facility failed to ensure a resident was supervised while outside to prevent a fall for 1 of 6 residents reviewed for accidents (Resident B). This deficient practice resulted in Resident B falling from her wheelchair while unattended outside in the courtyard, resulting in a fractured left femur and left humerous. Finding includes: The record for Resident B was reviewed on 8/03/17 at 9:50 a.m. [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Fall Risk, please place alarms A facility document titled Resident First Meeting Minutes dated 1/16/17, indicated the resident had falls at home and was noncompliant with asking for assistance. Safety Devices to be placed were a pressure pad alarm to the bed and wheelchair. An Admission Minimum Data Set (MDS) assessment dated [DATE], indicated Resident B was an extensive 1 person assist with transfers. Balance during transitions indicated when moving from a seated to a standing position the resident was not steady and was only able to stabilize with staff assistance. The fall history indicated the resident had falls prior to admission. A facility document titled Fall Event dated 4/05/17, indicated Resident B had an unwitnessed fall after transferring herself from her bed to the bathroom. The alarm sounded when the resident stood up from her bed. Resident B hit her head on the bar in the bathroom and her head was tender to touch. A Post Fall Interdisciplinary Team (IDT) review indicated a new intervention was to use a walker for ambulation. A facility document titled Fall Event dated 4/27/17, indicated Resident B had an unwitnessed fall transferring herself from the bed to the bathroom. The event indicated .bed alarm not sounding but hooked up properly et (and) batteries working A Post Fall IDT review indicated a new intervention was to .check alarm function and that it is turned on Resident B's care plan dated 5/19/17, addressed the problem the resident had impaired cognition with associated short term memory impairment and was at risk for confusion, disorientation, altered mood and impaired or reduced safety awareness related to the [DIAGNOSES REDACTED]. Resident not to be left alone outside or on toilet due to poor safety awareness and risk for falls A progress note dated 6/08/17 at 12:50 a.m., indicated .Resident refused to allow aid to assist in pulling up pants destabilizing feet et (and) resident fell between toilet et wall .Ill-fitting pants (too long) removed A facility document titled Fall Event dated 6/08/17, indicated Resident B had a witnessed fall in the bathroom while trying to pull her pants up and refused staff assistance. A Post Fall IDT review indicated a new intervention was to .monitor need for antianxiety medication to assist with decrease in resistance with care Resident B's morphine (a pain medication) and Lorazepam (an antianxiety medication) dosage was increased following the fall due to .continuing anxiety and worsening pain . A progress note dated 6/11/17 at 12:05 a.m., indicated the resident was found sitting on the floor and stated she was going to the bathroom and fell . A facility document titled Fall Event dated 6/11/17, indicated Resident B had an unwitnessed fall transferring herself back to bed. A Post Fall IDT review indicated a new intervention was to place hipsters. A progress note dated 6/16/17 at 4:10 a.m., indicated .Alarm going off. Arrived in room to find resident sitting on toilet A progress note dated 6/25/17 at 7:30 a.m., indicated .Resident found ambulating to the bathroom per self. Alarms sounding A progress note dated 6/25/17 at 8:00 a.m., indicated .Alarm sounding. Writer entered room and resident was wondering in room A progress note dated 7/05/17 at 12:06 p.m., indicated Resident B was in her room with an aid and was refusing to allow the aid to help her and while resisting care the resident fell against the closet and hit her head on the dresser. A facility document titled Fall Event dated 7/05/17, indicated Resident B had a witnessed fall in her room while resisting care. The resident lost her balance and fell against the closet, hitting her head on the dresser. Post Fall IDT review indicated a new intervention was to use calm redirection and approach during episodes of agitation. A progress note dated 7/07/17 at 2:18 p.m., indicated Resident B was attempting to self transfer herself from her bed to her bathroom throughout the shift. A progress note dated 7/07/17 at 7:05 p.m., indicated the staff was alerted to the resident's room with the alarm sounding from her bed. The resident was found sitting upright on the floor at the end of her bed. The resident was found to have on regular socks with no shoes. A facility document titled Fall Event dated 7/07/17, indicated Resident B had an unwitnessed fall transferring herself from her bed. Post Fall IDT review indicated a new intervention was to .place non-skid socks on the resident to assist with the prevention of slipping A progress note dated 7/19/17 at 9:45 a.m., indicated .Res (resident) fell from w/c (wheelchair) while out in the courtyard. Res had been sitting in w/c enjoying warm weather. States she was attempting to go to the toilet. Res earlier attempting to stand and use food cart as walker to get to toilet The resident had been incontinent of bowel three times today and the stools were soft and semi-loose. Resident B stated she did not want to move left elbow related to pain of a skin tear. Left knee had two shallow abrasions. A facility document titled Fall Event dated 7/19/17, indicated Resident B had an unwitnessed fall while transferring herself. Post Fall IDT review indicated a new intervention was to install a self releasing seat belt to remind the resident not to stand unassisted. A facility document titled Resident First Meeting Minutes dated 7/19/17, indicated Resident B had falls on 7/05/17, 7/07/17 and 7/19/17, to .add: Velcro seat belt don't let out alone A progress note dated 7/19/17 at 6:00 p.m., indicated the Medical Doctor saw the resident and ordered an x-ray to the left hip. Resident had a complaint of pain and would not allow staff to do any range of motion to the area. A progress note dated 7/20/17 at 1:20 a.m., indicated FALL: X-ray results back with Acute markedly displaced intertrochanteric fracture of the Proximal L (left) Femur .Held mid-noc (night) dose of Ativan d/t (due/to) sedation . winces when touched/moved for bedcheck (incontinence), L leg with considerable external rotation A progress note dated 7/20/17 at 12:08 p.m., indicated the Nurse Practitioner was in to evaluate the resident. New order for a 2-view of the left shoulder and clavicle x-ray. A progress note dated 7/20/17 at 1:15 p.m., indicated .x-ray results show intact clavicle, but a 'fracture involving the humeral neck with minimal displacement' .Spoke with res about results. Educated repeatedly to not attempt to reposition or transfer independently. Nodded head in understanding, but cognitive functioning/judgement limited . A progress note dated 7/20/17 at 4:38 p.m., indicated the resident had attempted to transfer out of her bed at 3:40 p.m. Bilateral bolsters to the lower sides of bed were applied. During an interview on 8/03/17 at 12:44 p.m., RN 1 indicated on the morning of 7/19/17, Resident B was in the hall and wanted to go to the bathroom. He indicated he took her to the toilet and she was incontinent of bowel, so he cleaned and changed her and brought her back out into the hallway. She indicated to RN 1 she wanted to go outside and he told her after he finished picking up the trays he would take her out. He indicated Resident B started taking off toward the courtyard, so he stopped and went with her and while he was outside CNA 1 came to the door and told him he was needed inside. Resident B refused to come back inside with him. He indicated he entered the building and told CNA 1 to go outside with Resident B and before CNA 1 was able to get outside the resident was out of her chair and on the ground. During an interview on 8/03/17 at 1:05 p.m., the Director of Health Services indicated she was in the building all day and was not notified of Resident B's fall until noon. She indicated yes when asked if Resident B was left unattended outside. She indicated .however she was not alone for more than 5 minutes She indicated the resident's fall was witnessed, but the CNA could not get to the resident before she fell . During an interview on 8/03/17 at 1:11 p.m., CNA 1 indicated on the morning of 7/19/17, she was transporting a resident back from the dining room when she noticed Resident B was outside alone. She indicated when she turned the corner RN 1 was at his medication cart on the north side of the 300 hall. She asked RN 1 about Resident B being outside alone and he indicated she was talking about smoking cigarettes and wanted to go outside, so he put her out there. CNA 1 indicated she turned around to go out and get Resident B and when she got out there Resident B was lying on her back on the ground and her pressure alarm to her wheelchair was not sounding. A current policy titled Fall Management Program Guidelines dated 5/31/17, provided by Director of Health Services on 8/3/17 at 2:20 p.m., contained the following, .Purpose: (Name of Facility) strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures This Federal tag relates to Complaint IN 422. 3.1-45(a)(2)

Based on record review and interview, the facility failed to provide timely prevention interventions and treatments to pressure ulcers for 2 of 3 residents reviewed for pressure ulcers. The residents were admitted with reddened areas that progressed to Stage 2 and 3 pressure ulcers. (Resident #12 & #48) Findings include: 1. The record for Resident #12 was reviewed on 8/21/13 at 3:45 p.m. [DIAGNOSES REDACTED]. A Nursing Admission Assessment document, dated 7/10/13, indicated red abdominal folds, present upon admission. A Skin Care Plan, dated 7/10/13, on the Nursing Admission Assessment document, indicated as an intervention, "prevent skin from touching skin". During an interview, on 8/20/13 at 5:00 p.m., the Director of Nursing (DON) indicated the red area was at her pants line, on her abdomen and said, "I don't believe there was an intervention implemented to prevent skin from touching skin." Physician assessment and progress notes, dated 7/10/13, exhibited no indication the abdomen was evaluated; there was no mentioning of redness to abdominal folds. A document titled, Skin Impairment Circumstance, Assessment and Intervention, dated 7/15/13, indicated the location of a stage 2 pressure wound impairment was to the right abdominal fold. During an interview with the DON on 8/20/13, at 5:00 p.m., the DON indicated she was informed of Resident #12's skin impairment on 7/15/13. A document titled, Skin Impairment Circumstance, Assessment and Intervention, dated 7/15/13, indicated the physician was notified of a Stage 2 pressure area to Resident #12's right abdominal fold on 7/16/13. Physician orders, dated 7/16/13, indicated the following, "Therahoney to right abdominal area, cover with [MEDICATION NAME], change every day." Wound Tracking documents, for Resident #12, indicated the following measurements, to the right abdominal fold, pressure ulcer: 7/16/13 Stage 3, 2.0 x 2.0 x less than 0.1 cm. (centimeters) 7/23/13 Stage 3, 1.2 x 1.2 x less than 0.1 cm. 7/30/13 Stage 3, 1.0 x 1.0 x less than 0.1 cm. A Resident First Conference note, dated 7/31/13, indicated Resident #12 had a Stage 3 pressure ulcer at the abdominal fold. The documentation provided failed to indicate the physician assessed the Stage 3 pressure area. During an interview with the DON, on 8/20/13 at 5:30 p.m., she indicated it is not typical for a resident with a Stage 3 pressure area to not be evaluated by a physician or a nurse practitioner. She indicated there were no notes to indicate any evaluation by a physician. 2. The clinical record of Resident #48 was reviewed on 8/21/13 at 1:30 p.m. Resident #48 was admitted to the facility on [DATE]. An Initial Nursing Assessment, dated 5/17/13 (no time noted), indicated red pressure areas on the left and right buttocks. The Resident was resistive to the initial body assessment regarding skin issues. Admitting Physician orders, dated 5/17/13, included but were not limited to, Riley's buttocks cream for redness and a Prime Air Mattress with setting at 120 - 164 pounds. A Nursing note, dated 5/18/13 at 9:00 p.m., indicated "Resident is still resistive to skin assessment." A Nursing note, dated 5/20/13 at 1:00 a.m., indicated "Open area to left inner buttocks 1 (centimeter) x 0.5 x <0.1...Multiple layers of scar tissue around area et (and) on buttocks... this is a chronic issue (per hx (history)) ..." A Pressure Ulcer Assessment, dated 5/20/13, indicated a Stage II Pressure Ulcer on the left inner buttocks, 1 x 0.5 x <0.1. Treatment was started to the area with cleansing and Therahoney. Measurements were as follows: 5/21/13 1.0 x .3 x <0.1 (The Softflex air overlay was placed on the bed) 5/28/13 1.5 x 1.5 (A Roho cushion was placed in the wheelchair 5/30/13) 6/4/13 1.3 x 1.6 x <0 6/11/13 1.0 x 1.0 x <.1 6/18/13 0.6 x 0.6 6/25/13 healed A Pressure Ulcer Assessment, dated 5/26/13, indicated a Stage II Pressure Ulcer to the right inner buttocks, 2.6 x 1.6 x .1. Treatment was started with cleansing, Therahoney and [MEDICATION NAME]. Measurements were as follows: 5/29/13 1.5 x 2.0 6/4/13 .5 x 3.4 x <1 6/11/13 1.0 x 0.5 x <.1 6/18 healed. A Pressure Ulcer Assessment, dated 5/26/13, indicated a Stage II Pressure Ulcer on the coccyx, .2 x .2 x <0.1. Treatment was started with calzyme cream with each incontinence episode and every shift. Measurements were as follows: 5/29/13 0.4 x 0.4 (Order changed to cleanse area, Threahoney and cover with a dressing) 6/4/13 0.6 x 0.5 x <0.1 6/11/13 0.1 x 0.1 x<0.1 6/18/13 0.1 x 0.1 6/25/13 healed During an interview with the Director of Nursing, on 8/21/13 at 3:30 p.m. she indicated the areas were not properly assessed when the resident was admitted on [DATE] and the air mattress was not placed on the bed until 5/21/13. 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to accurately assess and provide treatment for [REDACTED]. (Resident #2 and #38). Findings include: 1. On 4/26/11 at 2:00 P.M., with RN #1 and CNA #6, Resident #2 was assisted to stand with a walker. There was a clear bandage on the resident's left hip. The bandage was removed by the RN. The skin on the left hip was intact with pinpoint-sized dark area in the center. There was scar tissue surrounding the dark area. Resident #2's clinical record on 4/26/11 at 10:10 A.M. The resident was admitted with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) quarterly assessment dated [DATE] indicated the resident was severely impaired in cognitive decision-making skills, required limited one-person physical assistance in bed mobility, transfer, toilet use, and personal hygiene, had no pressure ulcers, and had no interventions in place. A current resident care plan dated 7/23/10 and updated 10/21/10 indicated "...potential for alteration in skin integrity...interventions...assess/record changes in skin status...barrier cream to perineal area p (after) each incontinet (sic) episode...nutrashield (a moisture barrier) to skin prn (as needed) dryness...provide/monitor effectiveness of pressure relieving or reduction device(s): pressure reducing mattress (indicated by checkmark)...chair cushion (indicated by checkmark)..." A resident care plan dated 3/28/11 indicated "...Unstageable pressure area to (L) (left) hip measures 1 cm (centimeters) x 1 cm...remind res to change (indicated by triangle) position with care while in bed...tx (treatment) as ordered...pressure reducing mattress...assess/record changes (indicated by triangle) in area..." A nurses' note dated 3/28/11 at 4:00 P.M. indicated "Unstageable pressure area to (L) hip observed. Currently measures 1 cm x 1 cm c (with) dry necrotic wound bed..." "Pressure/Stasis/Arterial/Diabetic Ulcer Assessment sheets indicated: 3/28/11 "Present on admission? N (circled)...Pressure (circled)...Stage/Thickness: E (unstageable)...Length 6 cm...Width 6 cm...Depth undetermined..." 4/4/11 "...unstageable...L (length) 0.7 W (width) 0.9...black eschar..." 4/11/11 "...L 0.2 W 0.5 D 0.1...pink..." A "Clinically at Risk Individual Monitoring Sheet" dated 3/31/11 indicated "...staff interviewed felt perhaps it was an area where a brief tag could have irritated or it was also identified that the resident preferred to lay on that (L) side. On 3/28/11 the area was reassessed and noted to be a pressure area c (with) eschar...Biofine c (with) [MEDICATION NAME] (a dressing) tx (treatment)..." A physician order [REDACTED]." A Treatment Administration Record (TAR) dated March 2011 indicated documentation was lacking related to a barrier cream being used. Further review of the TAR indicated the Biofine dressing had not been applied on 3/28 2011 through 3/31/11. A "Geriatrics Nursing Home Progress Note" dated 4/6/11 indicated "...1 cm black eschar c (with) underlying induration (L) hip...pressure ulcer (L) hip...refer to Wound Care..." A wound center noted dated 4/8/11 indicated "...pressure ulcer...0.7 x 0.5 x 0.1...eschar: 76-100%...measured over the eschar/scab today prior to debridement....no dressing on wound upon arrival into clinic..." A physician's orders [REDACTED]. Start [MEDICATION NAME] (a dressing) to (L) hip wound et change (indicated by triangle) q (every) 3 days..." A TAR dated April 2011 indicated the [MEDICATION NAME] had been applied on 4/11/11, 4/16/11 (5 days), and 4/22/11 (6 days). Documentation was lacking to indicate the [MEDICATION NAME] had been reapplied after 4/22/11. Interview on 4/26/11 at 12:30 P.M. with RN #1 indicated she was unaware of how the pressure ulcer was not found until it was unstageable. She indicated CNAs should be checking residents' skin with daily care. She indicated there was no documentation of the barrier cream being used. She indicated the [MEDICATION NAME] was not documented as being done as ordered. Review on 4/26/11 at 3:07 P.M. of an undated policy and procedure provided by the Director of Health Services titled "General Wound and Skin Care Guidelines" indicated "...Reevaluate dressing and skin integrity every shift..." 2. During an observation on 4/28/11 at 1:34 p.m., Resident #38 was in a wheel chair with non-skids socks on her feet. The resident's feet were resting on the floor. There were no prevalon boots in place. Resident #38's record was reviewed on 4/28/11 at 3:00 p.m. [DIAGNOSES REDACTED]. Documentation indicated the resident had a healing unstageable ulcer to the right heel. A physician's orders [REDACTED]." During an interview with RN #1 on 4/28/11 at 1:35 p.m., she indicated Resident #38 should have had the prevalon boots in place as ordered by the physician. During an interview with CNA #21 on 4/28/11 at 1:37 p.m., she indicated she "forgot to put them on her this morning, she was supposed to have them on." During an interview with RN #3 and the Clinical Support Nurse on 4/26/11 at 2:50 p.m., they indicated the prevalon boots should have been in place as ordered. 3.1-40(a)(1) 3.1-40(b)(2)