Every finding on record at University Heights Health and Living Community

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 3 residents reviewed. A controlled substance medication was given routinely instead of as needed. (Resident C) This deficient practice was corrected on August 11, 2026, prior to the start of the survey, and was therefore past noncompliance. Finding includes: On 8/24/26 at 11:25 a.m., Resident C's clinical record was reviewed. Resident C's diagnoses included, but were not limited to, dementia, congestive heart failure (a chronic condition where the heart muscle cannot pump blood efficiently), and cerebrovascular disease (a term for any condition that temporarily or permanently reduces blood flow or damages blood vessels in the brain). A Nursing Progress Note, dated 8/7/26 at 3:31 p.m., indicated Resident C returned to the facility from the hospital and all orders were entered into the eMAR (electronic medication administration record system). A Hospital Discharge summary, dated from 8/4/7 to 8/7/26, included, but was not limited to, an order to start taking Lorazepam (an anti-anxiety medication) 0.5 mg (milligrams)/0.25 mL (milliliters) concentrated oral solution as follows: Take 0.25 mL (0.5 mg total) by mouth every 2 (two) hours as needed for Anxiety.A review of the eMAR record for Resident C's lorazepam order from 8/7/26 through 8/11/26 indicated the following: Lorazepam concentrate; 2 mg/mL (equivalent to 0.5 mg/0.25 mL); amount to administer; give 0.25 mL (equivalent to 0.5 mg per dose); sublingual (under the tongue) with a frequency of every 2 hours scheduled on every even hour. The lorazepam order was marked as either given, or given but given late, for every 2-hour medication administration time on the even hours from 10:00 p.m. on 8/7/26 until 6:00 a.m. on 8/10/26 with the exception of the 2:00 p.m. dose on 8/8/26, which was marked as not administered due to condition. The lorazepam order was marked as not administered discontinued on 8/10/26 for the 8:00 a.m., 10:00 a.m., and 12:00 p.m. scheduled medication times, and the order was no longer active in the eMAR after 2:00 p.m. on 8/10/26. During an interview on 8/24/26 at 11:18 a.m., a family member of Resident C indicated that on Monday August 10, Resident C was extremely lethargic and overmedicated. Family noted that when Resident C came back on Friday August 7, the resident was acting fine, and that on Saturday August 8 the resident seemed more tired. On Monday August 10, the resident was very lethargic and the family indicated nursing staff had realized the medication had been put in as scheduled every 2 hours, instead of able to be given every 2 hours as needed for symptoms of anxiety. During an interview on 8/25/26 at 9:10 a.m., the Director of Nursing (DON) confirmed that the eMAR record indicated that Resident C had received lorazepam doses every 2 hours from Friday August 7 at 10:00 p.m. though Monday August 10 at 6:00 a.m., with the except of the one dose held at 2:00 p.m. on Saturday August 8. The DON stated that the order should not have been entered into the eMAR system as an order to give every 2 hours scheduled, it should have been for every 2 hours as needed for appropriate symptoms if present as stated in the hospital discharge orders. On 8/25/26 at 11:10 a.m., the DON provided a copy of a Medication Administration: General Policies and Procedures policy, and indicated it was the policy currently in use by the facility. A review of the policy indicated that all medications were to be administered only as prescribed by a physician.This deficient practice was corrected on August 11, 2026, after the facility implemented a systemic plan of correction that included the following actions: staff education on verifying admission orders for accuracy and ongoing monitoring.This citation relates to Intake 3154411.410 IAC (Indiana Administrative Code) 16.2-3.1-48(c)(2)

Based on interview and record review, the facility failed to prevent a cognitively impaired resident residing on a locked memory care unit from exiting from the facility for 1 of 1 resident reviewed for elopement. (Resident E) The deficient practice was corrected on August 14, 2026, prior to the start of the survey, and was therefore past noncompliance. Finding includes: On 8/24/26 at 12:40 p.m., Resident E's clinical record was reviewed. Resident E's diagnoses included, but were not limited to, vascular dementia and Alzheimer's disease. Resident E admitted to the facility for placement on their locked memory care unit. An admission Assessment, dated 5/1/26, indicated that Resident E did not wander aimlessly, did not exhibit exit seeking behaviors, and did not have a history of elopement but that resident was appropriate for the locked memory care unit due to diagnoses and cognitive deficits. Resident E's most recent Quarterly MDS (Minimum Data Set) assessment, dated 8/3/26, indicated that resident was severely cognitively impaired. On 8/14/26 with a noted time of incident of 9:10 a.m., a facility reportable incident indicated Resident E had left the facility unaccompanied, staff were notified, and assisted the resident back into the facility. A Nursing Progress Note, dated 8/14/26 at 9:53 a.m., indicated Resident E followed a laundry staff member off of the memory care unit. At the front door, another staff member thought Resident E was a visitor and allowed him out the door. A call to the facility was received from the emergency room from the hospital facility next door to the facility saying they had a confused resident there with no identification. Staff immediately went to the emergency room next door to get Resident E. During an interview on 8/24/26 at 11:55 a.m., the Executive Director (ED), Director of Nursing (DON), Assistant Administrator (AA), and Assistant Director of Nursing (ADON) indicated Resident E was independently ambulatory and when Laundry Staff 7 had their cart trying to get through the memory care entrance door, Resident E approached fully dressed in a hat and jacket and said Let's go to Laundry Staff 7. Laundry Staff 7 thought Resident E was a visitor leaving the unit and let Resident E through. At the front desk, the AA was covering the front door at that time, saw Resident E who waved at the AA and the AA allowed Resident E out the front door. The facility received a call that a confused resident without identification was next door and staff immediately went to check where it was confirmed that it was Resident E. The ED estimated the time from Resident E leaving memory care unit door until Resident E was back in the facility was approximately 20 minutes. They stated that Resident E should not have been allowed out of the memory care unit door or out the front door. On 8/24/26 at 1:00 p.m., the memory care unit and front door were observed. The locked and keypad coded memory care unit door exits near the therapy gym and door was located approximately 50 feet from the front lobby door and the main entrance to facility. Outside the main entrance facing generally south was a large parking lot area and side road. A bit further south were more parking lot areas for the nearby hospital and to the immediate southeast next to the facility, approximately a few hundred feet away, was the main emergency room entrance for the hospital next to the facility. During an interview on 8/24/26 at 1:05 p.m., the Memory Care Coordinator (MCC) indicated that they went next door to get Resident E when the emergency department called the facility. The MCC said Resident E had wandered into other rooms since being there, but was easily redirected back to Resident E's own room. The MCC indicated that Resident E had previously not had any exit seeking behaviors or purposeful wandering and Resident E usually preferred to stay in his own room. The MCC indicated that Resident E's spouse took Resident E out often. The MCC indicated the approximate time from Resident E leaving the unit to returning to facility was about 15 minutes. The MCC indicated that Resident E should not have been let out of memory care unit or let out of the front door. This deficient practice was corrected on August 14, 2026, after the facility implemented a systemic plan of correction that included the following actions: staff education on LOA (Leave of Absence), residents attempting to leave, elopement and elopement risk policies, with ongoing monitoring. This citation relates to Intake 316887. 410 IAC (Indiana Administrative Code) 16.2-3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure follow-up for physician orders and instructions for care were obtained for a new positioning device (splint) following an off-site medical appointment for 1 of 1 resident reviewed for splints. (Resident 98) Findings includes: On 5/6/26 at 1:20 p.m., Resident 98 was observed sitting in a rocking chair in the activity room. Resident 98 was observed wearing a black positioning device (splint) on her left wrist. During an interview at that time, Resident 98 indicated she had worn the splint for a month or so. On 5/6/26 at 1:02 p.m., Resident 98's clinical record was reviewed. The diagnosis included, but was not limited to, a fractured carpal bone (small bone located in the left wrist). The fracture occurred on 2/20/26 as a result of a fall. The admission MDS (Minimum Data Set) assessment, dated 2/19/26, indicated Resident 98 was severely cognitively impaired. A progress note, dated 2/20/26 at 6:01 p.m., indicated Resident 98 had sustained a fall while in the nursing facility and as a result fractured her left wrist. Resident 98 had been transferred to the hospital emergency room for evaluation and treatment. A progress note, dated 3/30/26 at 10:54 a.m., indicated Resident 98 was accompanied by an unidentified Certified Nurse Aide (CNA) for a follow-up medical appointment with the orthopedic physician related to the fractured wrist.Resident returned to the facility with removal of cast.left forearm.resident has on a black splint with tie string.Resident is to wear splint at all times except for bathing.no paperwork received at this time and the CNA reported that the doctor office will call facility with the follow-up. Resident 98's clinical record lacked an updated physician order and associated instructions regarding the use and care of the splint, documentation related to the facility staff having contacted the physician for an updated physician order and associated instructions, and a revised care plan related to the new splint device. During an interview on 5/11/26 at 9:45 a.m., Unit Manager 3 indicated Resident 98's care plan had not been revised to include the new splint device until 5/8/26. During an interview on 5/11/26 at 11:18 a.m., the Director of Nursing (DON) indicated Resident 98's care plan should have been updated in March when she began wearing the splint. During an interview, on 5/11/26 at 1:30 p.m., the DON indicated the clinical record lacked a physician's order that indicated Resident 98 no longer required a cast and was to utilize a splint for the resident's left wrist. The clinical record also lacked the physician's instructions regarding the use and care of the splint. The nursing staff should have followed up with the physician. During an interview on 5/12/26 at 9:00 a.m., Unit Manager 3 indicated on 2/20/26 Resident 98 fell and sustained a fractured wrist. She wore a cast until 3/30/26 at which time the physician removed the cast and then applied a black splint. The physician's office neglected to provide to the facility, a new order for the splint and the associated instructions for the splint. The facility staff should have contacted the physician to obtain current medical information related to the resident's updated health status. During an interview on 5/12/26 at 11:15 a.m., the DON indicated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility. On 5/11/26 at 1:00 p.m., the DON provided a copy of the Care Plan, Comprehensive Person-Centered policy, dated December 2016, and indicated it was the current policy in use by the facility. A review of the document indicated, .Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' condition change. 410 IAC (Indiana Administrative Code) 16.2-3.1-35(g)(1)

Based on observation, interview, and record review, the facility failed to ensure the clinical record documentation was accurate for a resident at risk for skin breakdown who was prescribed heel protection for 1 of 3 residents reviewed for skin breakdown. (Resident 100) Finding includes: During an observation on 6/2/25 at 11:00 a.m., Resident 100 was observed resting in bed and both feet were observed to be covered with non-skid socks. Resident 100 was not observed wearing Prevalon heel protection boots (specific boots designed with a cushioned bottom that floats the heel off the surface of the mattress helping to reduce pressure). No Prevalon heel protection boots were visible in the area. During an observation on 6/3/25 at 10:10 a.m., Resident 100 was observed resting in bed and both feet were observed to be covered with non-skin socks. Resident 100 was not observed wearing Prevalon heel protection boots. No Prevalon heel protection boots were visible in the area. During an observation on 6/5/25 at 9:35 a.m., Resident 100 was observed resting in bed and both feet were observed to be covered with non-skin socks. Resident 100 was not observed wearing Prevalon heel protection boots. No Prevalon heel protection boots were visible in the area. During an observation on 6/5/25 at 10:50 a.m., Resident 100 was observed resting in bed and both feet were observed to be covered with non-skin socks. Resident 100 was not observed wearing Prevalon heel protection boots. During an interview at that time, Resident 100 indicated he refused to wear the Prevalon heel protection boots because they were too hot. On 6/5/25 at 9:59 a.m., Resident 100's clinical record was reviewed. The diagnoses included, but were not limited to, traumatic brain injury, history of transient ischemic attack (TIA), and abnormalities of gait and mobility. The Quarterly Minimum Data Set (MDS) assessment, dated 4/11/25, indicated Resident 100 was cognitively intact and was at risk of skin breakdown. The current Physician Orders included, but not limited to, effective 12/20/24, while in bed, apply Prevalon boots to both of Resident 100's feet. There was no end date noted in the clinical record. The June 2025 Treatment Administration Record (TAR) was reviewed. A review of the document indicated staff had signed the record that identified Resident 100 had worn the Prevalon boots while in bed for all three shifts on the following days: 6/1/25, 6/2/25, 6/3/25, 6/4/25. The TAR document also indicated Resident 100 had the Prevalon boots on both feet during the first shift on 6/5/25. During an interview on 6/5/25 at 11:00 a.m., Qualified Medication Aide (QMA) 3 indicated Resident 100 usually refused to wear the Prevalon boots. During an interview on 6/5/25 at 11:14 a.m., the Director of Nursing (DON) indicated Resident 100 was non-compliant with wearing the prescribed Prevalon boots. The TAR document should have accurately reflected Resident 100's refusal to wear the Prevalon boots. On 6/5/25 at 1:28 p.m., the DON provided a copy of the Charting Errors and/or Omissions policy, dated December 2006, and indicated it was the current policy in use by the facility. A review of the document indicated, .accurate medical records shall be maintained by this facility . On 6/5/25 at 1:41 p.m., the DON provided a copy of the Administering Medications policy, dated December 2012, and indicated it was the current policy in use by the facility. A review of the document indicated, .shall be administered in a safe and timely manner, and as prescribed . 3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to develop a person-centered comprehensive care plan for a resident's refusal of care for 1 of 3 residents reviewed for skin breakdown. (Resident 100) Finding includes: During an observation on 6/2/25 at 11:00 a.m., Resident 100 was observed resting in bed and both feet were observed to be covered with non-skid socks. Resident 100 was not observed wearing Prevalon heel protection boots (specific boots designed with a cushioned bottom that floats the heel off the surface of the mattress helping to reduce pressure). No Prevalon heel protection boots were visible in the area. During an observation on 6/3/25 at 10:10 a.m., Resident 100 was observed resting in bed and both feet were observed to be covered with non-skin socks. Resident 100 was not observed wearing Prevalon heel protection boots. No Prevalon heel protection boots were visible in the area. During an observation on 6/5/25 at 9:35 a.m., Resident 100 was observed resting in bed and both feet were observed to be covered with non-skin socks. Resident 100 was not observed wearing Prevalon heel protection boots. No Prevalon heel protection boots were visible in the area. During an observation on 6/5/25 at 10:50 a.m., Resident 100 was observed resting in bed and both feet were observed to be covered with non-skin socks. Resident 100 was not observed wearing Prevalon heel protection boots. No Prevalon heel protection boots were visible in the area. During an interview at that time, Resident 100 indicated he refused to wear the Prevalon heel protection boots because they were too hot. On 6/5/25 at 9:59 a.m., Resident 100's clinical record was reviewed. The diagnoses included, but were not limited to, traumatic brain injury, history of transient ischemic attack (TIA), and abnormalities of gait and mobility. The Quarterly Minimum Data Set (MDS) assessment, dated 4/11/25, indicated Resident 100 was cognitively intact and was at risk of skin breakdown. The current Physician Orders included, but not limited to, effective 12/20/24, while in bed, apply Prevalon boots to both of Resident 100's feet. There was no end date noted in the clinical record. Resident 100's care plan failed to address Resident 100's refusal to wear the Prevalon boots as prescribed by the physician. During an interview on 6/5/25 at 11:00 a.m., Qualified Medication Aide (QMA) 3 indicated Resident 100 usually refused to wear the Prevalon boots. During an interview on 6/5/25 at 11:14 a.m., the Director of Nursing (DON) indicated Resident 100 was non-compliant with wearing the prescribed Prevalon boots and the care plan should have been updated to reflect the non-compliance. On 6/5/25 at 11:45 a.m., the DON provided a copy of the Care Plan, Comprehensive Person-Centered policy, dated December 2016, and indicated it was the current policy in use by the facility. A review of the document indicated, .a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .assessment of residents are ongoing and care plans are revised as information about the residents and the resident's condition changes . 3.1-35(a)

Based on observation, interview, and record review, the facility failed to ensure controlled medications were reconciled accurately for 4 of 8 medication carts. (200 Hall Medication Cart, 100 Hall Medication Cart, 400 Hall Medication Cart, 700/800 Hall Medication Cart) Findings include: 1. On 11/7/24 at 12:44 p.m., during the controlled medication reconciliation for the 200 hall medication cart, the Nurse's Narcotic Sign In/Out Sheet, dated 11/1/24 until 11/7/24 at 12:44 p.m., was reviewed. The document had a grid with lines that were numbered to correspond with each day of the month. There were spaces running across the grid for the nurse to write the number of controlled medication packets inside the cart at the beginning of the shift, the number of medication packets added or removed during that shift, and spaces for each nurse to sign once the medication packets and count sheets were reconciled. At that time, Qualified Medication Aide (QMA) 1 indicated the document was for the nurses to keep track of how many packets of controlled medications were inside the medication cart. QMA 1 should have filled out the document completely at the beginning of her shift. The following spaces were blank: - 11/1/24, night shift spaces were blank. - 11/2/24, day shift spaces were blank and night shift signature spaces were blank - 11/3/24, day shift spaces were blank and night shift signature spaces were blank - 11/4/24, day shift spaces were blank. - 11/5/24, evening shift signature spaces were blank - 11/6/24, day shift and evening shift signature spaces were blank - 11/7/24, day shift spaces were blank. 2. On 11/7/24 at 1:10 p.m., the Nurse's Narcotic Sign In/Out Sheet for the 100 hall medication cart, dated 11/1/24 until 11/7/24 at 1:10 p.m., was reviewed. The following spaces were blank: - 11/1/24, day shift spaces were blank - 11/2/24, day shift and evening shift spaces were blank - 11/3/24, evening and night shift spaces were blank - 11/5/24, day shift signature spaces and all night shift spaces were blank - 11/6/24, day and evening shift spaces were blank 3. On 11/7/24 at 1:30 p.m., the Nurse's Narcotic Sign In/Out Sheet for the 400 hall medication cart, dated 11/1/24 until 11/7/24 at 1:30 p.m., was reviewed. The following spaces were blank: - 11/1/24, day shift spaces were blank - 11/2/24, night shift spaces were blank - 11/3/24, evening shift and night shift spaces were blank 4. On 11/7/24 at 1:30 p.m., the Nurse's Narcotic Sign In/Out Sheet for the 700 and 800 halls, dated 11/1/24 until 11/7/24 at 1:30 p.m., was reviewed. The following spaces were blank: - 11/1/24, total number of sheets for all shifts were blank - 11/2/24, total number of sheets for all shifts were blank - 11/3/24, total number of sheets for all shifts were blank - 11/4/24, total number of sheets for all shifts were blank - 11/5/24, total number of sheets for all shifts were blank - 11/6/24, total number of sheets for all shifts were blank - 11/7/24, day shift spaces were blank On 11/7/24 at 12:52 p.m., the DON provided a copy of a document, titled Nurse's Narcotic Sign In/Out Sheet, dated 11/2024, and indicated this was the current document used by the facility to reconcile controlled medications. A review of the document indicated controlled medications were to be counted at the beginning and end of every shift. The on-coming and off-going nurses were to sign in the designated spaces to indicate correctness of the count (medication packets and count sheets). Discrepancies were to be reported immediately to the Director of Nursing (DON) and Administrator. This citation relates to Complaint IN00446489. 3.1-25(e)(3)

Based on observation, interview, and record review, the facility failed to ensure personal protective equipment (PPE) was used during a dressing change for a resident with an open wound on enhanced barrier precautions (EBP) for 1 of 1 residents observed for wound care. (Resident B) Findings include: On 11/7/24 at 8:39 a.m., Resident B's wound to the left heel was observed during wound care. The wound was approximately 5 centimeters (cm) by 5 cm, beefy red wound base with a scant amount of pink drainage and did not have any odor. The wound care was provided by RN 1 with the assistance from the Director of Nursing (DON). The DON and RN 1 applied alcohol based hand sanitizer to their hands and applied clean gloves but did not put on any other PPE. During an interview on 11/7/24 at 9:24 a.m., the DON indicated Resident B was on EBP and she and RN 1 should have put on a gown before providing wound care to Resident B. During an interview on 11/7/24 at 9:30 a.m., RN 1 indicated she was not sure if Resident B was on EBP. If Resident B was on EBP a physician's order would have been entered into the electronic medical record (EMR). RN 1 was not aware of any gowns in Resident B's room, but if she needed a gown she could go to the supply closet located approximately 40 feet from Resident B's room. At that time, RN 1 reviewed Resident B's physicians orders and indicated Resident B was on EBP and she should have worn a gown when providing wound care. On 11/7/24 at 9:32 a.m., observed the EBP sign hung above Resident B's head of bed. At that time, Resident B indicated staff rarely wore gowns when providing wound care. Resident B was not aware of any gowns in his room. The clinical record for Resident B was reviewed on 11/7/24 at 11:59 a.m. The diagnoses included, but were not limited to, diabetes, deep vein thrombosis, and a stage three pressure ulcer to left heel. The Annual Minimum Data Set (MDS) assessment, dated 9/30/24, indicated Resident B was cognitively intact and was admitted with an unhealed stage three pressure ulcer. A care plan, dated 7/29/24, indicated Resident B required enhanced barrier precautions related to wounds. The interventions included, but were not limited to, apply gown and gloves for chronic wound care and provide education to Resident B, Resident B's family, and staff as needed. A current physician's order started, on 7/23/24, indicated enhanced barrier precautions. On 11/7/24 at 11:16 a.m., the DON provided a copy of the enhanced barrier precautions sign that was hung in Resident B's room at the head of his bed. A review of the sign indicated that providers and staff must wear gloves and a gown for wound care. On 11/7/24 at 10:20 a.m., the DON provided a copy of a facility policy, titled Enhanced Barrier Precautions Policy and Procedure, dated 4/1/24, and indicated it was the current policy used by the facility. A review of the policy indicated use of EBP was indicated for residents with any skin opening the required a dressing such as a pressure ulcer or unhealed surgical wound. This citation relates to Complaint IN00445897. 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to ensure self-medication administration assessments were completed for 4 of 4 residents observed with medications at bedside. (Resident 53, Resident 1, Resident 105, Resident 39) Findings Include: 1. On 8/20/24 at 10:32 a.m., observed Resident 53 was sitting up in bed; no staff were observed to be in the room or in hallway. Resident 53 had an overbed table with the following observed to be sitting on top of the table; one clear plastic medication cup containing two small white tablets and one and a half large tablets. On 8/21/24 at 8:33 a.m., Resident 53 was observed sitting up in bed eating. A small plastic medication cup was observed sitting on the overbed table containing three small white tablets, two large white tablets broken in half, one orange tablet, and one peach colored tablet. On 8/21/24 at 8:40 a.m., Resident 53's clinical record was reviewed. The clinical record lacked a self-medication administration assessment. On 8/22/24 at 1:18 p.m., the Director of Nursing indicated that there was not a self-medication administration assessment for Resident 53. 2. On 8/21/24 at 8:56 a.m., Resident 1 was observed sitting up in bed holding a small plastic medication cup with a blue and white capsule. On 8/21/24 at 9:00 a.m., Resident 1's clinical record was reviewed. The clinical record lacked a self-medication administration assessment. On 8/22/24 at 1:18 p.m., the Director of Nursing indicated that there was not a self- medication administration assessment for Resident 1. 3. On 8/21/24 at 8:59 a.m., Resident 105 was observed lying in bed. On the overbed table there was a small plastic medication cup containing three small white tablets, one large white tablet, one oval yellow tablet, one cream tablet, and one white capsule. On 8/21/24 at 9:09 a.m., Resident 105's clinical record was reviewed. The clinical record lacked a self-medication administration assessment. On 8/22/24 at 1:18 p.m., The Director of Nursing indicated that there was not a self-medication administration assessment for Resident 105. During an interview on 8/22/24 at 1:05 p.m., Unit Manager 2 indicated nurses should stay with residents to make sure medications were taken. Unit Manager 2 indicated if the resident did not take the medications then the nurse should take the medications when the nurse left the room. During an interview on 8/22/24 at 1:18 p.m., the Director of Nursing indicated nurses should not leave medications in resident rooms. 38466 4. On 8/23/24 at 2:52 p.m., Resident 39's clinical record was reviewed. The quarterly Minimum Data Set assessment, dated 6/19/24, indicated Resident 39 was cognitively intact. Resident 39's clinical record lacked a self-medication administration assessment. On 8/26/24 at 8:30 a.m., Resident 39 was observed in her room sitting in the wheelchair. The over the bed table was positioned in front of the resident who was eating her breakfast meal. The table was observed to have a small clear plastic medicine cup that contained multiple large and small white unidentified medication pills and tablets. During an interview at that time, Resident 39 indicated the nurse dropped off the medication as the resident liked to take her pills after she had eaten. Resident 39 indicated sometimes staff left the medications in her room and had not watched her take the medications. During an interview on 8/26/24 at 8:30 a.m., Unit Manager 4 indicated Resident 39 had not been assessed to self-administer her medications. Staff were to administer Resident 39's medications and ensure all medications were taken before leaving the resident's room. Medications were not to be left at the resident's bedside. On 8/26/24 at 1:30 p.m., the Director of Nursing provided a copy of the Administering Medications policy, dated December 2012, and indicated it was the current policy in use by the facility. A review of the policy indicated, .Medications shall be administered in a safe and timely manner, and as prescribed .only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so . 3.1-11(a)

Based on interview and record review, the facility failed to follow the current vaccine administration guidelines for the pneumococcal vaccine for 1 of 8 residents reviewed for vaccination records. The CDC (Centers for Disease Control and Prevention) recommended pneumococcal vaccine series was not given for one resident. (Resident 27) Finding includes: On 8/20/24 at 11:50 a.m., Resident 27's clinical record was reviewed and indicated the following: - Resident 27's immunization records indicated Resident 27 received a pneumococcal polysaccharide 23 (PPSV 23) vaccine on 11/20/20, at an outside care setting prior to admission, but lacked documentation of any pneumococcal conjugate (PCV 13, 15, or 20) vaccines. - Resident 27's diagnoses included, but were not limited to, peripheral vascular disease (a chronic disorder that causes blood vessels outside of the heart to narrow, block, or spasm, reducing blood flow to organs like the brain and legs), and chronic kidney disease (a long-term condition that occurs when the kidneys are damaged and can't filter blood properly). - Resident 27 was of age [AGE] years of age or older. On 8/22/24 at 9:30 a.m., the DON (Director of Nursing) provided the informed consent form indicating Resident 27 had elected to receive the recommended pneumococcal vaccinations. During an interview on 8/23/24 at 11:55 a.m., the DON indicated that Resident 27 should have received both types of pneumococcal vaccination. On 8/20/24, the DON provided a policy, dated for 11/8/16, and titled, Clinical - Pneumonia Vaccination Policy, and indicated it was the policy currently in use. The policy indicated that both the pneumococcal conjugate vaccine and pneumococcal polysaccharide vaccine should be administered routinely in a series to all adults age [AGE] years and older as well as for adults with certain chronic conditions including chronic cardiac and kidney diseases. On 8/23/24 at 10:00 a.m., a review of the CDC guidelines at the following website regarding pneumococcal vaccine timing for adults (cdc.gov/vaccines/hcp/imz-schedules/adult-notes.html#note-pneumo), dated with an addendum update 6/27/24, indicated that chronic cardiovascular diseases and chronic kidney conditions were medical conditions are recommended for adults 19 through [AGE] years of age in addition to being recommended for adults [AGE] years of age and older. 3.1-13(a)

Based on interview and record review, the facility failed to provide a written notice to a resident prior to getting a new roommate. (Resident 25) Findings include: On 8/22/24 at 8:45 a.m., Resident 25 was observed in her wheelchair in the hall way. The resident was moving around in her chair and fidgeting with her hands. She indicated she was very nervous. She indicated the facility had recently given her a new roommate. The new roommate was receiving hospice services and was actively dying. The resident indicated she was unaware that she was going to get a new roommate and was surprised. The new roommate passed away after seven days. I had to sit and watch her die for seven days. Resident 25 indicated she was not informed about getting new roommate until the day before the new roommate was admitted and that was only because they were making sure the room was clean. The resident did not receive a written notice about a new roommate. On 8/23/24 at 9:33 a.m., the clinical record of Resident 25 was reviewed. The diagnosis included, but was not limited to, depression. The clinical record lacked documentation of Resident 25 being informed in writing that she was getting a new roommate. During an interview on 8/23/24 at 10:00 a.m., the Social Services Director indicted if a resident got a new roommate they were to be informed and it should be documented in the clinical record. During an interview on 8/23/24 at 1:00 p.m., the Director of Nursing (DON) indicated if a resident was notified of a change or new roommate it should be documented in the clinical record. On 8/27/24 at 11:30 a.m., the DON indicated they did not notify the residents in writing when they were getting a new roommate. On 8/26/24 at 2:17 p.m., the DON provided a policy titled, Resident Discharge and Transfer Policy, dated 11/24/14 and indicated it was the current policy being used by the facility. A review of the policy indicated [NAME] and Associates, Inc., has implemented the Resident discharge and Transfer policy in the interest of complying with all applicable laws, regulations and statutes surrounding the discharge or transfer of residents within the facility. 3.1-3(v)(2)

Based on record review and interview, the facility failed to ensure a resident was referred to the State-designated authority contractor for a Level II Screening (PASARR) for a new mental illness diagnosis evaluation for 1 of 1 residents reviewed. (Resident 53) Findings include: On 8/23/24 at 11:00 a.m., Resident 53's clinical record was reviewed. The diagnosis included, but was not limited to, bipolar disorder. On 12/9/21 Resident 53 received a new diagnosis of bipolar disorder. Resident 53 was not referred for a new Level II screening. A Quarterly Minimum Data Set (MDS) assessment, dated 4/3/24, indicated Resident 53 was cognitively intact. During an interview on 8/23/24 at 11:42 a.m., Social Service Director 3 indicated a PASARR Level II should have been done for Resident 53. On 8/23/24 at 1:21 p.m., the Director of Nursing Services (DON) indicated the facility followed the Indiana Guidelines for PASARR Level II assessments, which indicated a Level II PASARR evaluation is performed to identify the specialized needs of individuals with mental illness and intellectual disability/developmental disability. 3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

Based on observation, record review, and interview, the facility failed to provide ADL's (Activities of Daily Living) for a dependent resident for 1 of 2 residents reviewed. A resident with facial hair was not assisted with shaving. (Resident 62) Findings include: During an observation on 8/22/24 at 9:14 a.m., Resident 62 was observed in bed with multiple one half inch gray hairs protruding from her chin. During an observation on 8/26/24 at 10:22 a.m., Resident 62 was observed in bed with multiple one half inch gray hairs protruding from her chin. During an observation on 8/27/24 at 9:00 a.m., Resident 62 was observed with multiple one half inch gray hairs protruding from her chin. During an interview at that time, Resident 62 indicated the staff had not offered to assist with the removal of the facial hair. She indicated she was not aware the hair was so long on her chin. During an interview on 8/27/24 at 9:05 a.m., the Director of Nursing indicated the facial hair for residents should have been removed during the residents shower days. On 8/27/24 at 9:34 a.m., Resident 62's clinical record was reviewed. The diagnosis included, but was not limited to, weakness. An Admission Minimum Data Set (MDS) assessment, dated 7/30/24, indicated Resident 62 was cognitively intact and she required partial to moderate assist for shaving. A Care Plan, dated 7/29/24, indicated Resident 62 was unable to independently perform late loss ADLs related to weakness, and required assistance with hygiene. The interventions included, but were not limited to, assist Resident 62 with hygiene. A CNA Shower Review Sheet, dated 8/1/24, indicated resident 62 received a shower. A CNA Shower Review Sheet, dated 8/5/24, indicated resident 62 received a shower. A CNA Shower Review Sheet, dated 8/8/24, indicated resident 62 received a shower. A CNA Shower Review Sheet, dated 8/12/24, indicated resident 62 received a shower. A CNA Shower Review Sheet, dated 8/15/24, indicated resident 62 received a shower. On 8/27/24 at 10:41 a.m., the Director of Nursing provided a policy titled Activities of Daily Living (ADL), Supporting, dated 3/2018, and indicated it was the current policy being used by the facility. A review of the policy, indicated Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. 3.1-38(a)(3)(D)

Based on observation, interview, and record review, the facility failed to ensure a resident diagnosed with edema and congestive heart failure received services and treatments for 1 of 1 resident reviewed for lower extremity edema. The facility failed to ensure daily weights, monitoring for side effects of edema, and that daily compression stockings were in place. (Resident 39) Findings include: During an observation on 8/20/24 at 12:15 p.m., Resident 39 was in her room sitting in her wheelchair eating lunch. Resident 39's uncovered left lower leg and foot were observed to be swollen. During an interview at that time, Resident 39 indicated the prescribed water pill (diuretic) did not work as well as it used to work which caused the lower leg and foot to swell. The resident indicated she did not wear compression stockings. During an observation on 8/21/24 at 8:30 a.m., Resident 39 was in her room sitting in her wheelchair eating breakfast. Resident 39's uncovered left lower leg and foot were observed to be swollen. During an observation on 8/23/24 at 11:39 a.m., Resident 39 was in her room resting in bed and her uncovered left lower leg and foot were observed to be swollen. During an observation on 8/26/24 at 8:25 a.m., Resident 39 was in her room sitting in her wheelchair eating breakfast. Resident 39's uncovered left lower leg and foot were observed to be swollen. During an observation on 8/26/24 at 2:29 p.m., Resident 39 was in her room resting in bed and her uncovered left lower leg and foot were observed to be swollen. During an observation on 8/27/24 at 9:10 a.m., Resident 39 was observed sitting in her wheelchair in her room. Resident 39 was observed wearing black zippered compression stockings on both lower legs. The compression stockings covered her toes to the just below the knees. During an interview at that time, Resident 39 indicated this was the first time since her admission into the facility that she had worn compression stockings. The black compression stockings were her own personal stockings. Staff had asked her several times to put on compression stockings; however, she declined as she didn't like them. The resident's weights were not taken on a consistent basis. Resident 39's clinical record was reviewed on 8/23/24 at 2:52 p.m. The diagnoses included, but were not limited to, edema, HTN (hypertension), COPD (chronic obstructive pulmonary disease), and CHF (congestive heart failure). The Quarterly Minimum Data Set (MDS) assessment, dated 6/19/24, indicated Resident 39 was cognitively intact. Resident 39's care plan included, but were not limited to, Resident 39 had the potential for fluid volume excess/exacerbation related to CHF, initiated on 1/2/24. Resident was identified as non-compliant with daily weights on 8/23/24. The interventions included, but were not limited to, staff were to assess the resident and report weight gain and worsening edema to the physician. CNA assignment sheet indicated Resident 39 was to have daily weights taken, revised on 6/26/24. Resident to wear compression stockings daily, initiated on 3/18/24. The care plan identified Resident 39 as being non-compliant at times with wearing the compression stockings, on 8/26/24. 1. Physician orders included, but were not limited to, obtain and record daily weights upon rising before breakfast. Notify MD [Medical Doctor] if weight gain is 2 lbs [pounds] daily or 5 lbs [pounds] in a week. Daily at 7:00 a.m. Start date was 1/2/24 and was discontinued on 8/21/24. On 8/26/24 at 11:50 a.m., the Director of Nursing provided a copy of Resident 39's Medication Administration Record / Treatment Administration Record (MAR/TAR) documents from January 2024 through August 2024. A review of the MAR/TAR documents indicated the following dates lacked staff initials to validate a daily weight had been recorded in the clinical record as indicated by physician orders: - 3 of 29 opportunities during February - 9 of 31 opportunities during March - 13 of 30 opportunities during April - 6 of 31 opportunities during May - 5 of 30 opportunities during June - 10 of 31 opportunities during July - 6 of 21 opportunities during August 2. Physician orders included, but were not limited to, monitor for increased edema, shortness of breath and lung sounds. Notify MD [Medical Doctor] if condition declines. Document resident status every shift. Start date was 1/2/24 with no identified end date noted. The MAR/TAR documents indicated the following dates lacked staff initials that validated Resident 39's edema was monitored and recorded in the clinical record for each shift as indicated by physician orders: 7/17/24 - evening shift 7/18/24 - night shift 7/19/24 - day shift 3. Physician orders included, but were not limited to, compression stockings daily, once a day upon rising at 7:00 a.m . start date was 3/18/24 with no identified end date noted. The MAR/TAR documents indicated no compression stockings were applied to Resident 39's lower extremity on 7/19/24 as indicated by the physician orders. The clinical record lacked documentation that Resident 39's edema was monitored as prescribed by the physician as indicated by: - daily weights were not taken and recorded - daily monitoring for increased edema were not completed and recorded - compression stockings were not applied daily and recorded accordingly During an interview on 8/23/24 at 3:45 p.m., the Director of Nursing indicated that Resident 39's original physician order was for daily weights. The resident refused daily weights at times and so the order was changed to weekly weights on 8/21/24. The staff initials on the MAR/TAR indicated the weights were obtained or if the resident refused to be weighed. The MAR/TAR also indicated that the monitoring of the resident's edema was performed as well as applying the compression stockings. If no initials were listed on a specific date on the MAR/TAR, then that action had not completed. During an interview on 8/26/24 at 8:30 a.m., Unit Manager 4 indicated Resident 39's physician ordered compression stockings to be worn daily. Resident 39 tended to refuse to wear the stockings. During an interview on 8/26/24 at 3:17 p.m., the Director of Nursing indicated Resident 39 frequently refused to wear the compression stockings. The Director of Nursing indicated staff were to apply the compression stockings prior to Resident 39 getting out of bed and to remove them in the evening when the resident retired for the night. The Director of Nursing was unsure why the MAR/TAR indicated Resident 39 was wearing the compression stockings when she was observed to not have them on her person. On 8/26/24 at 1:30 p.m., the Director of Nursing provided a copy of the Administering Medications policy, dated 12/2012, and indicated it was the current policy in use by the facility. A review of the policy indicated, medications must be administered in accordance with the orders, including any required time frame . During an interview at that time, the Director of Nursing indicated this policy included residents treatments and services to promote the well-being of the resident. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure a comprehensive person-centered care plan was developed for a resident who required a hand brace for 1 of 6 residents reviewed for care plans. (Resident C) Findings include: During an observation on 5/23/24 at 10:50 a.m., Resident C was observed covered with a blanket and resting in bed. A hand brace was observed on the bedside table. During an observation on 5/23/24 at 12:02 p.m., Resident C was observed awake and resting in bed. During an interview at that time, Resident C indicated staff applied the left hand brace at times. It had been awhile ago since he had the brace on his hand. On 5/23/24 at 9:25 a.m., Resident C's clinical record was reviewed. Diagnoses included, but were not limited to, hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side; spastic hemiplegia (muscle stiffness or tightness, and involuntary contractions) affecting left non-dominant side; contracture (hardening of muscles and rigidity of joints) of left hand and left wrist (non-dominant side). Current Physician orders included, but were not limited to, left hand brace may be worn for 3 hours at a time. Check skin prior to application and removal. Notify provider of any changes. Every shift [days, evenings. and nights] and PRN [as needed] .start date 11/29/22 with no end date noted . The May 2024 Treatment Administration Record (TAR) indicated Resident C's left hand brace had been applied and removed on every shift from 5/1/24 through 5/22/24. The Annual Minimum Data Set (MDS) assessment, dated 3/14/24, indicated Resident C was cognitively intact and received restorative nursing care which included range of motion services. Resident C's clinical record lacked a comprehensive person-centered care plan for the utilization of the left hand brace as ordered by the physician. The clinical record also lacked a care plan that addressed the refusal to wear the brace. During an interview on 5/23/24 at 10:55 a.m., Licensed Practical Nurse (LPN) 3 indicated Resident C had used a left hand brace for a long time. Resident C had a history of refusing to allow staff to apply the brace. LPN 3 indicated the clinical record should have had a left hand brace care plan and it should have included a refusal to wear the brace. During an interview on 5/23/24 at 11:00 a.m., the Director of Nursing Services (DNS) indicated Resident C had a physician's order for the use of the left hand brace. The clinical record lacked a comprehensive person-centered care plan for the brace and lacked a care plan for the refusal to wear the brace. During an interview on 5/23/24 at 12:20 p.m., the Rehabilitation Supervisor indicated Resident C had a physician's order for a left hand brace due to the hand contracture. Resident C could utilize the brace for up to three hours at a time. Many times, Resident C would refuse to allow the staff to apply the brace. On 5/23/24 at 2:00 p.m., the DNS provided a copy of the Care Plans, Comprehensive Person-Centered policy, dated December 2016, and indicated it was the current policy in use by the facility. A review of the policy indicated, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident .describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being .aid in preventing or reducing decline in the resident's functional status . This citation relates to Complaint IN00433858. 3.1-35(a)

Based on observation, interview, and record review, the facility failed to ensure a knee brace was applied to a resident while in bed for 1 of 3 residents reviewed for range of motion. (Resident C) Findings include: On 5/23/24 at 9:25 a.m., Resident C's clinical record was reviewed. Diagnoses included, but were not limited to, hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side and spastic hemiplegia (muscle stiffness or tightness, and involuntary contractions) affecting left non-dominant side. Current Physician orders included, but were not limited to, left knee brace to be worn while in bed .every shift: days, evenings, nights .start date 6/27/23 with no end date noted . The May 2024 Treatment Administration Record (TAR) record indicated Resident C's left knee brace had been applied during every shift from 5/1/24 through 5/22/24. The Annual Minimum Data Set (MDS) assessment, dated 3/14/24, indicated Resident C was cognitively intact and received restorative nursing care which included range of motion services. Resident C's care plan indicated Problem: .required a brace to left knee when in bed .start date: 7/11/23 and current through 6/14/24 .Goal: .Resident will tolerate splint/brace to left knee without signs or symptoms of pain/discomfort through next review .Approach: apply splint/brace to left knee as ordered . During an interview on 5/23/24 at 10:55 a.m., LPN 3 indicated Resident C had the left knee brace for a long time. LPN 3 indicated Resident C did not have the knee brace in place at the start of her shift. During an interview on 5/23/24 at 11:00 a.m., the DNS indicated Resident C had a physician's order for the use of the left knee brace while the resident was in bed. During an observation on 5/23/24 at 12:02 p.m., Resident C was observed awake and resting in bed. Resident C's left knee was bent at a 90 degree angle. During an interview at that time, Resident C indicated he was supposed to wear a left knee brace while in bed. It had been awhile ago since he had the brace on his knee. Resident C indicated he did not know where the staff had put the knee brace. During an interview on 5/23/24 at 12:20 p.m., the Rehabilitation Supervisor indicated Resident C had a physician's order for a left knee brace due to the knee and leg contracture. The physician's order was for Resident C to wear the brace while in bed. During an observation on 5/23/24 at 12:10 p.m., LPN 3 was observed in Resident C's room searching for the resident's left knee brace. LPN 3 was unable to locate the brace. During an interview at that time, LPN 3 indicated she was unsure where the brace was or how long it had been inaccessible. On 5/23/24 at 2:00 p.m., the DNS provided a copy of the Resident Mobility and Range of Motion policy, dated July 2017. and indicated it was the current policy in use by the facility. A review of the policy indicated, .Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM [range of motion] .Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility . This citation relates to Complaint IN00433858. 3.1-42(a)(2)

Based on interview and record review, the facility failed to protect a resident's right to be free from verbal abuse by a staff member for 1 of 3 residents reviewed for abuse. A CNA (Certified Nursing Aide) yelled, cursed, and threatened a resident. (Resident C, CNA 1) Finding includes: During an interview on 12/5/23 at 10:03 a.m., the Administrator indicated on 11/11/23, staff reported CNA 1 had an argument with Resident C. After the argument, CNA 1 walked away from Resident C and indicated if CNA 1 wasn't moved off that assignment she was going to choke Resident C. CNA 1 was terminated. During an interview on 12/5/23 at 11:18 a.m., QMA 1 (Qualified Medication Aide) indicated she came back from a break and was standing at the nurse's station. Resident C came to the nurse's station to ask for his medications and had some tremors, which was normal for Resident C. CNA 1 indicated she thought Resident C was on that stuff again because Resident C had tremors. Resident C and CNA 1 told each other to go f*** yourself. As the nurse and another QMA were separating them CNA 1 was cursing at Resident C and indicated Resident C was a drug addict and wanted his f****** medicine whenever he wanted it. Then, as CNA 1 was being walked away CNA 1 told another staff member if CNA 1 didn't get moved to a new assignment CNA 1 could choke Resident C. CNA 1 was sent home immediately. The clinical record for Resident C was reviewed on 12/5/23 at 11:58 a.m. The diagnoses included, but were not limited to, Parkinson's disease, bipolar disorder, and history of pain. A quarterly MDS (Minimum Data Set) assessment, dated 11/8/23, indicated Resident C was cognitively intact. A resident statement, dated 11/11/23 at 9:00 a.m., indicated Resident C indicated he was at the nurse's station getting his morning medication. Resident C indicated to the nurse that the nurse was preparing a lot of medications. CNA 1 indicated to Resident C that he also took illegal drugs. Resident C became angry and called CNA 1 a meth head. There was some yelling back and forth. CNA 1 told Resident C she was going to choke him. Resident C indicated CNA 1 made mean remarks about him often and Resident C was fed up. A witness statement, dated 11/11/23 at 10:00 a.m., indicated QMA 1 came back inside from a break and heard CNA 1 argue with Resident C. CNA 1 was threatening and cursing. CNA 1 indicated she would choke Resident C if CNA 1 didn't get moved to a new assignment. Staff immediately separated Resident C and CNA 1. A witness statement, dated 11/11/23 at 10:00 a.m., indicated QMA 2 asked Resident C if QMA 2 could check his blood pressure. Resident C was having tremors as Resident C normally did. CNA 1 indicated look at Resident C, Resident C was on drugs. Resident C heard CNA 1 and started arguing with CNA 1. QMA 2 immediately separated Resident C and CNA 1. CNA 1 walked away and indicated she was going to choke Resident C. On 12/5/23 at 9:05 a.m., the Administrator provided a copy of a facility policy, dated 10/4/14, titled Abuse, Neglect, and Misappropriation Prohibition and Prevention Policy, and indicated this was the current policy used by the facility. A review of the policy indicated it is the policy of the facility to provide an environment that is free from verbal abuse. This tag relates to Complaint IN00421853. 3.1-27(b)

Based on interview and record review, the facility failed to protect a resident's right to be free from misappropriation of property for 1 of 3 residents reviewed for abuse. A resident's oxycodone (prescription narcotic controlled substance for pain) 30 mg (milligrams) was replaced by a different medication and could not be accounted for. (Resident B) Finding includes: During an interview on 12/5/23 at 10:03 a.m., the Administrator indicated LPN 1 recognized that there were 4 tablets taped into a packet of oxycodone 30 mg. The oxycodone 30 mg packet belonged to Resident B. LPN 2 was the nurse that normally administered Resident B's oxycodone 30 mg on evening shift. During an interview on 12/5/23 at 10:04 a.m., the DON (Director of Nursing) indicated there were 4 tablets of carbidopa/levadopa 10/100 mg (prescription medication used to treat Parkinson's disease) that were taped into the packet of Resident B's oxycodone 30 mg tablets, apparently, to replace the 4 oxycodone 30 mg tablets that were removed and could not be accounted for. During an interview on 12/5/23 at 12:24 p.m., LPN 1 indicated he recognized the carbidopa/levodopa 10/100 mg was taped into the packet of oxycodone 30 mg, on evening shift, about an hour before LPN 1 was going to do Resident B's dressing change. When he pulled the oxycodone 30 mg packet out of the medication cart's lock box he realized the oxycodone 30 mg tablets and the carbidopa/levodopa 10/100 mg were similar colors but different sizes The clinical record for Resident B was reviewed on 12/5/23 at 12:32 p.m. The diagnoses included, but were not limited to, diabetes, cerebrovascular disease, and bipolar disorder. A quarterly MDS (Minimum Data Set) assessment, dated 11/29/23, indicated Resident B was cognitively intact. A current physician's order initiated, on 10/20/23, indicated oxycodone 30 mg tablet orally once daily on evening shift 30 minutes prior to dressing change. The clinical record for Resident B lacked a physician's order for carbidopa/levodopa 10/100 mg. A narcotic count sheet (document used to track the number of oxycodone 30 mg tablets that were locked in the medication cart's lock box), dated 11/22/23, indicated the pharmacy delivered 15 oxycodone 30 mg tablets for Resident B, on 11/22/23. Resident B received 1 tablet of oxycodone 30 mg, on 11/23/23, 11/24/23, 11/25/23, 11/26/23, 11/27/23, 11/28/23, 11/29/23, 11/30/23, and 12/1/23. 1 tablet was signed out, on 11/26/23 and 11/30/23, as removed from the packet, but a line drawn through the date, time, and initials. On 12/5/23 at 9:05 a.m., the Administrator provided a copy of a facility policy, dated 10/4/14, titled Abuse, Neglect, Misappropriation Prohibition and Prevention Policy. A review of the policy indicated it is the policy of the facility to provide each resident with an environment that is free from misappropriation of property. This tag relates to Complaints IN00422914 and IN00422808. 3.1-28(a)

Based on interview and record review, the facility failed to ensure resident records were complete for 2 of 3 residents reviewed. Personal inventory sheets were not completed. (Resident D, Resident E) Findings include: 1. On 10/19/23 at 9:33 a.m., Resident D's clinical record was reviewed. The Quarterly MDS (Minimum Data Set) assessment, dated 10/2/23, indicated Resident D had severe cognitive impairment. The clinical record lacked a personal inventory sheet (to indicate the belongings brought in by the resident and family, during the residents stay at the facility). On 10/19/23 at 10:00 a.m., the Social Services Director indicated Resident D should have had a personal inventory sheet in the clinical record. 2. On 10/19/23 at 10:15 a.m., Resident E's clinical record was reviewed. A Brief Interview for Mental Status was conducted on 8/18/23 and indicated Resident E was cognitively intact. The clinical record lacked a personal inventory sheet. On 10/19/23, at 10:00 a.m., the Social Services Director, indicated Resident D should have had a personal inventory sheet in the clinical record. On 10/19/23 at 1:30 p.m., the Regional Nurse indicated the facility did not have a policy regarding the documentation of the residents personal inventory. This citation relates to Complaints IN00420041 and IN00420016. 3.1-9(g) 3.1-50(a)

Based on observation, interview, and record review, the facility failed to implement the care plan for 1 of 6 residents reviewed for falls. The call light was not within reach. (Resident 127) Findings include: On 9/20/23 from 9:33 a.m. until 9:40 a.m., observed Resident 127 in his bed. He was observed to be laying on his side with his legs partially hanging off the side of the bed. The call light was observed to be behind the headboard and was hanging from the wall to the floor out of the reach of the resident. On 9/20/23 at 9:40 a.m., observed Registered Nurse (RN) 2 untangle the cords that were hanging behind the bed including the call light cord. RN 2 placed the call light next to the resident. During an interview at that time, RN 2 indicated the call light should have been in the reach of the resident. On 9/20/23 at 11:25 a.m., the clinical record of Resident 127 was reviewed. The diagnoses included, but were not limited to, abnormalities of gait and mobility, weakness, and history of falling. A Quarterly Minimum Data Set (MDS) assessment, dated 8/11/23, indicated Resident 127 had moderate cognitive impairment. A care plan, dated 4/13/23 and current through 12/14/23, indicated resident was at risk for falling and fall related injuries related to debility. The interventions included, but were not limited to, call don't fall sign posted on the wall in the residents room and cue/remind resident to utilize call light to seek assist as needed. During an interview on 9/21/23 at 11:33 a.m., the Director of Nursing indicated the call light should have been within the reach of the resident. On 9/21/23 at 11:40 a.m., the Director of Nursing provided a policy titled: Care Plans, Comprehensive Person-Centered, dated December 2016, and indicated it was the current policy being used by the facility. A review of the policy, indicated .8. The comprehensive person centered care plan will: a. Include measurable objectives .9. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. 10. Identify problem areas and their causes, and developing interventions that are targeted and meaningful to the resident . 3.1-35(g)(2)

Based on observation, interview, and record review, the facility failed to ensure a medication cart was kept locked when staff were not at the cart for 1 of 10 medication carts observed. (300-hall medication cart) Finding includes: During a random facility observation on 9/20/23 from 3:05 p.m. to 3:08 p.m., the 300-hall medication cart was positioned in the hall between Resident rooms [ROOM NUMBERS]. The medication cart had 8 separate drawers. The medication cart was observed to be unlocked and no staff were visible in the area during that time. On 9/20/23 at 3:08 p.m. CNA (Certified Nursing Aide) 3 was observed walking from the nurse's station, located at the end of the 300-hall, toward the unlocked medication cart on the 300-hall. As CNA 3 walked past the medication cart, CNA 3 was observed having pushed the medication cart lock into the lock position. During an interview at that time, CNA 3 indicated the medication cart was supposed to be kept locked. The 300-hall nurse was at the nurse's station. During an observation on 9/20/23 at 3:10 p.m., LPN (Licensed Practical Nurse) 4 was observed sitting at the nurse's station charting in the electronic medical record. During an interview at that time, LPN 4 indicated she was the 300-hall nurse. LPN 4 indicated a little while ago she had been at the 300-hall medication cart and was called to assist a staff member on the 200-hall. LPN 4 left the medication cart unlocked and left the 300-hall to provide assistance on the 200-hall. LPN 4 then stopped at the nurse's station to catch-up on her documentation. LPN 4 indicated she had forgotten to lock the medication cart prior to leaving the 300-hall area. During an interview on 9/21/23 at 3:30 p.m., the Unit Manager indicated all medication carts were to be kept locked when not in use. During an interview on 9/21/23 at 4:00 p.m., the DNS (Director of Nursing Services) indicated there were 10 medication carts in use by the facility. All medication carts were to be kept locked when not in use. On 9/21/23 at 4:20 p.m., the DNS provided a copy of the Storage of Medications policy, dated April 2007, and indicated it was the current policy in use by the facility. A review of the document indicated, .the facility shall store all drugs and biologicals in a safe, secure and orderly manner .compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others .only persons authorized to prepare and administer medications shall have access to the medication rooms, including any keys . 3.1-25(m)

Based on interview and record review, the facility failed to assess and document a change in condition to a resident's skin that was later identified as an infected, unstageable ulcer, measuring 7 centimeters in length by 3.2 centimeters in width, which resulted in a hospitalization requiring the need for surgery for [REDACTED]. (Resident D) The Immediate Jeopardy began on 2/14/19, when the facility failed to follow-up with a change in condition to a resident's skin that was later identified as an infected, unstageable ulcer. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 2/26/19 at 3:15 p.m. The Immediate Jeopardy was removed and the deficient practice corrected on (MONTH) 17, 2019, prior to the start of the survey and was therefore Past Noncompliance. Findings include: The clinical record for Resident D was reviewed on 2/25/19 at 2:00 p.m. The [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS) assessment, dated 11/14/18, noted Resident D to have severe cognitive impairment and needed extensive assistance per staff for completion of activities of daily living. An Event Report, dated 1/21/19, indicated the following, .Change in Condition .open area to scrotum r/t (related to) excessive moisture r/t (related to) incontinence A physician order, dated 1/21/19, noted for [MEDICATION NAME] ointment to Resident D's scrotum every shift. The order was discontinued on 1/30/19. There was no documentation related to the reasoning on why the [MEDICATION NAME] ointment was discontinued. The Treatment Administration Record (TAR), for (MONTH) of 2019, noted a weekly skin inspection completed on 2/3/19 and 2/10/19. There was no documentation of any alterations in skin integrity for Resident D on those date(s). An interview conducted with Certified Nursing Assistant (CNA) 4, on 2/26/19 at 8:40 a.m., indicated she worked on 2/8/19 and Resident D's buttocks appeared red at that time. She was off of work on 2/9/19 and 2/10/19. When she returned to work, on 2/11/19, there was an open area that appeared to be the size of a penny to Resident D's buttock. She notified the nurse and cream was applied to Resident D's buttocks. She further indicated she would apply cream, identified as [MEDICATION NAME] ointment, to Resident D's buttocks, regularly, leading up to the open area being identified. An interview conducted with Licensed Practical Nurse (LPN) 8, on 2/26/19 at 10:20 a.m., indicated she was off of work on 2/14/19. On 2/13/19 or 2/11/19, unsure of exact date, she was notified by a CNA that Resident D's buttocks appeared worse. She didn't note any open areas but the excoriation had gotten worse. She notified Unit Manager 6 about Resident D's skin appearing worse on his buttocks. An interview conducted with Unit Manager 6, on 2/26/19 at 9:20 a.m., indicated he was not aware of any skin alterations on Resident D until 2/14/19. An interview conducted with LPN 9, on 2/26/19 at 5:04 p.m., indicated she worked 2/10/19 and only noted redness to his scrotal area. She then worked on 2/13/18, evening shift, and the CNA told her that Resident D's bottom looked worse. She was under the impression the CNA was referring to his scrotum. She did not observe Resident D's skin that shift and instructed the CNA to continue to apply barrier cream to the area. When she returned to work, on 2/14/19, she noted Resident D had an area to his right buttocks that was noted with dark and hard tissue. There were no physician orders for a medicated ointment to be applied to Resident D during the time period of 1/31/19 through 2/13/19. A document titled Wound Management, dated 2/14/19, indicated an unstageable pressure ulcer to Resident D's right buttock measuring 7 centimeters in length by 3.2 centimeters in width. The wound was present with 100% necrotic tissue. A Nurse Practitioner progress note, dated 2/14/19, indicated the following, .Patient was seen for wound rounds. Pt (patient) noted to have new skin breakdown to right buttock into coccyx. Pt (patient) poor historian but states wound has been present for a couple days .Reports mild pain at site .Unstageable ulcer noted to right buttock/coccyx area .Wound complicated by surrounding [MEDICAL CONDITION] .Refer for xray of pelvis and likely MRI as well to determine depth of wound .Skin: Right buttock into coccyx: 7 cm x 3.2 cm (centimeters) ulcer with wound bed 100% covered with black necrotic tissue. [DIAGNOSES REDACTED] extending 3 cm from wound bed A nurses' note, dated 2/16/19 at 12:57 p.m., indicated Resident D had a temperature of 102.8 and was sent to the hospital at that time. The hospital records were obtained on 2/25/19 at 10:00 a.m. They indicated the following, .ED (emergency department) Notes .2. Right proximal posterior thigh and right lower buttock has a chronic decubitus ulcer .Radiology Results .2/16/19 .soft tissue gas in the medial aspect of the posterior right upper thigh/lower right buttock over a region measuring 7.7 x 4.5 x 4.4 cm (centimeters) .Findings are concerning for soft tissue infection with gas-forming organism .History of Present Illness .presented to (name of hospital) ED on 2/16/18 (sic) from (name of facility) .Patient does has (sic) a known chronic decubitus ulcer present. Scrotal/Perineum abscess discovered on Wednesday 2/13 at the facility A hospital procedure note, dated 2/16/19, indicated the following, .necrotizing soft tissue infection, right upper inner thigh/perineum .Procedure: incision and drainage, debridement of necrotic tissue .necrotic tissue was excised .deeply all necrotic tissue was debrided down to and including fascia of the adductors and somewhat into the proximal hamstrings as well The hospital discharge summary, dated 2/23/19, noted the following in italics, . admited with decubitus ulcer/[DIAGNOSES REDACTED] status [REDACTED]. He has been transitioned to oral antibiotics. Wound VAC in place The hospital discharge summary indicated, .Primary Discharge Diagnosis: [REDACTED]. An Employee Discipline Form, dated 2/19/19, indicated the following, .(name of LPN 8) .Employer Statement Regarding Incident .For failure to follow procedure for notification of new health condition. Wound was reported to (name of LPN 8) without appropriate follow-up An interview conducted with the DON, on 2/16/19 at 10:34 a.m., indicated the expectations are for a skin event to be opened when any skin impairment is noted. There is to be a treatment in place, documentation of the skin impairment and what the staff member did for the skin impairment at that time. A policy titled Skin Assessment Policy, dated 1/15/15, was provided by the Director of Nursing (DON) on 2/25/19 at 1:45 p.m. The policy indicated the following, .a head-to-toe skin assessment completed by a licensed nurse upon admission and weekly thereafter .The nurse doing the assessment will document any abnormal findings affecting the skin .If a new skin condition is identified by a licensed nurse while completing a skin assessment, the nurse will open the change in condition assessment form and complete all of the sections that pertain to the patient including the skin section. The licensed nurse that discovers a new open area will perform the following actions: .1. Notify the MD and obtain a treatment order .2. Apply the initial treatment .6. Document these items in the patient medical record A policy titled Change in Resident's Condition or Status, revised (MONTH) of 2010, was provided by the DON on 2/26/19 at 11:40 a.m. The policy indicated the following, .1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: .d. A significant change in the resident's physical/emotional/mental condition .e. A need to alter the resident's medical treatment significantly The Past Noncompliance Immediate Jeopardy began on 2/14/19. The Immediate Jeopardy was removed and corrected by 2/17/19 after the facility completed skin assessments for all residents, in-serviced all nursing staff on prevention strategies for pressure ulcers and protocol when a wound or skin condition is identified, implemented an audit sheet for monitoring residents' skin, and instituted on-going daily audits of all residents' relating to their skin integrity. This Federal tag related to Complaint IN 320. 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview and record review, the facility failed to notify the physician for missed doses of medications for residents taking [MEDICAL CONDITION] medications. This affected 1 of 5 residents reviewed for taking [MEDICAL CONDITION] medication. Resident #B was hospitalized due to a critical TSH level. (Resident #B) Findings Include: 1) The clinical record for Resident #B was reviewed on 6/6/13 at 10:00 a.m. [DIAGNOSES REDACTED].) Resident #B had a physicians order to take "[MEDICATION NAME] ([MEDICAL CONDITION] hormone replacement medication), 137 mcg (micrograms/dosage), 1 tablet oral (by mouth), once a morning at 5:00 a.m." A Minimum Data Set (MDS) assessment completed on 3/15/13 indicated Resident #B had a Brief Interview for Mental Status score of 3/15, which indicated severe cognitive impairment. The MDS also indicated Resident #B required extensive assistance from staff to perform activities of daily living such as transferring, moving in the bed, eating, tilting and personal hygiene. An Electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 5/8/13 4:32 a.m., Not Administered: Refused (nurses notes indicated resident refused medication) 5/9/13 4:22 a.m., Not Administered: Refused 5/10/13 4:22 a.m., Not Administered: Refused 5/12/13 4:23 a.m., Not Administered: Refused to open mouth 5/15/13 4:19 a.m., Not Administered: Refused to open mouth 5/18/13 4:19 a.m., Not Administered: Refused A nurses note dated 5/21/13 and timed 11:29 a.m., indicated "Received call from _____ (name of caller) at Dr. _____ (name) office. _____ (Name of caller) stated that IV (intra-venous) [MEDICATION NAME] needed to be started immediately or she needed to be admitted to the hospital to get it. She has a critical TSH ([MEDICAL CONDITION] stimulating hormone) level of 214.5 (therapeutic or normal range is 0.3 to 5.0). This writer found out that we don ' t have [MEDICATION NAME] IV in the EDK (emergency drug kit) and that she would need to go to the hospital for treatment. Call placed back to _____ (name of caller) and was given orders to send through IU ER (Indiana University hospital emergency room ) and admit to hospital. Mother and friend was here for care plan meeting and was made aware of condition. Call placed to seals for transport to hospital. Report called to IU ER. call placed to [MEDICAL TREATMENT] center that she would not be getting [MEDICAL TREATMENT] today. EMS (emergency medical services) here to transport and mother accompanied them." A physicians "Final Report" from Indiana University hospital, dated 5/15/13 indicated "From a [MEDICAL CONDITION] perspective, she is getting 137 mcg of [MEDICATION NAME], but this is being sprinkled onto applesauce according to the mother who brought the patient today. We therefore need to check a TSH and free T4 (blood level), I think they may have to find an alternative way of giving her [MEDICATION NAME], if necessarily intramuscularly since its absorption will not be good with any kind of food. ... Plan: Our plan is to check her TSH and free T4 today and based on the results we will recommend alterative delivery mechanisms to the nursing home if they cannot get the [MEDICATION NAME] given to her on an empty stomach." The clinical record lacked documentation of any interventions or alternate means of medication administration, put into place to assist Resident #B to get required medications. The record also lacked documentation the physician providing care for Resident #B, while in the nursing facility, was aware of the missed medications. During an interview with the Director of Nursing (DON) on 6/6/13 at 12:00 p.m., further information was requested in regard to alternate means of medication administration, facility plan of care for a resident #B receiving [MEDICAL CONDITION] medication, and physician notification of missed medications. During an interview with the Nurse Consultant and DON on 6/6/13 at 3:30 p.m., no information could be found in regard to alternate means of medication administration, facility plan of care for Resident #B receiving [MEDICAL CONDITION] medication, or physician notification of missed medications. The DON indicated at that time the facility Nurse Practitioner would be in on 6/7/13 and would discuss the acknowledgement of missed medications with the survey team. During an interview with the DON on 6/7/13 at 9:00 a.m., the DON indicated the Nurse Practitioner did not feel comfortable to give a statement indicating she was aware Resident #B had missed any medications. The DON at that time indicated as of 6/6/13, the facility had reviewed and placed an update in the Electronic Administration Record for each resident in the facility that was taking the medication [MEDICATION NAME] ([MEDICATION NAME]) and if a dose was missed, the doctor would be notified. A facility policy provided by the Nurse Consultant on June 07, 2013 at 11:30 a.m., undated and titled WITHHOLDING OR REFUSAL OF MEDICATION OR TREATMENT, indicated, "The physician will be notified when a medication or treatment has been refused by the resident OR held by the nurse for a resident-related reason for 24 hours AND the resident's condition is medically STABLE (not presenting signs or symptoms)." This Federal tag relates to Complaint IN 606 3.1-5(a)(3)

Based on interview and record review, the facility failed to ensure residents received medications as prescribed by the medical doctor for 2 of 5 residents reviewed for medication administration. This resulted in the hospitalization of one resident. (Resident's, #B, and #E.) Findings Include: 1) The clinical record for Resident #B was reviewed on 6/6/13 at 10:00 a.m. [DIAGNOSES REDACTED]. Resident #B had a physicians order to take "[MEDICATION NAME] ([MEDICAL CONDITION] hormone replacement medication), 137 mcg (micrograms/dosage), 1 tablet oral (by mouth), once a morning at 5:00 a.m." A Minimum Data Set (MDS) assessment completed on 3/15/13 indicated Resident #B had a Brief Interview for Mental Status score of 3/15, which indicated severe cognitive impairment. The MDS also indicated Resident #B required extensive assistance from staff to perform activities of daily living such as transferring, moving in the bed, eating, tilting and personal hygiene. An Electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 5/8/13 4:32 a.m., Not Administered: Refused (nurses notes indicated resident refused medication) 5/9/13 4:22 a.m., Not Administered: Refused 5/10/13 4:22 a.m., Not Administered: Refused 5/12/13 4:23 a.m., Not Administered: Refused to open mouth 5/15/13 4:19 a.m., Not Administered: Refused to open mouth 5/18/13 4:19 a.m., Not Administered: Refused A nurses note dated 5/21/13 and timed 11:29 a.m., indicated "Received call from _____ (name of caller) at Dr. _____ (name) office. _____ (Name of caller) stated that IV (intra-venous) [MEDICATION NAME] needed to be started immediately or she needed to be admitted to the hospital to get it. She has a critical TSH ([MEDICAL CONDITION] stimulating hormone) level of 214.5 (therapeutic or normal range is 0.3 to 5.0). This writer found out that we don't have [MEDICATION NAME] IV in the EDK (emergency drug kit) and that she would need to go to the hospital for treatment. Call placed back to _____ (name of caller) and was given orders to send through IU ER (Indiana University hospital emergency room ) and admit to hospital. Mother and friend was here for care plan meeting and was made aware of condition. Call placed to seals for transport to hospital. Report called to IU ER. Call placed to [MEDICAL TREATMENT] center that she would not be getting [MEDICAL TREATMENT] today. EMS (emergency medical services) here to transport and mother accompanied them." A physicians "Final Report" from Indiana University hospital, dated 5/15/13 "From a [MEDICAL CONDITION] perspective, she is getting 137 mcg of [MEDICATION NAME], but this is being sprinkled onto applesauce according to the mother who brought the patient today. We therefore need to check a TSH and free T4 (blood level), I think they may have to find an alternative way of giving her [MEDICATION NAME], if necessarily intramuscularly since its absorption will not be good with any kind of food ... Plan: Our plan is to check her TSH and free T4 today and based on the results we will recommend alterative delivery mechanisms to the nursing home if they cannot get the [MEDICATION NAME] given to her on an empty stomach." The clinical record lacked documentation of any interventions or alternate means of medication administration, put into place to assist Resident #B to get required medications. The record also lacked documentation the physician providing care for Resident #B, while in the nursing facility, was aware of the missed medications. During an interview with the Director of Nursing (DON) on 6/6/13 at 12:00 p.m., further information was requested in regard to alternate means of medication administration, facility plan of care for a resident #B receiving [MEDICAL CONDITION] medication, and physician notification of missed medications. During an interview with the Nurse Consultant and DON on 6/6/13 at 3:30 p.m., no information could be found in regard to alternate means of medication administration, facility plan of care for a resident #B receiving [MEDICAL CONDITION] medication, or physician notification of missed medications. The DON indicated at that time the facility Nurse Practitioner would be in on 6/7/13 and would discuss the acknowledgement of missed medications with the survey team. During an interview with the DON on 6/7/13 at 9:00 a.m., the DON indicated the Nurse Practitioner did not feel comfortable to give a statement indicating she was aware Resident #B had missed any medications. The DON at that time indicated as of 6/6/13, the facility had reviewed and placed an update in the Electronic Administration Record for each resident in the facility that was taking the medication [MEDICATION NAME] ([MEDICATION NAME]), and if a dose was missed, the doctor would be notified. A facility policy, undated provided by the Nurse Consultant on June 07, 2012 at 11:30 a.m., and titled WITHHOLDING OR REFUSAL OF MEDICATION OR TREATMENT, indicated, "The physician will be notified when a medication or treatment has been refused by the resident OR held by the nurse for a resident-related reason for 24 hours AND the resident's condition is medically STABLE (not presenting signs or symptoms). ... The physician will be notified AFTER THE FIRST MISSED DOSE when a drug from the following classes has been refused by the resident OR held for a medically related reason: ANTIBIOTICS ANTIDIABETICS ANTICOAGULANTS ANTICONVULSANTS [MEDICATION NAME] CARDIOACTIVES... The nurse may determine per professional discretion to notify the physician sooner than above parameters if such notification is necessary in order to provide appropriate resident care." 2) On 6/5/13 at 1:30 p.m., Resident #E was observed lying in his bed with his right leg in a CPM (Continuous Passive Motion) machine. He was observed to have a bandage covering his right knee that had a date of 6/5/13 and a time of 10:30 a.m. In an interview, the resident indicated he had admitted to the facility on Saturday, June 1, 2013 at 2:50 p.m. A review of the resident's clinical record on 6/5/13 at 2:00 p.m., indicated [DIAGNOSES REDACTED]. The clinical record indicated physician's orders [REDACTED]. [MEDICATION NAME] 30 mg (milligrams) 1 po (by mouth) q (every) 5:00 p.m. aspirin 81 mg 1 po q 8:00 a.m. [MEDICATION NAME] 2 mg 1 po 1 8:00 a.m. [MEDICATION NAME] 0.5 mg 1 po b.i.d. (twice daily) colase 100 mg 1 po b.i.d. [MEDICATION NAME] 20-100 mcg (micrograms) [MEDICATION NAME]-quaifenesin 10-100 mg/5 ml (milliliters) 10 ml qhs (every hour of sleep) prn (as needed) [MEDICATION NAME] inhaler 200-5 mcg 2 puffs b.i.d. at 8:00 a.m. and 5:00 p.m. [MEDICATION NAME] 50 mg 1 po b.i.d. at 8:00 a.m. and 5:00 p.m. isorbide ER (extended release) 60 mg 1 po qd (every day) at 5:00 p.m. klonopin 1 mg 1 po t.i.d. (three times per day) [MEDICATION NAME] 25 mg 2 po qd at 5 p.m. [MEDICATION NAME] 2.5-0.025 mg 2 po q.i.d. (four times per day) prn losartin 50 mg 1 po qd at 8:00 a.m. [MEDICATION NAME] 40 mg/0.4 ml subcutaneous (beneath the skin) qd at 8:00 a.m. [MEDICATION NAME] 100 mg 1 po b.i.d. at 8:00 a.m. and 5:00 p.m. multivitamin 1 po qd at 8:00 a.m. nicotine 21 mg/24 hour 1 patch [MEDICATION NAME] (through the skin) qd at 8:00 a.m. [MEDICATION NAME] 15 mg 1 po qhs at 8:00 p.m. [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg 1 po q 4 hours prn requip 2 mg 1 po t.i.d. at 8:00 a.m., 1:00 p.m., and 5:00 p.m. [MEDICATION NAME] 10 mg 1 po qhs at 8:00 p.m. spireva 18 mcg 1 capsule with inhalation qd at 8:00 a.m. [MEDICATION NAME] 150 mg 1 po b.i.d. at 8:00 a.m. and 5:00 p.m. [MEDICATION NAME] 100 mg 1 po with 50 mg to equal 150 mg qhs at 8:00 p.m. A review of the resident's clinical record on 6/5/13 at 2:00 p.m., indicated medications not given on 6/1/13 at 5:00 p.m. and/or 8:00 p.m. included but not limited to: [MEDICATION NAME] 30 mg 1 po at 5:00 p.m. [MEDICATION NAME] 0.5 mg 1 po b.i.d. colase 100 mg 1 po b.i.d. [MEDICATION NAME] respimat aerosol 20-100 mcg 1 puff inhaled [MEDICATION NAME] 60 mg 1 po at 5:00 p.m. klonopin 1 mg 1 po t.i.d. at 5:00 p.m. [MEDICATION NAME] 25 mg 2 po at 5:00 p.m. [MEDICATION NAME] 100 mg 1 po b.i.d. at 5:00 p.m. [MEDICATION NAME] 15 mg 1 po at 8:00 p.m. [MEDICATION NAME] 150 mg 1 po at 5:00 p.m. On 6/2/13, the resident did not receive medications including but not limited to: [MEDICATION NAME] 30 mg 1 po at 5:00 p.m. [MEDICATION NAME] 0.5 mg 1 po b.i.d. The 8:00 a.m. and 5:00 p.m. doses were not administered. colase 100 mg 1 po b.i.d. The 8:00 a.m. and 5:00 p.m. doses were not administered. [MEDICATION NAME] aerosol inhaler 200-5 mcg 2 puffs inhaled [MEDICATION NAME] respimat aerosol 20-100 mcg 1 puff inhaled. The 8:00 a.m. and 5:00 p.m. doses were not administered. [MEDICATION NAME] 60 mg 1 po at 5:00 p.m. klonopin 1 mg 1 po t.i.d. at 8:00 a.m. or 1:00 p.m. [MEDICATION NAME] 25 mg 2 po at 5:00 p.m. [MEDICATION NAME] 40 mg 1 po qd at 7:00 a.m. nicotine patch 24 hr 21 mg/24 hr 1 patch [MEDICATION NAME] at 8:00 a.m. [MEDICATION NAME] 20 mg 2 po q 5:00 a.m. [MEDICATION NAME] 15 mg 1 po q 8:00 p.m. [MEDICATION NAME] 10 mg 1 po q 8:00 p.m. [MEDICATION NAME] with inhalation device 18 mcg q 8:00 a.m. [MEDICATION NAME] 100 mg 1 po q 8:00 p.m. [MEDICATION NAME] 50 mg 1 po q 8:00 p.m. On 6/3/13 the resident did not receive medications including but not limited to: klonopin 1 mg 1 po t.i.d. at 8:00 a.m. or 1:00 p.m. [MEDICATION NAME] 20 mg 2 po q 5:00 a.m. [MEDICATION NAME] 15 mg 1 po q 8:00 p.m. [MEDICATION NAME] 10 mg 1 po q 8:00 p.m. [MEDICATION NAME] 100 mg 1 po q 8:00 p.m. [MEDICATION NAME] 50 mg 1 po q 8:00 p.m. A review on 6/6/13 at 1:30 p.m., of nursing progress notes dated 6/1/13, indicated, "resident had arrived to UHHLC (University Heights Health and Living Center) and none of his 5 p.m. medications were passed due to, medication was not available." A nursing progress note dated 6/3/13, at 2:18 p.m., indicated the physician was notified of the medications that were not passed 6/1/13 at 5 p.m. No new orders were received from the physician at that time. Nursing spoke with pharmacy on 6/2/13, who indicated the medications would be sent that evening (6/2/13). During an interview on 6/6/13 at 11:20 a.m., the resident indicated he did not receive all of his medications "for a couple of days." He indicated the nurses were able to give him his pain medication and "some of his other medications that they got from other areas." The resident indicated the staff told him his medications were not available because the pharmacy had not delivered them. 3.1-35(g)(2)

Based on interview and record review, the facility failed to provide the necessary care and services to attain the highest practicable physical well being for residents taking medications. This affected 2 of 5 residents reviewed for taking medications. This resulted in the hospitalization for one resident. (Resident's, #B, and #E.) Findings Include: 1) The clinical record for Resident #B was reviewed on 6/6/13 at 10:00 a.m. [DIAGNOSES REDACTED]. Resident #B had a physicians order to take "[MEDICATION NAME] ([MEDICAL CONDITION] hormone replacement medication), 137 mcg (microgram/dosage), 1 tablet oral (by mouth), once a morning at 5:00 a.m." A Minimum Data Set (MDS) assessment completed on 3/15/13, indicated Resident #B had a Brief Interview for Mental Status score of 3/15, which indicated severe cognitive impairment. The MDS also indicated Resident #B required extensive assistance from staff to perform activities of daily living such as transferring, moving in the bed, eating, tilting and personal hygiene. An Electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 5/8/13 4:32 a.m., Not Administered: Refused (nurses notes indicated resident refused medication) 5/9/13 4:22 a.m., Not Administered: Refused 5/10/13 4:22 a.m., Not Administered: Refused 5/12/13 4:23 a.m., Not Administered: Refused to open mouth 5/15/13 4:19 a.m., Not Administered: Refused to open mouth 5/18/13 4:19 a.m., Not Administered: Refused A nurses note dated 5/21/13 and timed 11:29 a.m., indicated "Received call from _____ (name of caller) at Dr. _____ (name) office. _____ (Name of caller) stated that IV (intra-venous) [MEDICATION NAME] needed to be started immediately or she needed to be admitted to the hospital to get it. She has a critical TSH ([MEDICAL CONDITION] stimulating hormone) level of 214.5 (therapeutic or normal range is 0.3 to 5.0). This writer found out that we don ' t have [MEDICATION NAME] IV in the EDK (emergency drug kit) and that she would need to go to the hospital for treatment. Call placed back to _____ (name of caller) and was given orders to send through IU ER (Indiana University hospital emergency room ) and admit to hospital. Mother and friend was here for care plan meeting and was made aware of condition. Call placed to seals for transport to hospital. Report called to IU ER. call placed to [MEDICAL TREATMENT] center that she would not be getting [MEDICAL TREATMENT] today. EMS (emergency medical services) here to transport and mother accompanied them." A physicians "Final Report" from Indiana University hospital, dated 5/15/13 "From a [MEDICAL CONDITION] perspective, she is getting 137 mcg of [MEDICATION NAME], but this is being sprinkled onto applesauce according to the mother who brought the patient today. We therefore need to check a TSH and free T4 (blood level), I think they may have to find an alternative way of giving her [MEDICATION NAME], if necessarily intramuscularly since its absorption will not be good with any kind of food. ... Plan: Our plan is to check her TSH and free T4 today and based on the results we will recommend alterative delivery mechanisms to the nursing home if they cannot get the [MEDICATION NAME] given to her on an empty stomach." The clinical record lacked documentation of any interventions or alternate means of medication administration, put into place to assist Resident #B to get required medications. The record also lacked documentation the physician providing care for Resident #B, while in the nursing facility, was aware of the missed medications. During an interview with the Director of Nursing (DON) on 6/6/13 at 12:00 p.m., further information was requested in regard to alternate means of medication administration, facility plan of care for a resident #B receiving [MEDICAL CONDITION] medication, and physician notification of missed medications. During an interview with the Nurse Consultant and DON on 6/6/13 at 3:30 p.m., no information could be found in regard to alternate means of medication administration, facility plan of care for a resident #B receiving [MEDICAL CONDITION] medication, or physician notification of missed medications. The DON indicated at that time the facility Nurse Practitioner would be in on 6/7/13 and would discuss the acknowledgement of missed medications with the survey team. During an interview with the DON on 6/7/13 at 9:00 a.m., the DON indicated the Nurse Practitioner did not feel comfortable to give a statement indicating she was aware Resident #B had missed any medications. The DON at that time indicated as of 6/6/13, the facility had reviewed and placed an update in the Electronic Administration Record for each resident in the facility that was taking the medication [MEDICATION NAME] ([MEDICATION NAME]), and if a dose was missed, the doctor would be notified. 2) On 6/5/13 at 1:30 p.m., Resident #E was observed lying in his bed with his right leg in a CPM (Continuous Passive Motion) machine. He was observed to have a bandage covering his right knee that had a date of 6/5/13 and a time of 10:30 a.m. In an interview, the resident indicated he had admitted to the facility on Saturday, June 1, 2013 at 2:50 p.m. A review of the resident's clinical record on 6/5/13 at 2:00 p.m., indicated [DIAGNOSES REDACTED]. The clinical record indicated physician's orders [REDACTED]. [MEDICATION NAME] 30 mg (milligrams) 1 po (by mouth) q (every) 5:00 p.m. aspirin 81 mg 1 po q 8:00 a.m. [MEDICATION NAME] 2 mg 1 po 1 8:00 a.m. [MEDICATION NAME] 0.5 mg 1 po b.i.d. (twice daily) colase 100 mg 1 po b.i.d. [MEDICATION NAME] 20-100 mcg (micrograms) [MEDICATION NAME]-quaifenesin 10-100 mg/5 ml (milliliters) 10 ml qhs (every hour of sleep) prn (as needed) [MEDICATION NAME] inhaler 200-5 mcg 2 puffs b.i.d. at 8:00 a.m. and 5:00 p.m. [MEDICATION NAME] 50 mg 1 po b.i.d. at 8:00 a.m. and 5:00 p.m. isorbide ER (extended release) 60 mg 1 po qd (every day) at 5:00 p.m. klonopin 1 mg 1 po t.i.d. (three times per day) [MEDICATION NAME] 25 mg 2 po qd at 5 p.m. [MEDICATION NAME] 2.5-0.025 mg 2 po q.i.d. (four times per day) prn losartin 50 mg 1 po qd at 8:00 a.m. [MEDICATION NAME] 40 mg/0.4 ml subcutaneous (beneath the skin) qd at 8:00 a.m. [MEDICATION NAME] 100 mg 1 po b.i.d. at 8:00 a.m. and 5:00 p.m. multivitamin 1 po qd at 8:00 a.m. nicotine 21 mg/24 hour 1 patch [MEDICATION NAME] (through the skin) qd at 8:00 a.m. [MEDICATION NAME] 15 mg 1 po qhs at 8:00 p.m. [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg 1 po q 4 hours prn requip 2 mg 1 po t.i.d. at 8:00 a.m., 1:00 p.m., and 5:00 p.m. [MEDICATION NAME] 10 mg 1 po qhs at 8:00 p.m. spireva 18 mcg 1 capsule with inhalation qd at 8:00 a.m. [MEDICATION NAME] 150 mg 1 po b.i.d. at 8:00 a.m. and 5:00 p.m. [MEDICATION NAME] 100 mg 1 po with 50 mg to equal 150 mg qhs at 8:00 p.m. A review of the resident's clinical record on 6/5/13 at 2:00 p.m., indicated medications not given on 6/1/13 at 5:00 p.m. and/or 8:00 p.m. included but not limited to: [MEDICATION NAME] 30 mg 1 po at 5:00 p.m. [MEDICATION NAME] 0.5 mg 1 po b.i.d. colase 100 mg 1 po b.i.d. [MEDICATION NAME] respimat aerosol 20-100 mcg 1 puff inhaled [MEDICATION NAME] 60 mg 1 po at 5:00 p.m. klonopin 1 mg 1 po t.i.d. at 5:00 p.m. [MEDICATION NAME] 25 mg 2 po at 5:00 p.m. [MEDICATION NAME] 100 mg 1 po b.i.d. at 5:00 p.m. [MEDICATION NAME] 15 mg 1 po at 8:00 p.m. [MEDICATION NAME] 150 mg 1 po at 5:00 p.m. On 6/2/13, the resident did not receive medications including but not limited to: [MEDICATION NAME] 30 mg 1 po at 5:00 p.m. [MEDICATION NAME] 0.5 mg 1 po b.i.d. The 8:00 a.m. and 5:00 p.m. doses were not administered. colase 100 mg 1 po b.i.d. The 8:00 a.m. and 5:00 p.m. doses were not administered. [MEDICATION NAME] aerosol inhaler 200-5 mcg 2 puffs inhaled [MEDICATION NAME] respimat aerosol 20-100 mcg 1 puff inhaled. The 8:00 a.m. and 5:00 p.m. doses were not administered. [MEDICATION NAME] 60 mg 1 po at 5:00 p.m. klonopin 1 mg 1 po t.i.d. at 8:00 a.m. or 1:00 p.m. [MEDICATION NAME] 25 mg 2 po at 5:00 p.m. [MEDICATION NAME] 40 mg 1 po qd at 7:00 a.m. nicotine patch 24 hr 21 mg/24 hr 1 patch [MEDICATION NAME] at 8:00 a.m. [MEDICATION NAME] 20 mg 2 po q 5:00 a.m. [MEDICATION NAME] 15 mg 1 po q 8:00 p.m. [MEDICATION NAME] 10 mg 1 po q 8:00 p.m. [MEDICATION NAME] with inhalation device 18 mcg q 8:00 a.m. [MEDICATION NAME] 100 mg 1 po q 8:00 p.m. [MEDICATION NAME] 50 mg 1 po q 8:00 p.m. On 6/3/13 the resident did not receive medications including but not limited to: klonopin 1 mg 1 po t.i.d. at 8:00 a.m. or 1:00 p.m. [MEDICATION NAME] 20 mg 2 po q 5:00 a.m. [MEDICATION NAME] 15 mg 1 po q 8:00 p.m. [MEDICATION NAME] 10 mg 1 po q 8:00 p.m. [MEDICATION NAME] 100 mg 1 po q 8:00 p.m. [MEDICATION NAME] 50 mg 1 po q 8:00 p.m. A review on 6/6/13 at 1:30 p.m., of nursing progress notes dated 6/1/13, indicated, "resident had arrived to UHHLC (University Heights Health and Living Center) and none of his 5 p.m. medications were passed due to, medication was not available." A nursing progress note dated 6/3/13, at 2:18 p.m., indicated the physician was notified of the medications that were not passed 6/1/13 at 5 p.m. No new orders were received from the physician at that time. Nursing spoke with pharmacy on 6/2/13, who indicated the medications would be sent that evening (6/2/13). During an interview on 6/6/13 at 11:20 a.m., the resident indicated he did not receive all of his medications "for a couple of days." He indicated the nurses were able to give him his pain medication and "some of his other medications that they got from other areas." The resident indicated the staff told him his medications were not available because the pharmacy had not delivered them. A facility policy provided by the Nurse Consultant on June 7, 2013 at 11:30 a.m., undated and titled WITHHOLDING OR REFUSAL OF MEDICATION OR TREATMENT, indicated, "The physician will be notified when a medication or treatment has been refused by the resident OR held by the nurse for a resident-related reason for 24 hours AND the resident's condition is medically STABLE (not presenting signs or symptoms). ... The physician will be notified AFTER THE FIRST MISSED DOSE when a drug from the following classes has been refused by the resident OR held for a medically related reason: ANTIBIOTICS ANTIDIABETICS ANTICOAGULANTS ANTICONVULSANTS [MEDICATION NAME] CARDIOACTIVES... The nurse may determine per professional discretion to notify the physician sooner than above parameters if such notification is necessary in order to provide appropriate resident care." This Federal tag relates to Complaint IN 606 3.1-37(a)

Based on record review and interview, the facility failed to provide services as indicated by the plan of care, and failed to follow a physicians order for blood sugar monitoring. The facility failed to provide services for 2 of 3 Residents as indicated by the plan of care(Resident #B and #C), and failed to follow physicians orders for 1 of 10 residents reviewed for unnecessary medications (Resident 269). Findings Include: 1. The clinical record for Resident #269 was reviewed on 4/18/13 at 11:30 a.m. [DIAGNOSES REDACTED]. A physicians order written 3/29/13 indicated, if blood sugar level was "greater than 350 call the doctor." Blood sugar levels were as follows, 4/5/13, 4:00 p.m., blood sugar level was 367, 4/8/13, 4:00 p.m., blood sugar level was 363, 4/9/13, 12:00 p.m., blood sugar level was 533, and on 4/10/13, 4 p.m. blood sugar level was 417. No information was found in the clinical record, that Resident #269's doctor was notified of the blood sugar levels. Further information was requested from the Director of Nursing (DON), on 4/18/13 at 1:30 p.m. During an interview with the DON on 4/18/13 at 3:30 p.m., she indicated the medical doctor had not been notified as indicated by orders. 2. The clinical record of Resident #B was reviewed on 4/19/13 at 9:00 a.m. [DIAGNOSES REDACTED]. Resident #B was admitted to the facility on [DATE]. A care plan for Resident #B, dated 3/5/13, indicated a problem of, "Resident is at risk for skin breakdown (related to) impaired mobility. The goal was, "Resident will be free from skin breakdown." Approaches included, "Weekly skin assessment." Review of skin assessments for Resident #B, indicated they had been done on 3/7/13, 3/14/13, 3/21/13, and 4/8/13. No documentation was found which indicated Resident #B's skin had been assessed between 3/21/13 and 4/8/13, or after 4/8/13. Further information was requested from the Director of Nursing (DON) on 4/19/13 at 3:00 p.m. regarding skin assessments done between 3/21/113 and 4/8/13, and after 4/8/13. She indicated pressure ulcer evaluations had been done on Resident #B's coccyx pressure ulcer, but no other overall skin assessments had been done during these weeks to monitor for further skin breakdown. 3. The clinical record of Resident #C was reviewed on 4/18/13 at 11:00 a.m. [DIAGNOSES REDACTED]. Resident #C was admitted to the facility on [DATE]. A care plan for Resident #C, dated 9/6/12 and updated 2/20/13, indicated a problem of, "(resident's name) is at risk for skin breakdown (related to) decreased mobility. The goal was, "Resident's skin will remain intact." Approaches included, "Conduct a systematic skin inspection weekly. Pay particular attention to the bony prominences." Weekly Skin Inspections were found in Resident #C's record for 2/6/13, 3/5/13, and 3/26/13. Further information was requested from the DON on 4/18/13 at 3:00 p.m., regarding whether any Weekly Skin Inspections had been done for Resident #C in February, March, or April, 2013, other than on 2/6/13, 3/5/13, and 3/26/13. On 4/19/13 at 11:00 a.m., the DON indicated she was not able to find any other Weekly Skin Inspections for Resident #C for February, March or April, 2013. At that time she provided shower sheets which had been filled out for Resident #C. The DON indicated at that time the shower sheets were filled out by a Certified Nursing Assistant (CNA) and signed by a nurse. The shower sheets had a front and back picture of the naked human body for the CNA to mark any skin irregularities, a "yes" or "no" question to be circled "Skin issue identified (circle one)," followed by "If Yes Nurse Notified IMMEDIATELY." The CNA was supposed to fill in the name of the nurse she notified about any new skin issues. A review of the shower sheets indicated the following: 2/1/13 - no skin issues identified. CNA documented "Nothing new." 2/5/13 - no skin issues identified. 2/12/13 - no skin information found on this sheet 2/15/13 - no skin issues identified. CNA documented "Nothing new." 2/19/13 - no skin issues identified. CNA documented "Nothing new." 2/26/13 - no skin information found on this sheet 3/5/13 - no skin issues identified 3/8/13 - no skin information found on this sheet 3/12/13 - no skin information found on this sheet 3/15/13 - no skin issues identified 3/19/13 - no skin information found on this sheet 3/22/13 - no skin issues identified 3/26/13 - picture of back of resident's body marked with "bruise" in 2 places. No information which indicated if a nurse was notified immediately, or the name of the nurse notified. 3/29/13 - no skin issues identified 4/2/13 - no skin information found on this sheet. CNA had written "Shower completed." 4/5/13 - No skin information found on this sheet 4/9/13 - no skin information found on this sheet 4/12/13 - no skin issues identified 4/16/13 - no skin issues identified There was a licensed nurse's signature on all the shower sheets, but there was no indication the nurse had inspected the resident's skin herself, or documented the findings. A facility policy, dated 4/2011, titled "Skin Care and Pressure/Non-Pressure Ulcer Management Program," received from the Nurse Consultant on 4/22/13 at 10:55 a.m., indicated, "...Risk Interventions...12. Complete a documented weekly skin inspection...", "...Weekly Skin Inspection - A licensed nurse should inspect skin on a weekly schedule and document findings..." 3.1-35(g)(2)

Based on interview and record review, the facility failed to ensure residents received medications as prescribed by the medical doctor for 2 of 5 residents reviewed for medication administration. This resulted in hospitalization of one resident. (Resident's, #B, and #E.) Findings Include: 1) The clinical record for Resident #B was reviewed on 6/6/13 at 10:00 a.m. [DIAGNOSES REDACTED]. Resident #B had a physicians order to take "[MEDICATION NAME] ([MEDICAL CONDITION] hormone replacement medication), 137 mcg (micrograms/dosage), 1 tablet oral (by mouth), once a morning at 5:00 a.m." A Minimum Data Set (MDS) assessment completed on 3/15/13 indicated Resident #B had a Brief Interview for Mental Status score of 3/15, which indicated severe cognitive impairment. The MDS also indicated Resident #B required extensive assistance from staff to perform activities of daily living such as transferring, moving in the bed, eating, tilting and personal hygiene. An Electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 5/8/13 4:32 a.m., Not Administered: Refused (nurses notes indicated resident refused medication) 5/9/13 4:22 a.m., Not Administered: Refused 5/10/13 4:22 a.m., Not Administered: Refused 5/12/13 4:23 a.m., Not Administered: Refused to open mouth 5/15/13 4:19 a.m., Not Administered: Refused to open mouth 5/18/13 4:19 a.m., Not Administered: Refused A nurses note dated 5/21/13 and timed 11:29 a.m., indicated "Received call from _____ (name of caller) at Dr. _____ (name) office. _____ (Name of caller) stated that IV (intra-venous) [MEDICATION NAME] needed to be started immediately or she needed to be admitted to the hospital to get it. She has a critical TSH ([MEDICAL CONDITION] stimulating hormone) level of 214.5 (therapeutic or normal range is 0.3 to 5.0). This writer found out that we don't have [MEDICATION NAME] IV in the EDK (emergency drug kit) and that she would need to go to the hospital for treatment. Call placed back to _____ (name of caller) and was given orders to send through IU ER (Indiana University hospital emergency room ) and admit to hospital. Mother and friend was here for care plan meeting and was made aware of condition. Call placed to seals for transport to hospital. Report called to IU ER. Call placed to [MEDICAL TREATMENT] center that she would not be getting [MEDICAL TREATMENT] today. EMS (emergency medical services) here to transport and mother accompanied them." A physicians "Final Report" from Indiana University hospital, dated 5/15/13 "From a [MEDICAL CONDITION] perspective, she is getting 137 mcg of [MEDICATION NAME], but this is being sprinkled onto applesauce according to the mother who brought the patient today. We therefore need to check a TSH and free T4 (blood level), I think they may have to find an alternative way of giving her [MEDICATION NAME], if necessarily intramuscularly since its absorption will not be good with any kind of food ... Plan: Our plan is to check her TSH and free T4 today and based on the results we will recommend alterative delivery mechanisms to the nursing home if they cannot get the [MEDICATION NAME] given to her on an empty stomach." The clinical record lacked documentation of any interventions or alternate means of medication administration, put into place to assist Resident #B to get required medications. The record also lacked documentation the physician providing care for Resident #B, while in the nursing facility, was aware of the missed medications. During an interview with the Director of Nursing (DON) on 6/6/13 at 12:00 p.m., further information was requested in regard to alternate means of medication administration, facility plan of care for a resident #B receiving [MEDICAL CONDITION] medication, and physician notification of missed medications. During an interview with the Nurse Consultant and DON on 6/6/13 at 3:30 p.m., no information could be found in regard to alternate means of medication administration, facility plan of care for a resident #B receiving [MEDICAL CONDITION] medication, or physician notification of missed medications. The DON indicated at that time the facility Nurse Practitioner would be in on 6/7/13 and would discuss the acknowledgement of missed medications with the survey team. During an interview with the DON on 6/7/13 at 9:00 a.m., the DON indicated the Nurse Practitioner did not feel comfortable to give a statement indicating she was aware Resident #B had missed any medications. The DON at that time indicated as of 6/6/13, the facility had reviewed and placed an update in the Electronic Administration Record for each resident in the facility that was taking the medication [MEDICATION NAME] ([MEDICATION NAME]), and if a dose was missed, the doctor would be notified. A facility policy, undated provided by the Nurse Consultant on June 7, 2013 at 11:30 a.m., and titled WITHHOLDING OR REFUSAL OF MEDICATION OR TREATMENT, indicated, "The physician will be notified when a medication or treatment has been refused by the resident OR held by the nurse for a resident-related reason for 24 hours AND the resident's condition is medically STABLE (not presenting signs or symptoms). ... The physician will be notified AFTER THE FIRST MISSED DOSE when a drug from the following classes has been refused by the resident OR held for a medically related reason: ANTIBIOTICS ANTIDIABETICS ANTICOAGULANTS ANTICONVULSANTS [MEDICATION NAME] CARDIOACTIVES... The nurse may determine per professional discretion to notify the physician sooner than above parameters if such notification is necessary in order to provide appropriate resident care." 2) On 6/5/13 at 1:30 p.m., Resident #E was observed lying in his bed with his right leg in a CPM (Continuous Passive Motion) machine. He was observed to have a bandage covering his right knee that had a date of 6/5/13 and a time of 10:30 a.m. In an interview, the resident indicated he had admitted to the facility on Saturday, June 1, 2013 at 2:50 p.m. A review of the resident's clinical record on 6/5/13 at 2:00 p.m., indicated [DIAGNOSES REDACTED]. The clinical record indicated physician's orders [REDACTED]. [MEDICATION NAME] 30 mg (milligrams) 1 po (by mouth) q (every) 5:00 p.m. aspirin 81 mg 1 po q 8:00 a.m. [MEDICATION NAME] 2 mg 1 po 1 8:00 a.m. [MEDICATION NAME] 0.5 mg 1 po b.i.d. (twice daily) colase 100 mg 1 po b.i.d. [MEDICATION NAME] 20-100 mcg (micrograms) [MEDICATION NAME]-quaifenesin 10-100 mg/5 ml (milliliters) 10 ml qhs (every hour of sleep) prn (as needed) [MEDICATION NAME] inhaler 200-5 mcg 2 puffs b.i.d. at 8:00 a.m. and 5:00 p.m. [MEDICATION NAME] 50 mg 1 po b.i.d. at 8:00 a.m. and 5:00 p.m. isorbide ER (extended release) 60 mg 1 po qd (every day) at 5:00 p.m. klonopin 1 mg 1 po t.i.d. (three times per day) [MEDICATION NAME] 25 mg 2 po qd at 5 p.m. [MEDICATION NAME] 2.5-0.025 mg 2 po q.i.d. (four times per day) prn losartin 50 mg 1 po qd at 8:00 a.m. [MEDICATION NAME] 40 mg/0.4 ml subcutaneous (beneath the skin) qd at 8:00 a.m. [MEDICATION NAME] 100 mg 1 po b.i.d. at 8:00 a.m. and 5:00 p.m. multivitamin 1 po qd at 8:00 a.m. nicotine 21 mg/24 hour 1 patch [MEDICATION NAME] (through the skin) qd at 8:00 a.m. [MEDICATION NAME] 15 mg 1 po qhs at 8:00 p.m. [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg 1 po q 4 hours prn requip 2 mg 1 po t.i.d. at 8:00 a.m., 1:00 p.m., and 5:00 p.m. [MEDICATION NAME] 10 mg 1 po qhs at 8:00 p.m. spireva 18 mcg 1 capsule with inhalation qd at 8:00 a.m. [MEDICATION NAME] 150 mg 1 po b.i.d. at 8:00 a.m. and 5:00 p.m. [MEDICATION NAME] 100 mg 1 po with 50 mg to equal 150 mg qhs at 8:00 p.m. A review of the resident's clinical record on 6/5/13 at 2:00 p.m., indicated medications not given on 6/1/13 at 5:00 p.m. and/or 8:00 p.m. included but not limited to: [MEDICATION NAME] 30 mg 1 po at 5:00 p.m. [MEDICATION NAME] 0.5 mg 1 po b.i.d. colase 100 mg 1 po b.i.d. [MEDICATION NAME] respimat aerosol 20-100 mcg 1 puff inhaled [MEDICATION NAME] 60 mg 1 po at 5:00 p.m. klonopin 1 mg 1 po t.i.d. at 5:00 p.m. [MEDICATION NAME] 25 mg 2 po at 5:00 p.m. [MEDICATION NAME] 100 mg 1 po b.i.d. at 5:00 p.m. [MEDICATION NAME] 15 mg 1 po at 8:00 p.m. [MEDICATION NAME] 150 mg 1 po at 5:00 p.m. On 6/2/13, the resident did not receive medications including but not limited to: [MEDICATION NAME] 30 mg 1 po at 5:00 p.m. [MEDICATION NAME] 0.5 mg 1 po b.i.d. The 8:00 a.m. and 5:00 p.m. doses were not administered. colase 100 mg 1 po b.i.d. The 8:00 a.m. and 5:00 p.m. doses were not administered. [MEDICATION NAME] aerosol inhaler 200-5 mcg 2 puffs inhaled [MEDICATION NAME] respimat aerosol 20-100 mcg 1 puff inhaled. The 8:00 a.m. and 5:00 p.m. doses were not administered. [MEDICATION NAME] 60 mg 1 po at 5:00 p.m. klonopin 1 mg 1 po t.i.d. at 8:00 a.m. or 1:00 p.m. [MEDICATION NAME] 25 mg 2 po at 5:00 p.m. [MEDICATION NAME] 40 mg 1 po qd at 7:00 a.m. nicotine patch 24 hr 21 mg/24 hr 1 patch [MEDICATION NAME] at 8:00 a.m. [MEDICATION NAME] 20 mg 2 po q 5:00 a.m. [MEDICATION NAME] 15 mg 1 po q 8:00 p.m. [MEDICATION NAME] 10 mg 1 po q 8:00 p.m. [MEDICATION NAME] with inhalation device 18 mcg q 8:00 a.m. [MEDICATION NAME] 100 mg 1 po q 8:00 p.m. [MEDICATION NAME] 50 mg 1 po q 8:00 p.m. On 6/3/13 the resident did not receive medications including but not limited to: klonopin 1 mg 1 po t.i.d. at 8:00 a.m. or 1:00 p.m. [MEDICATION NAME] 20 mg 2 po q 5:00 a.m. [MEDICATION NAME] 15 mg 1 po q 8:00 p.m. [MEDICATION NAME] 10 mg 1 po q 8:00 p.m. [MEDICATION NAME] 100 mg 1 po q 8:00 p.m. [MEDICATION NAME] 50 mg 1 po q 8:00 p.m. A review on 6/6/13 at 1:30 p.m., of nursing progress notes dated 6/1/13, indicated, "resident had arrived to UHHLC (University Heights Health and Living Center) and none of his 5 p.m. medications were passed due to, medication was not available." A nursing progress note dated 6/3/13, at 2:18 p.m., indicated the physician was notified of the medications that were not passed 6/1/13 at 5 p.m. No new orders were received from the physician at that time. Nursing spoke with pharmacy on 6/2/13, who indicated the medications would be sent that evening (6/2/13). During an interview on 6/6/13 at 11:20 a.m., the resident indicated he did not receive all of his medications "for a couple of days." He indicated the nurses were able to give him his pain medication and "some of his other medications that they got from other areas." The resident indicated the staff told him his medications were not available because the pharmacy had not delivered them. 3) The clinical record for Resident #D was reviewed on 6/5/13 at 1:00 p.m. [DIAGNOSES REDACTED]. A physicians order, dated 7/30/12, indicated Resident #D was to receive "[MEDICATION NAME] ([MEDICAL CONDITION] hormone replacement medication), 25 mcg (micrograms/dosage) by mouth, once a morning at 5:00 a.m." An Electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"Not Administered: Refused (nurses notes indicated resident refused medication)." The clinical record lacked documentation in regard to alternate means of medication administration for Resident #D receiving [MEDICAL CONDITION] medication, and physician notification of missed medications. During an interview with the Director of Nursing (DON) on 6/6/13 at 12:00 p.m., further information was requested in regard to alternate means of medication administration for Resident #D receiving [MEDICAL CONDITION] medication and physician notification of missed medications. During an interview with the DON and Nurse Consultant on 6/6/13 at 1:30 p.m., they indicated no further information was available. 4) The clinical record for Resident #C was reviewed on 6/6/13 at 9:00 a.m. [DIAGNOSES REDACTED]. A physicians order, dated 12/5/12, indicated Resident #C was to receive "[MEDICATION NAME] ([MEDICAL CONDITION] hormone replacement medication), 75 mcg (microgram/dosage) by mouth, once a morning at 5:00 a.m." An Electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"Not Administered: Refused (nurses notes indicated resident refused medication)." The clinical record lacked documentation in regard to alternate means of medication administration, facility plan of care for a resident #C receiving [MEDICAL CONDITION] medication, and physician notification of missed medications. During an interview with the Director of Nursing (DON) on 6/6/13 at 12:00 p.m., further information was requested in regard to alternate means of medication administration, facility plan of care for a resident #C receiving [MEDICAL CONDITION] medication, and physician notification of missed medications. A facility Care Plan dated 10/6/11, for Resident #C indicated, "Approach: medications as ordered." During an interview with the DON and Nurse Consultant on 6/6/13 at 1:30 p.m., no further information was available. This Federal tag relates to Complaint IN 606. This deficiency was cited on April 23, 2013. The facility failed to implement a systemic plan of correction to prevent recurrence. 3.1-35(g)(2)