Every finding on record at University Park Rehabilitation and Healthcare

Based on interview and record review the facility failed to ensure residents were free of verbal abuse for 1 of 3 residents reviewed (Resident B). The deficient practice was corrected on 7/24/26, prior to the start of the survey, and was therefore Past Noncompliance.Findings include:In an interview, on 8/11/26 at 9 AM, the Administrator and Director of Nursing (DON) indicated Resident B was on a video phone call with a friend when Qualified Medication Aide (QMA) 2 made bunny ears behind Resident B's head. Resident B told QMA 2 not to touch him and then QMA 2 indicated she didn't touch him. The Administrator indicated this led to a verbal argument between QMA 2 and Resident B. QMA 2 reported the incident to Assistant Director of Nursing (ADON) as Resident B followed her. The Administrator indicated QMA 2 was terminated due to unprofessional conduct.In an interview, on 8/11/26 at 9:36 AM, Resident B indicated on 7/24/26, he was on a video phone call with a friend when QMA 2 came up behind him and placed bunny ears on his head. Resident B indicated he told QMA 2 not to touch his head. Resident B indicated QMA 2 yelled at him and told him she didn't touch him. Resident B indicated QMA 2 entered the ADON office and he followed. Resident B indicated QMA 2 told the ADON about the situation, Resident B intervened and said QMA 2 touched his head. Resident B indicated QMA 2 raised her voice and said she was f****ing tired of this place and being disrespected. Resident B indicated QMA 2 yelled and cursed multiple times in front of him.In an interview, on 8/11/26 at 11:02 AM, the ADON indicated QMA 2 entered her office, raised her voice and cursed in front of Resident B. The ADON indicated QMA 2 indicated she did not touch Resident B's head, but Resident B indicated QMA 2 touched his head. The ADON indicated QMA 2 stated this f****ing place, I don't have to f****ing take this. The ADON indicated Resident B and staff were present when QMA 2 yelled and cursed. The ADON indicated verbal abuse consisted of any negative or foul language used in front or towards a resident.In an interview, on 8/11/26, at 10:07 AM, Registered Nurse (RN) 4, indicated when a resident requested to be left alone staff respected the resident's wishes and reapproached later. RN 4 indicated staff should never argue or curse in front of residents.An investigation file was provided by the DON on 8/11/26 at 11:19 AM. The file included the following:A report, dated 7/24/26, indicated Resident B was on a video phone call when QMA 2 approached him and made bunny ears behind Resident B's head. Resident B told QMA 2 not to touch him and QMA 2 indicated she did not touch Resident B. The report indicated Resident B and QMA 2 got into a verbal argument.Resident B's statement, dated 7/24/26, indicated QMA 2 was behind him while he was on video phone call and made bunny ears behind his head. Resident B indicated he told QMA 2 not to touch him and QMA 2 responded she didn't touch him. Resident 2 indicated he didn't play nor liked her touching him and requested QMA 2 to stay away from him. Resident B indicated QMA 2 and him continued to argue back and forth and then QMA 2 entered the ADON office as Resident B followed. Resident B indicated QMA 2 told the ADON she didn't touch him, and Resident B interjected she touched him. Resident B indicated the ADON tried to calm down QMA 2, but she continued to yell and raised her voice. Resident B indicated QMA 2 cursed many times in front of him.Licensed Practical Nurse (LPN) 3's statement, dated 7/24/26, indicated she overheard Resident B tell QMA 2 not to touch him. LPN 3 indicated she heard QMA 2 yell and curse at Resident B. LPN 3 also indicated she observed QMA 2 go behind the desk yelling and cursing I quit, I'm not doing this anymore when Resident B was present in the hallway.The ADON's statement, dated 7/24/26, indicated on 7/24/26 around 9:30 AM, QMA 2 entered her office yelling about how Resident B told her not to touch him and all she did was air bunny ears behind his head. The ADON indicated Resident B was outside of the door, indicated I don't want you to touch me was all I said. QMA 2 yelled and cursed at Resident B, I know what I f***ing saw. The ADON indicated QMA 2 indicated she quit and wasn't working at this f***ing place anymore.QMA 2's statement, dated 7/24/26, indicated on 7/24/26 around 9 AM, when Resident B was on a video phone call with a friend, she made bunny ears behind his head. QMA 2 indicated Resident B told her not to touch him and Resident B and QMA 2 started to argue back and forth. QMA 2 indicated she went to ADON's office, informed her she did not touch Resident B, while Resident B followed her. QMA 2 indicated she grabbed her stuff and indicated this place has me so f***ed up I put in too much work here to be disrespected like this in front of Resident B. QMA 2 indicated she continued to repeat I'm leaving, I am done with this place; I am walking out y'all got me f***ed up.Resident B's record was reviewed on 8/11/26 at 9:19 AM. Diagnoses included schizophrenia, bipolar and anxiety.A quarterly Minimum Data Set (MDS) assessment, dated 6/20/26, indicated Resident B had a Brief Interview of Mental Status (BIMS) score of 11/15 (moderate cognitive impairment).A nursing note, dated 7/24/26, indicated Resident B reported QMA 2 invaded his personal space and had asked staff not to touch the back of his head.A policy, dated 5/12/2023, titled Abuse and Incident Reporting was provided by the DON on 8/11/26 at 10:45 AM. The policy indicated verbal abuse consisted of use of oral, written, or gestured communication or sounds to residents within hearing distance, regardless of age/ability to comprehend or disability.The past noncompliance began on 7/24/26 when staff failed to respect the Resident B's right to not be touched or disrespected. The deficit practice was corrected on 7/24/26 when the facility reviewed and resident's treatment with dignity and respect. All staff were re-educated on dignity and respect of all residents. A performance improvement plan was put in place. The plan included monitoring and audits 4x/week for dignity and respect for 1 month followed by audits 3x/week for 4 months until 100% compliance completed. Audits and findings would be reviewed each month during quality assurance meetings.This finding relates to Intake 3110715.410 IAC (Indiana Administrative Code) 16.2-3.1-27(a)(b)

Based on interview and record review, the facility failed to ensure accident prevention interventions were implemented for 1 of 2 residents reviewed for accidents. A resident exited the facility unattended, his whereabouts unknown for approximately 13 hours. He was not noticed to be missing until an hour and half before being found approximately 1 mile away from the facility. (Resident B).Findings include:The Immediate Jeopardy began on 5/19/26 when Resident B was last seen about 1:00 a.m. and reported missing at 2:00 p.m. the next day. He was located at 3:15 p.m., approximately 1 mile from the facility on sidewalk of busy 6 lane highway with a speed limit of 45 mph. He was brought back to the facility where he refused to re-enter the building and was escorted by local law enforcement to the hospital for evaluation. The facility Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on June 11, 2026, at 3:03 P.M. The Immediate Jeopardy was removed, and the deficient practice corrected, on 5/20/26, prior to the start of the survey and was therefore Past Noncompliance.Resident B's record was reviewed on 6/10/26 at 1:20 P.M. Diagnoses included high blood pressure and adjustment disorder (emotional/behavioral reaction to stressful life event).A quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident B had moderately impaired cognition. He was independent with activities of daily living (ADL) but refused oral care, toileting hygiene, personal hygiene, and shower/bathing.Care plans indicated the resident was at risk for falls, impaired safety, and injury related to smoking. He had history of behaviors including refusing care, verbal/physical aggression with staff, yelling, cursing, verbal threats, paranoia, auditory hallucinations, agitation, talking to self, anxious complaints, indecisiveness, and racing thoughts. Resident B had current behaviors of urinating/putting feces on bathroom walls, floor and was non-compliant with taking medications. A revised care plan, dated 2/19/26, indicated Resident B had previously been homeless, was appointed a guardian while in the hospital, and needed long-term care. Interventions included to keep the resident safe during episodes of behaviors and attempt to redirect.A physician order, dated 12/16/25, was Resident B may not go on LOA (leave of absence) unless accompanied by a facility staff member for medically necessary appointments. A nurse note, dated 5/19/26, indicated at 2:00 p.m., the Administrator and DON were notified Resident B was unable to be located in the facility. Staff searched the building and grounds around the building but were unable to locate the resident. Staff searched the surrounding areas, and the resident was eventually located at 3:15 p.m., a mile from the facility on the sidewalk next to a busy 6 lane highway with a speed limit of 45 mph. He was brought back to the facility but refused to enter the building. Staff stayed with Resident B outside in the parking lot, talking and trying to coax him to come into the building. Due to continued refusal to return inside and concern for resident's safety, local law enforcement was called. Upon arrival of police, Resident B remained uncooperative and was eventually transported by police vehicle to the hospital for evaluation.Resident B's record had not indicated the resident was not able to be located in the facility.Meal intake records, dated 5/19/26, indicated there was no documentation completed to indicate the resident had eaten breakfast or lunch on 5/19/26.Medication Administration Records (MAR), dated May 2026, indicated Resident B had not received his medications as scheduled on 5/19/26 at 8:00 a.m.On 6/10/26 at 4:00 P.M., Qualified Medication Aid (QMA) 2 was interviewed. She indicated she had been the only employee working on the south hall where Resident B resided and had last seen him on 5/19/26 between 12:00 a.m.-1:00 a.m. QMA 2 indicated she hadn't seen him during the remaining hours when she left at 7:00 a.m. She indicated Resident B wandered throughout the facility day and night and the QMA assumed he had been in the building during the night.On 6/11/26 at 10:06 A.M., QMA 6 was interviewed. She worked on the east hall on night shift from 7:30 p.m. on 5/18/26 to 7:00 a.m. 5/19/26 and was the only staff member on the hall. She had not seen Resident B ambulating through the facility during her shift. She indicated Resident B was usually up through the night, would wander around the facility and out to the courtyard during all hours of the night.On 6/11/26 at 10:13 A.M., Registered Nurse (RN) 7 was interviewed. She indicated she was the charge nurse from 7:00 p.m., 5/18/26 until 7:30 a.m. on 5/19/26. She indicated 2 Certified Nurse Aids (CNA) called in on 3rd shift 5/18-5/19/26. She had a QMA and CNA down on her hall and there was 1 QMA on each of the other halls. She had been very busy during the night and hadn't recalled seeing Resident B. She indicated she was unaware no one else had seen the resident. On 6/11/26 at 9:12 A.M., Dietary Aide 10 was interviewed. She indicated on 5/19/26, Resident B's breakfast tray had been returned uneaten.On 6/11/26 at 9:14 A.M., Dietary Aide 11 was interviewed and indicated on 5/19/26, Resident B's lunch tray was sent out but came back uneaten which was unusual as he typically ate 75 % of his meals. She indicated the lunch tray looked like it hadn't been touched or taken off the cart.On 6/11/26 at 12:00 P.M., Licensed Practical Nurse (LPN) 8 was interviewed. She worked 1st shift on the south hall on 5/19/26. She indicated she had just returned from medical leave and was working on an unfamiliar hall. She went to give Resident B his 8:00 a.m. medications and he wasn't in his room. She indicated the resident usually refused his medications, so she hadn't looked for him.Confidential interviews conducted during the survey indicated:-The facility was short-staffed the night Resident B was missing.-The resident usually walked around the facility all day and night drinking coffee and smoking with supervision. He walked around the building and outside in the courtyard without supervision. Resident B always talked to and answered himself. He would speak to people who weren't there.-Staff assumed Resident B was walking throughout the building like per his usual but hadn't had time to look for him.On 6/10/26 at 4:53 P.M., the Administrator and Social Services Designee (SSD) were interviewed. The Administrator indicated she was first notified of the resident's absence at 2:00 p.m. on 5/19/26. The facility elopement plan was put in place and the building and grounds were searched. She then drove around the area in her car and located the resident about a mile away on the sidewalk near a busy 6 lane highway. He returned to the facility with her but hadn't wanted to come back in. When asked, the Administrator indicated through their investigation, they were unable to account for the resident's whereabouts from 1:00 a.m. until 3:00 p.m. on 5/19/26. Resident B told the Administrator, he had moved a table in the courtyard over to the fence and climbed over it. The fence was 6 ft. high. There were cameras in the courtyard, and she reviewed them but was unable to see when the resident had exited the courtyard. The SSD indicated Resident B had been homeless prior to admission to the hospital for a fall with injury. He admitted to the facility after being hospitalized . Resident B's cognition fluctuated, he had daily refusals of care and behavior of talking to himself and others not present. He'd made no attempts previously, to leave the building and had seemed content to walk throughout the facility, drinking coffee, and smoking during scheduled smoke breaks.Current facility policies, titled Emergency Procedure-Missing resident and Routine Resident Checks, were provided on 6/11/26 at 9:20 A.M. which indicated residents at risk for wandering and/or elopement would be monitored and staff would take necessary precautions to ensure their safety. Nursing staff were to make routine resident checks on each unit, at least once per 8-hour shift.The past non-compliance Immediate Jeopardy began on 5/19/26. The Immediate Jeopardy was removed and the deficit practice corrected by 5/20/26 after the facility assessed all residents for elopement risk and exit-seeking behaviors, updated care plans, re-educated all staff on elopement prevention, including routine frequent checks of resident's whereabouts, and removed all moveable furniture in the secured courtyard, and began routine monitoring of each resident's whereabouts in the facility.This Citation relates to Intakes 3019142 and 3020354.410 IAC (Indiana Administrative Code) 16.2-3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure monitoring of adequate hypochlorite (sanitizer) use in the facility dishwasher and sanitary food handling during food service. 82 of 82 residents residing in the facility were served food prepared in the facility kitchen. Findings include:1) During a kitchen tour, on 02/15/2026 10:00 AM, Dietary Aide (DA) 2 was observed pulling a rack of wet dishes out of the dishwasher and reloading the dishwasher with dirty dishes. In an observation, on 02/15/2026 10:18 AM, DA 2 and DA 4 were in the dish room washing dishes, with 3 racks of wet dishes observed in the clean area. The Dietary Manager (DM) dipped a test strip into the filled dishwasher testing well during the sanitizing cycle. The test strip turned lavender in color, slightly darker than the 25 parts per million (PPM) indication on the test strip color guide, but not as dark as the 50 ppm color indicator. The DM ran two additional dishwasher cycles, inserting at test strip during the sanitizing cycle with the same color resulting. In a record review, on 02/15/2026 10:20 AM, a document titled Sample Dish Machine Temp Log- Low Temperature, dated February, 2026, indicated staff should allow the dish machine to complete wash and rinse cycles and indicate temperatures and PPM on the log. The document indicated the minimum wash temperature was 120 degrees and sanitizer PPM should be between 150 and 400. The log contained spaces for wash temperatures, PPM, action, and employee initials for breakfast, lunch, and dinner meals each day. Blank spaces with no data recorded were found on the forms for the following times:2/3/26 PPM reading for dinner (only temperature recorded)2/5/26 dinner2/6/26 breakfast, lunch, and dinner 2/7/26 breakfast, lunch, and dinner2/8/26 breakfast, lunch, and dinner 2/9/26 dinner 2/10/26 PPM reading for dinner (only temperature recorded)2/11/26 breakfast, lunch, and dinner2/12/26 breakfast and lunch2/13/26 breakfast, lunch, and dinner2/14/26 breakfast and lunch2/15/26 breakfast In an interview, on 02/15/2026 10:24 AM, the DM indicated the test strip must turn a color depth matching between 50 and 100 ppm hypochlorite on the back of the test strip package. He indicated the color produced in the three tests he had just performed indicated an inadequate amount of sanitizer had been dispensed into the dishwasher. He indicated all dishes washed that morning should not be used until rewashed with adequate solution. The DM indicated the dishwasher chemicals should be tested on the first load in correlation with each meal every day. He indicated the dishwasher temperature log should have been filled out for every meal every day. He indicated some staff members were new and not accustomed to testing the dishwasher chemicals as they should. He indicated the chemicals should have been tested on the first load of dishes done that morning. He indicated he did not know why the testing had not been done that morning. In an interview, on 02/15/2026 1:31 PM, DA 2 and DA 4 indicated they had been trained on dishwasher chemical testing, and did not give a reason for not testing the dishwasher chemicals that morning. 2) In an observation, on 02/15/2026 12:26 PM, the DM licked his fingers on his right hand to flip through paper tickets and placed the tickets on meal service trays. The DM then held a serving spoon in his right hand and distributed food to plates, then used his right hand to place plates of food on the food service trays. The DM touched his eye glasses several times during meal service. No hand hygiene had been performed in the process. In an interview, on 02/15/2026 1:28 PM, the DM indicated employees should wash their hands after touching their face, glasses, or otherwise contaminating clean hands prior to touching serving utensils or dishes. In an interview on 02/17/2026 2:11 PM the DON indicated all 82 residents were served food prepared in the facility kitchen. A current policy, titled Cleaning Dishes/Dish Machine, dated 2022, provided by the Administrator on 2/15/16 at 8:53 AM, indicated the dish machines should be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitizing. The policy indicated the sanitation cycle should dispense hypochlorite at a concentration of 50 PPM. A current policy, titled Employee Hygiene for Food Safety, undated, provided by the Administrator on 2/15/16 at 8:53 AM, indicated employees should avoid touching their face and mouth during food preparation and should wash hands if they became contaminated.3.1-21(a)(2)

Based on observation, interview, and record review the facility failed to ensure physician orders were followed for medications and wound care for 3 of 19 residents reviewed. ( Resident 36, Resident 82, and Resident 15)2.A record review for Resident 82 began on 2/16/26 at 11:36 AM. Diagnoses included cellulitis, venous statis ulcers, chronic congestive heart failure, coronary artery disease, and morbid obesity. A review of Resident 82's current admission MDS, dated [DATE], indicated their BIMS (Basic Interview for Mental Status) score was 15 (cognitively intact). The MDS indicated the resident had medically complex conditions, coronary artery disease, heart failure, hypertension, a history of sepsis, Parkinson's disease, cellulitis, and morbid obesity. A review of Resident 82's current Care Plan, titled Resident is at Risk for self-care deficits, indicated the resident had a problem of bilateral lower extremity cellulitis. Interventions included staff assistance for dressing, bathing, and transfers. A Care Plan titled at Risk for impaired skin integrity indicated the resident had a problem of bilateral venous ulcers. Interventions included medications/treatments were given as ordered by the physician and staff provided assistance as needed. A review of physician orders, dated 12/4/25-12/17/25, indicated arterial ulcers on Resident 82's right foot, were to be cleansed with wound cleanser, patted dry, xeroform applied, covered with a dressing, and wrapped with rolled gauze every day shift. A review of the Treatment Administration Record (TAR) dated 12/1/25-12/31/25, indicated treatments of arterial ulcers on the right foot were not documented as completed on 12/5/25,12/8/25, 12/12/25, 12/15/25. A review of physician orders, dated 12/3/25-12/17/25, indicated venous ulcers on Resident 82's right calf were to be cleansed with wound cleanser, patted dry, xeroform applied, covered with a dressing, and wrapped with rolled gauze every shift and as needed for soilage or drainage. A review of physician orders, dated 12/18/25-12/30/25, indicated venous ulcers on Resident 82's right calf were to be cleansed with wound cleanser, patted dry, calcium alginate applied, covered with a dressing, and wrapped with rolled gauze. A review of the Treatment Administration Record (TAR) dated 12/1/25-12/31/25, indicated treatment of venous ulcers on resident's right calf were not documented as completed on 12/5/25, 12/8/25, 12/10/25, 12/12/25, 12/15/25, and 12/22/25. A review of progress notes dated 12/1/25-12/31/25, indicated no documentation was completed for wound treatments on 12/5/25, 12/8/25, 12/12/25, 12/15/25, and 12/22/25. 3. During an observation, on 2/19/26 at 10:20 AM, wound care was observed on Resident 15's right posterior knee. A scabbed area, approximately 0.8 cm by 0.5 cm, was surrounded by skin purple in color. A record review for Resident 15 began on 2/15/26 at 11:43 AM. Diagnoses included right sided below the knee amputation, diabetes type 2, chronic kidney disease stage 3, peripheral vascular disease, spastic hemiplegia affecting left dominant side. A review of Resident 15's current annual MDS, dated [DATE], indicated their BIMS (Basic Interview for Mental Status) score was 15 (cognitively intact). A review of Resident 15's current Care plan, titled At Risk for Impaired psychosocial well-being, sensory deficits, communication deficits, cognitive deficits indicated interventions included staff was to administer medications per physician orders. A review of physician orders dated 2/11/26, indicated the abrasion to the right posterior knee was to be cleansed with wound cleaner, patted dry, and skin prep applied every day shift. A review of the Treatment Administration Record (TAR), dated 2/1/26-2/17/26, indicated treatments of the right posterior knee wound were not documented as completed on 2/13/26 or 2/14/26. A review of physician orders, dated 11/12/25, indicated baclofen 10 mg was to be given by mouth three times a day for muscle spasms at 8:00 AM, 2:00 PM, and 8:00 PM. A review of physician orders, dated 7/17/25, indicated dantrolene sodium 25 mg was to be given by mouth three times a day for musculoskeletal problems at 8:00 AM, 2:00 PM, and 8:00 PM. A review of physician orders, dated 7/5/25, indicated gabapentin 600 mg was to be given by mouth three times a day for peripheral vascular disease at 8:00 AM, 2:00 PM, and 8:00 PM. A review of physician orders, dated 9/4/25, indicated hydrocodone-acetaminophen was to be given by mouth three times a day for chronic pain at 8:00 AM, 2:00 PM, and 8:00 PM. A review of the Medication Administration Record (MAR), dated 2/1/26-2/17/26, indicated Resident 15 did not receive baclofen 10 mg, dantrolene sodium 25 mg, gabapentin 600 mg, hydrocodone-acetaminophen 7.5 mg-325 mg at 2:00 PM on 2/4/26. A review of progress notes, dated 1/30/26-2/19/26, indicated documentation was not completed for medications and/ or wound treatments not given on 2/4/26, 2/13/26, and 2/14/26. In an interview, on 2/19/25 at 11:06 AM, the Director of Nursing indicated scheduled medications and treatments should be documented as given or a reason not given and not left without documentation. A current policy, undated, provided by the Administrator, indicated medications were administered as ordered by the physician. Staff will initial the residents' MAR or TAR after giving each medication. If a medication with withheld, refused, or given at a time other than the scheduled time, the staff administering the medication would initial and circle the MAR space provided for that medication and dose. 3.1-37 1.On 2/17/26 at 2:57 PM, Resident 36 was observed sitting in their wheelchair in their room. Resident 36's feet were resting on foot pedals. Resident 36's right foot was wrapped with an elastic bandage. In an interview, on 2/17/26 at 3:00 PM, Resident 36 requested to have their door closed. Resident 36 indicated the wound on their right foot was not healing. Resident 36 indicated they believed the wound was not healing due to the dressing not being changed every day. Resident 36's record was reviewed on 2/18/26 at 10:58 AM. Diagnoses included heart failure, obesity and swelling of their lower legs. Resident 36 was admitted to the facility for rehabilitation due to fractures of both lower legs. Resident 36's quarterly Minimum Data Set (MDS) indicated their Brief Interview for Mental Status (BIMS) score was 13 (no cognitive loss). Resident 36's Medication Administration Record, (MAR), dated 1/1/26 through 1/31/26, indicated the resident's right foot treatment had not been completed on 1/25/26 and 1/26/26. Resident 36's MAR, dated 2/1/26 through 2/28/25, indicated the resident's right foot treatment had not been completed on 2/6/26, 2/7/26, 2/8/26 and 2/9/26. A weekly skin assessment, dated 1/13/26, indicated Resident 36's right foot wound measured .5 centimeters (cm) long, .5 cm wide and .1 cm deep. A weekly skin assessment, dated 1/20/26, indicated Resident 36's right foot wound measured 2 cm long, .7 cm wide and .1 cm deep. A weekly skin assessment, dated 2/10/26, indicated Resident 36's right foot wound measured 1.9 cm long, 1 cm wide and .1 cm deep. On 2/19/26 at 9:35 AM, Licensed Practical Nurse (LPN) 21 was observed providing wound care to Resident 36's right foot. The wound was rectangular in shape. The wound measured 2.7 cm long, 1.5 cm and .4 cm deep. The wound was red in the middle; the surrounding edges were dark purple. A small amount of clear pink drainage was on the previous dressing. In an interview, on 2/19/26 at 11:06 AM, the Director of Nursing (DON) indicated treatments should be signed after completion. The DON indicated there should be no blank spaces in the MAR unless the nurse documents the reason for the treatment not being done.

Based on observation, interview, and record review the facility failed to ensure safety measures were identified and put into place and hazardous chemicals were stored properly for 3 of 19 residents reviewed. (Resident 1, Resident 35, and Resident 56). Findings include: 1. A record review for Resident 1 began on 2/16/26 at 12:18 PM. Diagnoses included hypertension, seizure disorder, schizoaffective disorder, left side hemiplegia defined as paralysis of one side of the body, post-traumatic stress disorder, and chronic pain. A review of Resident 1's current quarterly MDS, 10/23/25, indicated their BIMS (Basic Interview for Mental Status) score was 13 (cognitively intact). The MDS indicated the resident had medically complex conditions, hypertension, hemiplegia, seizure disorder, anxiety, schizophrenia, post traumatic stress disorder, muscle wasting and atrophy, epilepsy. Resident 1 was taking an antipsychotic, antidepressant, diuretic, opioid, and an anticonvulsant. A review of Resident 1's current Care Plan, titled Resident is at risk for impaired safety/injury, indicated the resident had a problem of falls. Interventions included administering medications as ordered, bed in the lowest position, non-skid footwear, adequate lighting, and reminding resident to use call light. A review of a standard Fall Risk Assessment, Section F, indicated antihypertensive, antiseizure, psychotropic, and diuretic medications increase the risk of falls. Residents that had taken 1-2 high risk medications had a lower fall risk metric than residents that had taken 3-4 high risk medications. Section G indicated predisposed diseases, such as seizures, loss of limbs, stroke, and arthritis. Residents that had 1-2 diseases had a lower risk of falls metric than residents that had 3 or more diseases. A review of a Fall Risk Assessment, dated 1/17/26 at 10:08 AM, indicated Resident 1 had no predisposing disease that elevated the risk of falls. The total Fall Risk Assessment Score was 8, at risk for falls. A review of a Fall Risk Assessment, dated 2/17/26 at 1:55 AM, indicated Resident 1 was ambulatory/continent, had a normal gait/balance, and took 1-2 high risk medications in the last 7 days. The total Fall Risk Assessment Score was 4, not at risk for falls. A review of progress notes, dated 2/17/26 at 1:46PM, indicated the interdisciplinary team determined Resident 1 had fallen asleep in their wheelchair and slid onto the floor on 2/16/26 at 12:30 AM. In an interview, on 2/18/26 at 2:41 PM, LPN 16 indicated Resident1's Fall Risk Assessment Score would be a 10, at risk for falls. Resident 1 was not completely chair bound but used assistive devices to walk. Resident 1 was taking 3-4 high risk medications and had 1-2 predisposed diseases that would have increased the risk of falls. 2. A record review for Resident 35 began on 2/18/26 at 11:00 AM. Diagnoses included Alzheimer's disease, hypertension, and adult failure to thrive. A review of Resident 35's current admission MDS, dated [DATE], indicated their BIMS (Basic Interview for Mental Status) score was 6 (cognitively impaired). The MDS indicated the resident used a wheelchair, needed maximal assistance to stand and transfer from bed to chair, chair to bed, and toileting. A review of Resident 35's current Care Plan titled Resident is at risk for falls indicated Resident 35 had impaired safety related to malnutrition, weakness, and a history of frequent falls, dated 12/06/2025. A review of a standard Fall Risk Assessment, Section A indicated intermittent confusion elevated the risk of falls. Section B indicated 3 or more falls in the past 3 months elevated the risk of falls. Section G indicated predisposed diseases, such as seizures, loss of limbs, stroke, and arthritis had a higher risk of falls. A review of progress notes, dated 12/8/25 at 1:05 PM, indicated the interdisciplinary team determined Resident 35 rolled out of bed. A review of a Fall Risk Assessment, dated 12/8/25 at 2:00 PM, indicated Resident 35 was alert and oriented and no falls had occurred in the last 3 months. The total Fall Risk Assessment Score was 8, at risk for falls. A review of a Fall Risk Assessment, dated 1/8/26 and 1:44 PM, indicated Resident 35 had no predisposing diseases that elevated the risk of falls. The total Fall Risk Assessment Score was 16, at risk for falls. A review of progress notes, dated 12/26/25 at 8:52 AM, indicated the interdisciplinary team determined Resident 35 had slid out of their wheelchair and was found lying on the floor in the dining room on 12/23/25. A current policy, dated 10/20/2023, provided by the Administrator, indicated risk for falls assessments were to be completed after a fall. Data from the fall risk assessment was used to develop and implement a resident centered fall plan of care. Fall Risk Factors include resident specific conditions and medical factors such as cognitive impairment, pain, weakness of extremity strength, side effects of medications, functional impairments, incontinence, seizure disorder, neurological conditions, balance, and gait disorders. 3) During an observation, on 02/15/2026 12:40 PM, an opaque white bottle labeled bleach and a clear plastic bottle about 1/2 full of purple liquid, labeled Fabuloso (a chemical cleaning product) were observed on the bedside table in Resident 56's room. A large can labeled Raid ant spray was observed on the window ledge in Resident 56's room. Two buckets about half full of murky grey liquid were observed next to the door inside Resident 56's room. One of the buckets contained a mop. Resident 56's room had a strong chemical odor. In an interview, on 02/15/2026 12:41 PM, Resident 56 indicated he had high standards for cleanliness. He indicated his small grandchildren visited regularly and touched the floor. Resident 56 indicated he had prayer mats that he placed on the floor so his family may pray while visiting. Resident 56 indicated he wanted his floor to be clean and staff did not complete cleaning tasks to his standards. Resident 56 indicated housekeeping did not clean his room on the weekends. During an interview on 02/15/2026 12:56 PM, the Environmental Services Director (ESD) indicated Resident 56 frequently refused to have housekeepers clean his room. The ESD indicated bleach, chemical cleaning products, and ant spray contained hazardous chemicals and should be stored in secured areas, only accessible by authorized personnel. Resident 56's record was reviewed on 02/17/2026 12:15 PM. Diagnoses included bipolar disorder with rapid mood cycling. A current quarterly Minimum Data Set (MDS) assessment, dated 12/4/25, indicated Resident 56 had a Basic Interview for Mental Status (BIMS score of 15 (cognitively intact). A current policy, titled Storage of Hazardous Chemicals, provided by the Administrator on 2/16/26 at 8:53 AM, indicated hazardous chemicals should be properly labeled, securely stored in a manner to prevent accidental exposure, contamination, misuse, or injury. The policy indicated hazardous chemicals should be inaccessible to residents at all times. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure oxygen was administered according to physician's orders for 1 of 1 residents reviewed (Resident 5).Findings include:During an observation, on 02/18/2026 10:18 AM, a portable oxygen tank was observed at Resident 5's bedside. The tank was set to deliver 5 liters of oxygen per minute. Resident 5 was not in his room. On 02/18/2026 10:21 AM, Resident 5 was observed propelling his motorized w/c with no oxygen on. In an interview, on 02/18/2026 10:22 AM, Assistant Director of Nursing (ADON) 6 indicated she did not know why Resident 5 did not have his oxygen in place. Resident 5's record was reviewed on 02/18/2026 10:40 AM. Diagnoses included chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia. A current admission Minimum Data Set (MDS)assessment, dated 11/17/25, indicated Resident 5 had a Basic Interview for Mental Status (BIMS) score of 9 (cognitively impaired). The MDS indicated Resident 5 used oxygen. A physician order, dated 11/8/2025, indicated Resident 5 should receive oxygen at 4 liters per minute via a nasal cannula continuously. Progress notes, dated January and February 2026, did not include any documentation of refusal of oxygen. Resident 5's care plan did not address oxygen use or any refusal to use oxygen. Resident 5's current certified nurse aide assignment sheet (Kardex), provided by the Administrator on 2/18/26 at 12:46 PM, indicated Resident 5 should be provided oxygen according to physician's orders. A Medication and Treatment record, dated February 2026, indicated Resident 5 received oxygen at 4 lpm via nasal cannula continuously each day without any record of refusal. In an interview, on 02/18/2026 11:14 AM, Certified Nurse Aide 8 indicated Resident 5 used his oxygen off and on and managed oxygen use himself. In an interview, on 02/18/2026 11:18 AM, Licensed Practical Nurse 12 indicated Resident 5 only used his oxygen at night. She indicated Resident 5 did not use oxygen during the day because he propelled himself around the building and frequently went outside to smoke. In an interview, on 02/18/2026 11:20 AM, ADON 10 indicated any resident receiving oxygen should have oxygen use addressed on their care plan. She indicated any refusal of continuous use by the resident should result in notification of the physician or nurse practitioner, assessment of oxygen saturation levels, education for the resident and updating of the care plan if the resident chooses not to accept continuous use as ordered. In an interview, on 02/18/2026 11:22 AM, ADON 6 indicated Resident 5 did what he wanted to in regards to his oxygen use. A current policy titled Oxygen Administration, undated, provided by the Administrator on 2/18/26 at 11:08 AM, indicated physicians orders and care plans should be reviewed by staff providing oxygen to residents. The policy indicated refusal, reason for refusal, and interventions taken. The policy indicated staff should notify the supervisor of refusal. 3.1-47(a)(6)

Based on observation, interview and record review, the facility failed to ensure a registered nurse was on duty for 8 consecutive hours every day. 65 residents resided at the facility. Findings include: On 4/11/25 at 10:14 AM, a review of the as worked nursing schedule, dated 4/3/25 through 4/10/25, indicated the following: On 4/4/25, Registered Nurse (RN) 4 clocked in at 8:44 AM and clocked out at 2:10 PM. On 4/5/25, RN 4 clocked in at 9:49 AM and clocked out at 2:05 PM. On 4/7/25, RN 4 clocked in at 11:20 AM and clocked out at 2:41 PM. In an interview, on 4/11/25 at 10:51, the Director of Nursing (DON) indicated RN 4 was the only RN scheduled on 4/4/25 and 4/7/25. The DON indicated they had split the shift with RN 4 on 4/5/25. The DON indicated the Assistant Director of Nursing (ADON) covered the rest of the required 8 hours on 4/4/25 and 4/7/25. The DON indicated the time clock entries were accurate for RN 4. In an interview, on 4/11/15 at 11:00 AM, the ADON indicated they had been in the facility on 4/4/25 and 4/7/25. There were no time clock entries or other documentation to indicate the DON or ADON, in conjunction with RN 4, had filled the consecutive 8 hour RN requirement available for review by the time of exit. This citation is related to Complaint IN00456775. 3.1-17(b)(3)

Based on observation, interview and record review the facility failed to ensure open items in the kitchen and unit refrigerators were labeled, dated, discarded when appropriate, and hair was covered for all employees present in the kitchen. 65 of 65 residents residing in the facility were served food prepared in the kitchen. Findings include: During an observation, on 4/7/25 at 9:16 AM, a container of a brown lumpy substance covered with clear plastic wrap and a plastic bag of parsley with its original seal opened, twist ied shut were observed on a shelf in the walk-in cooler. Neither item was labeled or dated. A container of strawberries soaking in red liquid on a shelf in the cooler was dated 3/28. A bag of corn observed in the walk-in freezer was tied closed and did not have an open date. A large, uncovered cart holding trays with food items was observed adjacent to the tray line where two dietary staff members were assembling and serving food items to residents. A tray containing bowls of uncovered lettuce salads and a tray of cups of fruit cocktail was observed on the cart. In an interview, on 4/7/25 at 9:18 AM, the Dietary Manager (DM) indicated the container with the lumpy brown substance was left over bananas foster from a previous day. He indicated leftovers should be labeled and dated. He indicated all bags of fresh produce should be labeled and dated when opened. He indicated the bowls of salad and fruit cocktail were left over from the evening meal and should not have been stored on the tray line with the drinks and food items set up for the current breakfast service. He indicated the items were not covered or dated and should have been discarded. During an observation, on 4/7/25 at 9:28 AM, Certified Nurse Aide (CNA 3) walked into the dish room entrance to the kitchen, walked throughout the food prep and service area stopping at the tray line to obtain food items. CNA 3's waist length hair was not restrained or contained in a hairnet. In an interview, on 4/7/25 at 9:29 AM, the DM indicated no employees should be in the kitchen without a hairnet. During an observation, on 4/8/25 at 10:18 AM, a container of grapes with no label or date was observed in the west hall nurses station refrigerator. A snack package containing cheese and crackers had a piece of tape partially closing the container with the cellophane cover turned up, allowing air to the product. The package had a resident's name, but no open date. Three separate containers were labeled with resident names but did not have dates. The containers appeared to contain leftover food items. A Styrofoam cup of ice and a container half full of ice cream were observed in the freezer with no label or date. In an interview, on 4/8/25 at 10:36 AM, Registered Nurse 7 indicated all items in the refrigerator should be labeled with a resident's name and date. During an observation, on 4/8/25 at 10:34 AM, a large bowl of grapes, cut up melon and a cup of foamy, coffee colored liquid was observed in the unit refrigerator with no label or date. Four insulated, zippered bags were observed in the refrigerator. The freezer contained an open ice cream container with no date and a candy bar with no label or date. In an interview, on 4/8/25 at 10:35 AM, Qualified Medicine Aide 8 indicated there were not many resident items in the refrigerator. Most of the items in the refrigerator belonged to staff. In an interview, on 4/8/25 at 10:42 AM, the Administrator indicated he had asked an employee to check the unit refrigerators, and was displeased that it had not been done. He indicated items should be labeled, dated and staff should not be storing their lunches in resident designated refrigerators. A current policy titled General Food Preparation and Handling, undated, provided by the Administrator on 4/8/25 at 10:45 AM indicated leftover food must be dated, labeled, covered, cooled and stored. Leftovers should be used within 7 days and then discarded. A current policy titled Employee Hygiene for Food Safety, dated 2022, provided by the Administrator on 4/8/25 at 10:45 AM indicated Hair restraints should be worn to prevent hair from contact with exposed food. A current policy titled Food Safety for Your Loved One, dated 2022, provided by the Administrator on 4/8/25 at 10:45 AM indicated foods in unmarked, unlabeled containers should be marked with the current date the food item was stored and the resident's name. A current policy titled Food Brought in from Outside Sources and Personal Food Storage, undated, provided by the Administrator on 4/8/25 at 10:45 AM indicated food and beverages brought in from outside sources that require refrigeration or freezing should be labeled with the resident's name and date, and stored in the refrigerator or freezer apart from facility food. Unlabeled or undated foods dated outside facility policy should be disposed of by staff. 3.1-21(i)(3)

Based on interview and record review the facility failed to ensure a process was in place to correct deficiencies and keep them from re-occurring. 65 residents resided in the building. Findings include: An annual survey completed on 6/7/2024 identified non-compliance of labeling and dating food items in the kitchen. The facility indicated the deficient practice would be corrected by 7/5/24. An annual survey completed on 6/7/2024 identified non-compliance of maintaining facility waste in the dumpster. The facility indicated the deficient practice would be corrected by 7/5/24. See F812 for additional information about current kitchen findings. See F814 for additional information about current maintenance of facility waste findings. A review of the current Quality Assurance and Improvement Program (QAPI) did not include performance improvement plans pertaining to labeling and dating items in the kitchen or maintenance of the facility dumpster. During an interview, on 4/11/25 at 2:30 PM, the Administrator indicated he had reviewed the kitchen and waste container concerns cited last annual survey for six months as committed to in the plan of correction. He indicated at the end of six months the concerns were closed and the Quality Assurance team moved on to different areas of concern, including the physical environment, infection control, weights and falls. A current policy titled Quality Assurance and Improvement Program Policy, dated 10/1/23 provided by the Administrator on 4/11/24 at 2:51 PM, indicated the facility's QAPI plan should develop corrective actions to ensure the monitoring of effectiveness of performance improvement activities. The policy indicated the program should ensure the improvements are sustained. 3.1-52

Based on observation, interview and record review, the facility failed to ensure a clean and sanitary environment was maintained on 3 of 3 units observed. 65 residents resided in the facility. Findings include: During a facility tour, on 4/11/25 from 9:50 AM until 10:07 AM, an air vent above the 200 hall nurses' station was observed to be covered with grey clumps too numerous to count. Near the 300-hall entrance, an air vent was observed to be covered with grey clumps. An air vent near room [ROOM NUMBER], was observed to have grey clumps around the edges. During an observation, on 4/11/25 at 11:14 AM, pencil eraser sized grey clumps too many to count were observed on the vented cover of the return air duct above the hallway near the east nurses' station. The Maintenance Director opened the cover causing clumps to fall to the counter of the nurses' station and nearby floor. The Maintenance Director pulled out the filter covering the circle shaped return air duct and revealed a covering of dust on the outside of the filter (part of the filter facing the cover). The filter was dated 3/26/25. During an interview, on 4/11/25 at 11:17 AM, the Maintenance Director indicated the filters were changed monthly. The Maintenance Director indicated the vent covers were cleaned monthly. The Administrator indicated due to the filter's proximity to the residents' smoking area door and high traffic of the unit, the filter typically accumulated a lot of dust and debris. A current facility policy, dated 9/11/23, indicated the facility would maintain the cleanliness of exhaust fans monthly. The policy indicated all the dust from the vents would be removed with a vacuum and an air compressor when needed. This citation is related to Complaint IN00456775. 3.1-19(e)

Based on observation, interview, and record review, the facility failed to maintain procedures to help prevent the development and transmission of communicable diseases and infections during 3 of 3 observations. Findings include: 1. During an observation on 04/09/25 at 09:53 AM, Licensed practical nurse (LPN) 2 placed her laptop on the mattress of Resident 23. The resident's covered foot contacted the laptop during a blood glucose measurement. LPN 2 placed the laptop and the glucometer on top of the medication cart without disinfecting the devices. LPN 2 placed the glucometer into the drawer of the medication cart. In an interview, on 04/09/25 at 10:05 AM, LPN 2 indicated Resident 23 was the only resident that used the glucometer. 2. During an observation, on 04/09/25 at 10:42 AM, LPN 2 had gloves on, gave an intramuscular injection, removed the gloves, but did not perform hand hygiene before touching the medication cart. In an interview, on 04/09/25 at 10:59 AM, the Assistant Director of Nursing (ADON), indicated staff should perform hand hygiene before and after giving medications to each resident. 3. During an observation on 04/09/25 at 11:02 AM LPN 2 returned from the medication room and placed medication on the cart. LPN 2 took the pitcher of water from the cart to the ice chest and scooped new ice into the pitcher without performing hand hygiene before touching the ice scoop. In an interview, on 04/09/25 at 11:15 AM, the Director of Nursing (DON) indicated staff should wipe down the glucometer with Super Sani-Cloth Wipes before putting the meter into a drawer. She also indicated the laptop should not have been on the bed with a resident. A current policy, dated 6/11/24, titled Capillary Blood Sampling Devices, provided by the DON on 4/9/25 at 1:32 PM, indicated blood glucose meters are cleaned and disinfected between resident use. Use an approved disinfectant, wipe the meter clean and allow the meter to stay wet during the duration of the manufacturer's contact time. Remove gloves and wash hands. A current policy, dated 9/11/23, titled Handwashing/ Hand Hygiene/ Gloving, provided by the DON on 4/9/25 at 1:32 PM, indicated staff should use an alcohol-based hand rub before and after direct contact with residents, before preparing or handling medications, after contact with resident's intact skin, after contact with blood and body fluid, after removing gloves, and before handling food. A current policy, undated, titled Intramuscular Injections, provided by the DON on 4/9/25 at 1:32 PM, indicated staff should perform hand hygiene before putting on gloves. After removing gloves, staff should wash and dry hands. 3.1-18(a)(l)

Based on observation, interview and record review the facility failed to ensure accurate weights were obtained for 2 of 16 residents reviewed (Resident 48 and Resident 5). Findings include: 1. Resident 48's record was reviewed on 4/7/25 at 1:21 PM. Diagnoses included adult failure to thrive, major depressive disorder, recurrent, and type 2 diabetes without complications. A review of Resident 48's current quarterly Minimum Data Set (MDS) dated [DATE] indicated their Basic Interview for Mental Status (BIMS) score was 13 (cognitively intact, etc.). The MDS indicated Resident 48 had a significant weight loss. A review of Resident 48's current care plan titled .altered nutritional status . indicated the resident had a problem of being severely underweight with a goal date of 5/20/25. Interventions included obtaining weights as indicated and reporting significant changes to the dietician, physician and family. A review of current physician orders did not contain orders specific to obtaining weight. A review of a document titled Weight and Vitals Summary indicated Resident 48's weights were recorded as follows: On 7/18/24 at 2:24 PM, 140.2 lbs. On 7/19/24 at 5:54 PM, 139 lbs. On 8/2/24 2:28 PM, 144 lbs. On 9/16/24 at 11:28 PM, 132 lbs. On 10/10/24 at 11:06 PM, 141 lbs. On 11/12/24 at 8:32 AM, 120.4 lbs. On 12/5/24 at 2:19 PM, 101.5 lbs. On 12/10/24 at 2:05 PM, 98.4 lbs. On 12/18/24 at 12:20 PM, 101 lbs. On 12/23/24, at 2:41 PM, 101 lbs. On 12/24/24, at 3:15 PM, 99 lbs. On 12/27/24, at 2:31 PM, 99.3 lbs. On 1/6/25 at 9:42 AM, 98.5 lbs. On 1/13/25 at 12:07 PM, 100.4 lbs. On 1/13/25 at 12:31 PM, 100.4 lbs. On 2/5/25 at 4:44 PM, 109 lbs. On 2/5/25 at 6:38 PM, 109 lbs. On 3/5/25 at 4:11 PM, 112 lbs. On 4/10/25 at 11:02 AM, 117.8 lbs. No additional weights were available for review. A review of progress notes, dated 11/12/24 at 9:59 AM, indicated the Dietician recommended a reweight due to a 21 lb. weight loss in 30 days. A progress note, dated 11/27/24 at 12:21 PM, indicated the Dietician had requested a reweight and a re-weight had not been obtained. The note indicated the Dietician recommended weekly weights. A progress note, dated 12/27/24 at 2:34 PM, indicated the Clinical Support Nurse had reviewed hospital notes prior to admission, recording Resident 48's weight at 116 lbs. prior to admission to the facility and weights obtained around the time of admission were 135-140 lbs. Daily weights were ordered, and staff should have been using the same scale and the wheelchair weight should have been subtracted if used. Progress notes reviewed, dated between 10/1/24 and 4/10/25, did not include any record of weight refusals. In an interview, on 4/11/25 at 2:30 PM, the Administrator indicated staff had not been weighing residents as they should. During an interview, on 4/10/25 at 11:10 AM, the Director of Nursing (DON) indicated she noticed weight inconsistencies around October 2024. She indicated weight variances might have been due to not using the same scale or not subtracting off a wheelchair weight. She indicated daily unit huddles included discussion of using the same device and accurately recording weight device in the medical record. She indicated this topic was also covered during a November 2025 in-service. She indicated she and the dietician reviewed weights monthly and would request reweights if a weight was significantly different than the prior month. She indicated she had not identified any inconsistent weights since December. She indicated any weight refusals would be documented in the progress notes. 51881 2. Resident 5's record was reviewed on 4/10/25 at 2:00 PM. Diagnoses included hypertension, heart failure, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and chronic kidney disease stage 3. A review of Resident 5's current quarterly Minimum Data Set (MDS) dated [DATE] indicated their Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact, etc.). The MDS indicated Resident 5 had a significant weight gain. A review of a document titled Weight and Vitals Summary indicated Resident 5's weights were recorded as follows: On 11/8/24 at 5:30 PM, 184.0 lbs. On 11/15/24 at 5:53 PM, 184.0 lbs. On 11/30/24 at 12:49 PM, 211.5 lbs. On 12/6/24 at 4:56 PM, 211.0 lbs. On 1/3/25 at 4:50 PM, 198.5 lbs. On 2/5/25 at 4:44 PM, 198.5 lbs. On 3/5/25 at 4:11 PM, 197.0 lbs. On 4/10/25 at 8:12 AM, 168.5 lbs. On 4/10/25 at 2:55 PM, 187.0 lbs. During an interview, on 04/10/25 at 3:03 PM, CNA 4 indicated, when a weight was 5 lbs. or more different than the previous weight, they would let the nurse know. A current procedure undated, received from the DON at 4/11/25 at 1:45 PM, indicated staff should zero the scale, record weight immediately, and report unusual readings to the nurse. The procedure indicated accuracy is necessary. A current policy, dated 8/1/23, provided by the Administrator, on 4/10/25 at 11:37 AM, indicated nursing staff should measure weights on admission and at least monthly unless otherwise ordered by the physician. The policy indicated the dietician should follow the individual weight trends over time and the team should evaluate negative trends to determine whether the criteria were met for significant weight changes. The policy indicated the threshold for significant, unplanned weight loss should be based on the following criteria: Greater than 5% in 1 month Greater than 7.5% in 3 months Greater than 10% in 6 months. 3.1-46

Based on observation, interview and record review, the facility failed to ensure behavioral interventions were resident specific for 1 of 2 residents reviewed (Resident 37). Findings include: On 4/8/25 at 9:22 AM, Resident 37 was observed sitting in the activity room. Resident 37 was yelling loudly to be assisted to the restroom. An unknown male resident indicated Resident 37 yells all day. Resident 37's record was reviewed on 4/10/25 at 10:28 AM. Diagnoses included congestive heart failure, emphysema, cognitive communication deficit and tobacco use. Resident 37's Admission Minimum Data Set, (MDS) dated [DATE], indicated the resident's Brief Interview for Mental Status (BIMS) score was 8 (moderate cognitive impairment). A physician order, dated 2/13/25, indicated Resident 37 could be treated by counseling services. A physician order, dated 2/14/25, indicated Resident 37 could receive mental health services as needed. A Baseline Care Plan, dated 2/17/25, indicated Resident 37 had a history of substance abuse. The Baseline Care Plan indicated Resident 37 had a BIMS score of 13. A progress note, dated 3/18/25 at 11:58 AM, indicated Resident 37 was tearful and missed her family. A physician order, dated 3/25/25, indicated Resident 37 was to be administered methadone 10 milligrams once daily for pain and for substance abuse. A progress note, dated 3/27/25 at 8:54 AM, indicated Resident 37 refused to participate in a doctor's appointment. The resident refused to be examined and refused to answer questions. A progress note, dated 3/27/25 at 3:27 PM, indicated Resident 37 had refused to allow their eye drops to be administered. A progress note, dated 3/27/25 at 3:28 PM, indicated Resident 37 had refused to take their supplement. A progress note, dated 3/27/25 at 10:06 PM, indicated Resident 37 had refused to allow their eye drops to be administered. A progress note, dated 4/1/25 at 2:44 PM, indicated Resident 37 had been repeatedly yelling for help. Resident 37 began yelling for help again immediately after their needs were met. Resident 37 had been repeatedly asking to go smoke. A progress note, dated 4/2/25 at 7:50 PM, indicated Resident 37 had refused to allow their eye drops to be administered. A progress note, dated 4/3/25 at 2:49 PM, indicated Resident 37 had been continuously yelling out. Redirection was not effective. A progress note, dated 4/3/25 at 9:16 PM, indicated Resident 37 had refused to allow their eye drops to be administered. A progress note, dated 4/3/25 at 2:49 PM, indicated Resident 37 had been continuously yelling out. Redirection was not effective. A progress note, dated 4/5/25 at 11:52 AM, indicated Resident 37 had been continuously yelling out. Redirection was not effective. A progress note, dated 4/5/25 at 12:57 PM, indicated Resident 37 had been continuously yelling out. Redirection was not effective. A progress note, dated 4/6/25 at 3:49 PM, indicated Resident 37 had been continuously yelling out. Redirection was not effective. A progress note, dated 4/7/25 at 3:37 PM, indicated Resident 37 had refused to take all their medications. A progress note, dated 4/8/25 at 8:33 AM, indicated Resident 37 had refused their supplement. A progress note, dated 4/8/25 at 9:48 AM, indicated Resident 37 had been continuously yelling out. Resident 37 repeatedly asked to smoke. Resident 37 continued to yell after numerous needs had been met. The Psychiatric Nurse Practitioner had been notified of the resident's increased yelling. A progress note, dated 4/9/25 at 3:15 PM, indicated Resident 37 had been continuously yelling out. The resident continued to yell after their needs were met. Redirection was not effective. A progress note, dated 4/9/25 at 9:01 PM, indicated Resident 37 had refused to take all their medications. Resident 37's Care Plan, dated 2/17/25, indicated the resident was at risk for impaired psychosocial well-being. The resident had a history of substance abuse. Interventions for mood and behavior included encourage socializing, non-judgmental support, discussing possible conflict solutions, and psychiatric services as needed. Resident 37's Care Plan did not include resident specific behaviors such as refusal of medications, refusal of care, being tearful or frequent yelling. The Care Plan did not include resident specific stressors. In an interview, on 4/10/25 at 2:10 PM, Resident 37 reported displeasure due to the smoke break being 10 minutes late. Resident 37 abruptly ended the interview and started yelling for help. In an interview, on 4/11/25 at 2:13 PM, the Social Service Director (SSD) indicated they had not been made aware of Resident 37's behaviors of yelling, refusal of meds or refusal to be evaluated by a doctor. The SSD indicated they learned of behaviors on report sheets and behavior logs. The SSD indicated new behaviors are reviewed at Interdisciplinary (IDT) meetings. The SSD indicated regular IDT meetings had not been completed this week due to the annual state survey. The SSD indicated Resident 37 had signed on for substance abuse counseling but had refused to attend the sessions. In an interview on 4/11/25 at 2:40 PM, the Administrator indicated Resident 37's behavior of yelling was new. The Administrator indicated the resident had signed the substance abuse contract. The Administrator indicated the resident had not participated in the substance abuse program due to refusal. A current facility policy, dated 12/26/24, provided by the SSD on 4/11/25 at 2:20 PM indicated documentation of behaviors should be precise. The policy indicated documentation should include specific behaviors and possible triggers. The policy indicated identified behaviors should be included in the resident's plan of care. 3.1-37 3.1-43

Based on observation, interview, and record review the facility failed to ensure medications are stored and labeled properly in 2 of 4 storage areas. Findings include: During a continuous observation, on [DATE] at 1:57 PM - 2:10 PM, the following was observed: In the 200 hall medication room, 6 of 7 boxes of Pulmicort were found to be expired on ,d+[DATE]. In an interview, on [DATE] at 1:59 PM, Licensed Practice Nurse (LPN) 10 indicated third shift was supposed check for outdates and the expired medication removed from the current storage area. In the 200 hall medication cart, 2 open vials of insulin did not have an opened date. The insulin was delivered by the pharmacy on [DATE]. A bottle of liquid Konvomep was expired on [DATE]. The bottle was labeled to refrigerate, but was not refrigerated. In an interview, on [DATE] at 2:05 PM, LPN 10 indicated insulin should be labeled, and the expired medication should be removed from the cart. In an interview, on [DATE] at 01:57 PM, the Director of Nursing indicated medications should be labeled when opened. A current policy, dated [DATE], provided by Administration on [DATE] at 3:10 PM, indicated medications requiring refrigeration should not be stored in the medication cart. Temperatures for refrigerated medications will be kept at ,d+[DATE] degrees Fahrenheit. Disposal of outdated medications should be timely and removed immediately from stock. 3XXX,d+[DATE] (1)

Based on interview and record review the facility failed to ensure notification of significant abnormal results for 1 of 2 reviewed. (Resident 12) Findings include: A review of Resident 12's record on 04/10/25 at 2:53 PM, indicated diagnoses of diabetes type 2, obesity, depression, and hypertension. During a record review, on 4/10/2024 at 2:53 PM, a blood glucose, dated 4/4/25 at 7:31 PM, measured 527 mg/dL. The progress notes did not indicate a physician was notified of a glucose measurement of > 500 mg/dL. During a record review, on 4/10/2024 at 2:53 PM, a blood glucose, dated 4/10/2025 12:01 AM, measured 560 mg/dL. The progress notes did not indicate a physician was notified of >500 blood glucose. In an interview, on 04/10/25 at 3:01 PM, LPN 11 indicated notifying a physician when a glucose measurement was over 500mg/dL was the facility policy. A current policy, dated 9/11/2023, provided by the Director of Nursing, on 4/9/25 at 1:32 PM, indicated the physician should be notified for a glucose > 500 mg/dL. 3.1-49 (2)

Based on observation, interview and record review the facility failed to ensure snacks were available at night for 3 of 24 residents reviewed (Resident B, Resident C and Resident D) Findings include: During an observation, on 4/8/25 at 10:18 AM, the west hall refrigerator contained a few packages of snacks with names of residents written on the packages. No general snacks available to all residents on the unit were observed. No dry storage of snacks was observed on the unit. In an interview, on 4/18/25 at 10:19 AM, Registered Nurse (RN) 7 indicated general snacks for all residents were not stored on the unit. She indicated snacks were delivered by the kitchen staff and given to residents when the snacks were received. During an interview, on 4/9/25 at 1:55 PM, Resident B indicated snacks were usually gone in the evening and there was nothing available during the night when a person was hungry. They indicated when snacks were available, they were not always diabetic friendly or easy for people without teeth to consume. During an interview, on 4/9/25 at 1:56 PM, Resident C indicated snacks were delivered to the unit most evenings, but the same people would take them all off the tray and back to their rooms so no one else would be able to receive any. They indicated when residents were not waiting at the desk as the snacks were delivered, they wouldn't get any. During an interview, on 4/9/25 at 1:57 PM, Resident D indicated no food was available during the nighttime hours when a person needed it. During an interview on, 4/9/25 at 3:30 PM, Certified Nurse Aide (CNA) 5 indicated snacks were brought down to the unit by dietary staff and offered to each resident. When some snacks were left over, they were kept on the unit. The sncaks were left at the desk until they run out. She indicated there was nothing staff could do when they ran out of snacks. During an interview, on 4/9/25 at 3:32 PM, CNA 4 indicated there were not always snacks available when residents call for snacks in the night. She indicated she had gone into the kitchen to retrieve food once, although she was not allowed to be in there. During an interview, on 4/9/25 at 3:33 PM, Qualified Medicine Aide 6 indicated dietary staff were supposed to bring snacks to the unit each day, but they did not always bring them. He indicated nursing staff signs for snacks when they are delivered to the unit and then they offer them to the residents. He indicated any leftover snacks were kept at the nurses station for residents to eat during the night but they normally run out. When residents requested snacks and they were not available, he indicated he would buy residents food with his own money, so they had something to eat. He indicated staff could not access the kitchen. A current undated policy titled Mealtimes and Frequency, provided by the Administrator on 4/10/25 at 11:37 AM, indicated the facility should provide at least 3 meals daily at regular times in accordance with resident's needs, preferences and requests. The policy indicated all residents should be offered a snack at bedtime. This citation is related to Complaint IN00456775. 3.1-21(i)(e)

Based on observation, record review and interview, the facility failed to ensure garbage and refuse were contained inside the dumpster for 2 of 3 observations. Findings include: During an observation, on 4/7/25 at 9:05 AM, a dumpster lid was observed flipped up leaving the dumpster wide open and fully accessible. A large plastic bag was observed partially hanging out of the dumpster door. Multiple tears were observed in the trash bag with a fast-food cup, lid and straw partially hanging out of the bag. Cups, straws, snack and candy packages, gloves, and plastic bags were observed strewn throughout the lawn near the dumpster. Additional cups, candy and snack wrappers, cigarette packs and straw papers were observed in the parking lot, sidewalks, and grassy enclosures in the parking lot area. During an interview, on 4/7/25 at 9:32 AM, the Dietary Manager (DM) indicated all dumpster doors should be closed to prevent rodent access. The DM indicated trash should not be present in the lawn area. During an observation, on 4/7/25 at 1:22 PM, the side door of the dumpster was observed to be partially open with a trash bag partially hanging out of the door. Trash remained (cups, candy and snack wrappers, cigarette packs and straw papers) in the parking lot, sidewalks, and grassy enclosures in the parking lot area were observed. In an interview, on 4/7/25 at 1:35 PM, the Administrator indicated he had closed the dumpster at the beginning of his shift at 7:45 AM and did not know why it had been left open. He indicated the dumpster should have had all lids and doors closed to prevent access to rodents He indicated trash items should never be found in the lawn, sidewalks and parking lots. A current policy titled Waste Storage, dated 5/2012, indicated the Maintenance supervisor or designee should verify the lids were closed three times daily after each meal service. The policy indicated waste should be stored in such a way to protect it from animals. 3.1-21(i)(5)

Based on interview and record review, the facility failed to ensure the physician was notified of a change in condition following a fall for 1 of 3 residents reviewed. (Resident R) Findings include: On 12/16/24 at 10:56 A.M., Resident R's record was reviewed. Diagnoses included, non-alcohol related cirrhosis of the liver with liver cancer, dementia, muscle wasting and atrophy, and protein-calorie malnutrition. He was admitted to the facility for rehabilitation services following hospitalization for a fall with fractured neck vertebrae. An admission Minimum Data Set (MDS) assessment, dated 10/1/24, indicated the resident had no cognitive impairment; no signs of delirium; and no behaviors. He required set-up assistance with eating, oral hygiene, and personal hygiene. He was independent with bed mobility and required moderate assistance with toileting hygiene, showering and dressing. He was able to walk with his walker and supervision to touch assistance. He was receiving therapy services with speech, physical, and occupational therapies. A care plan, revised on 11/13/24, indicated Resident R had chronic conditions with risk for discomfort, complication and/or decline related to dementia, anemia, cirrhosis, renal disease, dysphasia (difficulty swallowing), and hypertension. Interventions included: medications per physician orders, monitor for side effects and report to physician; observe for and report to physician signs/symptoms of hypertension (headache, visual problems, confusion/disorientation, lethargy, etc); observe for and report to physician signs/symptoms of anemia complications (pallor, headache, weakness, feeling cold, changes in condition, abnormal bleeding and bruising, etc); report to physician signs/symptoms of hepatic (liver) impairment [malaise, fatigue, loss of appetite, significant weight loss or gain, increased swelling, altered level of consciousness, increased confusion, ascites (fluid/swelling on abdomen), confusion/disorientation, etc]. Skilled Charting, dated 12/6/24 at 9:55 p.m., indicated Resident R was alert and oriented to person, place, time, and situation. He had no acute changes in his mental status. His speech was clear and distinct, he understood others and was easily understood by others. He required one staff assistance with bed mobility and toilet hygiene, and supervision with eating. He was continent of bladder and had no complaints related to his bowels. He had no wounds or skin concerns and his appetite was adequate. An Initial Occurrence Note, dated 12/8/24 at 7:30 a.m., indicated the resident was found lying on the floor, next to his bed. The resident indicated he slid out of the bed. He had no apparent injuries and was alert and oriented to time, person, place and situation. A 72 HR. Occurrence F/U (Follow up) Charting note, dated 12/8/24 at 7:30 p.m., indicated the resident was alert and disoriented-same as baseline. The resident had no pain and no new injuries. Skilled Charting, dated 12/8/24 at 11:03 p.m., indicated Resident R was alert to person and was confused. This was an acute change in his mental status. His speech was unclear with slurred and mumbled words. The resident was incontinent of bowel and bladder and he had no wounds. He usually understood others and his speech was usually understood with difficulty finishing his thoughts and finding words. The skilled charting, follow up occurrence charting nor nurse progress notes indicated the physician or Nurse Practitioner (NP) was not notified of the acute change in his mental status and unclear speech until 12/8/24 at 11:03 p.m. On 12/16/24 at 3:00 P.M., the Administrator was interviewed. He indicated the physician should be notified when a resident had a change in condition. He indicated notification should be documented in the resident record. There was no policy provided by the facility for notification of changes in resident condition to the physician. This Citation relates to Complaint IN00449065. 3.1-5(a)(2)

Based on interview and record review, the facility failed to ensure monitoring and assessments were completed for a resident with a history of substance use disorder, and multiple falls for 1 of 3 residents reviewed (Resident C). Findings include: A complaint, reported to the Indiana Department of Health on 11/4/24, indicated Resident C had been hospitalized following multiple falls at the facility and acute illness. While hospitalized , a urine drug test was completed and was positive for illegal drugs. The complainant indicated Resident C had a substance use disorder (SUD) but hadn't used any drugs or alcohol the past year. The complainant indicated they were unsure where the resident had gotten the illegal substances from. The complainant indicated the family hadn't been notified of the resident's deteriorating condition and multiple falls. The facility was aware of the resident's SUD prior to admission to the facility. On 11/22/24 at 11:45 A.M., Resident C's record was reviewed. Diagnoses included diabetes, major depressive disorder, anxiety disorder, psychoactive substance abuse, alcohol dependence, and history of stroke affecting her left side. She admitted to the facility for rehabilitation services following hospitalization for falls and diabetic ketoacidosis (complication of diabetes in which acids build up in the blood to life-threatening levels) due to not taking her diabetes medications as prescribed. Hospital records indicated drug and alcohol tests were completed and had been negative. A quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident C had no cognitive impairment. She had no mood indicators or behaviors. She required set-up help, supervision or touching assistance with her activities of daily living. She denied pain and had not received any pain medications. She'd had no falls since admission to the facility on [DATE]. Care plans indicated: -Initiated 9/5/24: The resident was at risk for impaired psychosocial well-being due to anxiety, depression, history of substance abuse, insomnia, and recent admission to the facility. Interventions included: monitor for side effects of medications and disease conditions which could affect cognition and orientation; review new/changed medications for adverse effects; behavior health consults as needed; follow up with psychiatric services as needed; observe and report any changes in mental status caused by situational stressors. -Initiated 9/5/24: Resident was at risk for impaired safety/injury due to weakness, non-compliance with fall interventions, and unsafe smoking (10/18/24-assessed as needing supervision to smoke). Interventions included a smoking assessment to be completed quarterly and as needed. An intervention, dated 10/22/24, was for STAT labs and to decrease the resident's routine opioid medication to every 12 hours as needed for 7 days and then discontinue. Care plans hadn't indicated what steps were to be taken when the resident had a relapse or a positive drug test was observed. A facility form, titled Guidelines for Admissions with a History of Substance Abuse was signed and dated on 9/6/24 and 10/28/24 by Resident C. The form included: 1. Random drug screens and/or alcohol level checks would be made if a resident was non-compliant with the facility substance abuse guidelines and could be asked to voluntarily or involuntarily discharge from the facility. 2. If any positive drug screens or alcohol level checks came back as failed, the resident's medications would be reviewed and any prescribed narcotics subjected to discontinuing or lowered dosage. 3. Room checks with the resident present if suspicion of relapse. 4. Only cigarettes were approved as allowable smoking item. 5. Residents would need to attend substance abuse meetings if provided by the facility. 6. Residents would be seen by psychiatric services. A physician order, dated 9/5/24 at 6:45 p.m., indicated to give Hydrocodone-Acetaminophen (Opioid pain medication) 5-325 milligram tablets; take 1 tablet every 4 hours as needed for pain. Additionally, she was prescribed Baclofen 4 times per day for muscle relaxant and Pregabalin 3 times per day for nerve pain. A Medical Nurse Practitioner (NP) progress note, dated 9/6/24 at 1:03 p.m., indicated the resident had been seen for admission to the facility. Prior to admission, she had been hospitalized and was at the facility for medical management and therapy. She a formerly used tobacco, had previous alcohol abuse, and previous substance abuse. During the visit she complained of pain in her right ankle from previous fall/fracture prior to admission. A Social Services Director (SSD) progress note, dated 9/6/24 at 4:14 p.m., indicated the the resident had intact intellectual functioning and no communication deficits. She had diagnoses of major depression, insomnia, anxiety, was prescribed Trazodone (used to treat depression and help with sleep disorders) and Hydroxyzine (anti-histamine used to treat anxiety) to manage her symptoms. She was referred to the psychiatric NP for her mental health needs and medication management. A Psychiatric Nurse Practitioner (NP) progress note, dated 9/24/24 at 7:25 a.m., indicated the resident was seen to establish care and psychiatric assessment of anxiety, depression, insomnia, and psychoactive substance abuse. She was a former smoker, had no drug or alcohol use for the past year, and currently vaped. The plan was to continue with Trazodone 200 mg and Melatonin 3 mg at bedtime for insomnia; and continue with Hydroxyzine 3 times per day for anxiety. Staff were to contact the NP for any psychiatric related questions, changes, or concerns. Resident C had falls on the following dates and times: -10/11/24 at 3:40 a.m. -10/13/24 at 12:16 a.m. -10/16/24 at 11:17 a.m. -10/18/24 at 6:52 a.m. -10/19/24 at 12:37 a.m. and 9:45 p.m. -10/22/24 at 9:00 a.m., 10:40 a.m., and at 10:15 p.m. A Medical NP progress note, dated 10/21/24 at 1:44 p.m., indicated the resident was seen due to having several falls. Staff indicated she had been found falling asleep while sitting up in her wheelchair and would then fall forward. They indicated she had not sustained injuries from the falls nor had she lost consciousness. Upon examination, the resident was sitting up in her wheelchair and appeared slightly drowsy. She denied head, neck or back pain. The NP informed her due to her increased drowsiness, the dosages of some of her medications, which may be contributing to her falls, would be decreased. She had no concerns or complaints. This was discussed with nursing. Her Baclofen (muscle relaxant) dosage was decreased from 4 times per day to 3 times and her Pregabalin (for nerve pain) was decreased from 3 times per day to 2 times. Staff were to continue monitoring her closely. Nurse progress notes, dated 10/22/24, indicated: -At 9:00 a.m., the resident was heard yelling for help and had been found on her left side between the toilet and wall. She indicated she had turned to fast when transferring herself from the wheelchair onto the toilet. She had no injuries and denied pain. She was assisted off the floor and neuro checks started. Her vital signs were obtained and within normal limits except for her pulse which was elevated at 120 beats per minute (bpm-normal 60-100), The medical NP was notified. -At 10:40 a.m., the resident was heard yelling after a loud noise came from her bathroom. The resident was found sitting on the floor in the middle of the bathroom. She indicated she had been trying to get back on the toilet again and knew she should have called for assistance. She was assisted back into her chair, neuro checks continued and her vital signs checked. Her pulse remained elevated at 120 bpm. The medical NP was notified. -At 12:52 p.m., the resident complained of inability to urinate in the toilet for residual. The medical NP was notified and order given to try and catheterize her. This was completed and over 300 milliliters of dark yellow urine was collected. The NP ordered an indwelling foley catheter be anchored and urine sample sent for urinalysis. A urine drug screen was ordered and completed at the facility using the facility in-house urine drug test. The urine drug test was positive for tricyclic anti-depressants. Resident F was not prescribed antidepressants, and positive for Morphine. The resident was not prescribed Morphine. The NP was notified and new order given to decrease the resident's Hydrocodone-Acetaminophen 5-325 mg dose from every 4 hours as needed to every 12 hours as needed for 7 days and then discontinue the medication. -At 5:15 p.m., the resident was heard yelling out for help. She was observed leaning forward in her wheelchair and had been unable to sit herself back up. She was assisted to scoot back in the wheelchair. When asked, the resident indicated she had no idea what she had been doing but had not fallen asleep. -At 9:15 p.m., the resident was observed lying on the floor, fully clothed. She complained of pain but there was no evidence of injury. She refused to have neuro checks completed. An NP progress note, dated 10/23/24 at 2:20 p.m., indicated the resident was visited for acute urinary retention and placement of an indwelling catheter. She had yellow, clear urine in the catheter bag and a urinalysis was pending. The plan was to continue her current medication regimen, plan of care, and continued monitoring. The note had not indicated the resident had a positive urine drug screen on 10/22/24 nor the change in pain medication addressed. There was no documentation to indicate the Medical NP had spoken with the resident regarding the positive drug screen and informed her pain medications would be discontinued on 10/29/24. A Psychiatric NP progress note, dated 10/25/24 at 11:27 a.m., indicated the resident was visited for continued assessment of moods, changes in behaviors, efficacy and possible side effects of psychotropic medications, and review of labs related to psychotropic medications. The resident was noted with urinary retention and an indwelling catheter placed. The Medical NP had asked provider to review her medications. The resident was not prescribed medication which would lead to urinary retention. The resident's appetite was fair and she had no insomnia. During the visit, Resident C was awake, alert, but made little eye contact. Her mood was appropriate and she had no visible anxiety, agitation or worry. She was animated with a short attention span. The plan was to continue Trazodone 200 mg and Melatonin 3 mg at bedtime for insomnia and Hydroxyzine 25 mg 3 times per day for anxiety. The note had not indicated the resident had a positive urine drug screen on 10/22/24. The note did not include pain medications had been decreased and would be discontinued at the end of 7 days (10/29/24). The Medical NP saw the resident on 10/25/24 at 12:40 p.m. to follow up on the resident's urinary retention. Her urinalysis results had been negative for acute findings and she continued with good urine output in her foley catheter. She was informed a new medication would be prescribed to help with the urinary retention and a voiding trial would be attempted the following week which she was agreeable to. The note had not indicated the resident had a positive urine drug screen on 10/22/24, change in pain medication, nor upcoming date of discontinuation for her pain medications. An SSD progress note, dated 10/28/24 at 4:07 p.m., indicated staff had reported the resident was non-compliant with the smoking policy. The SSD reviewed the smoking policy with Resident C and she signed the policy in acknowledgement. She remained supervised with smoking. The SSD spoke with the resident's mother on 10/25/24 and informed her the resident was now a supervision with smoking and when cigarettes were brought in for her, the smoking materials needed to be given to nursing staff for safety. The note hadn't indicated the mother was made aware of the positive urine drug screen. A nurse progress note, dated 10/30/24 at 11:06 a.m., indicated the resident had complained of nausea and vomiting, requested and given Zofran. She refused her routine insulin due to not eating because of the nausea and vomiting. At 3:35 p.m., the medical NP was notified of the resident's change in condition. She had an altered level of consciousness, required more assistance and had general weakness. Her pulse was elevated at 116 bpm and her blood pressure low at 71/41(Normal 120/80). She continued to complain of nausea and no appetite but had stopped vomiting. Orders were given to give a 1 time dose of Midodrine 5 mg by mouth to increase her blood pressure and re-check. On re-check, her blood pressure was lower at 66/40. Additional orders were given to obtain STAT labs and start IV or hypodermoclysis (under skin) and give 1000 milliliters of fluid. Documentation indicated the family was not notified because the resident was aware of the orders. At 5:00 p.m., the fluids were to be given via IV or hypodermoclysis but the resident refused and pulled her hand back and pushed the nurse with her legs. She refused to have STAT labs drawn. Her blood pressure was 64/40 and pulse 115. The NP was made aware and indicated oral fluids were to be encouraged. The resident was asked if she wanted to go to the hospital but she refused and told the nurse to leave her alone. There was no further assessments or documentation completed after 10/30/24 at 5:00 p.m. until 10/31/24 at 4:34 a.m. when the resident was observed lying in bed, unresponsive with a pulse of 42, blood pressure of 97/52, labored breathing, clammy to touch and oxygenation at 78% (normal >90%). The NP was notified and new order given to send resident to the emergency room where she was treated for a brain bleed and sepsis. Hospital records indicated the resident had a positive drug test for amphetamines and meth. Confidential interviews, conducted during the survey, indicated staff knew the signs and symptoms of substance use relapse were changes in behavior, changes in vital signs including elevated pulse rate, changes in consciousness and alertness, changes in pupils of the eye, etc. One staff member indicated they hadn't known the resident had a positive urine test done at the facility or what monitoring or assessments were to be done following the positive test. On 11/25/24 at 2:00 P.M., the SSD was interviewed. She indicated the only policy and protocol the facility had regarding substance use in residents was the form residents with substance use were asked to sign upon admission. The form indicated drug tests could be done when suspected; positive results could be cause for discharge; and the medical provider would be notified which could result in lowering dosages of or discontinuation of prescribed narcotics. Residents with substance use diagnoses had no specific care planned interventions to address relapse. On 11/25/24 at 3:30 P.M., the Administrator indicated the facility accepted residents who had substance use diagnoses and they were expected to sign the facility form for guidelines/consequences of not following upon admission had no policy/procedure or monitoring/assessing guidelines regarding care of residents who had a diagnosis of substance use and were found to have a positive urine test for drugs. This Citation relates to Complaint IN00446547. 3.1-37

Based on interview and record review, the facility failed to ensure a quarterly Minimum Data Set (MDS) assessment was coded accurately for 1 of 3 residents reviewed for assessments (Resident F). Findings include: On 11/25/24 at 11:03 A.M., Resident F's record was reviewed. Diagnoses included chronic obstructive pulmonary disease, chronic kidney disease, and lymph edema. The resident had been hospitalized ,d+[DATE]-[DATE] due to altered mental status, abnormal labs, and hypotension. An Admission Observation form, dated 9/27/24 at 2:30 p.m., indicated the resident had been readmitted to the facility following hospitalization for encephalopathy (altered brain function). Her skin assessment indicated she had a pressure area to her left heel measuring 6 centimeters (cm) by 6 cm and a pressure wound to her right ankle. The right ankle wound measured 0.5 cm by 0.5 cm. A quarterly MDS assessment, dated 10/3/24, indicated in Section M-Skin Condition, a formal and clinical assessment was completed and the resident was at risk for pressure ulcers. The assessment indicated Resident F had no unhealed pressure ulcers. A quarterly MDS assessment, dated 10/4/24, indicated in Section M-Skin Condition, a formal and clinical assessment was completed and the resident was at risk for pressure ulcers. She had 1 unhealed pressure ulcer which was unstageable with suspected deep tissue injury in evolution. The MDS indicated the pressure ulcer was present on re-entry to the facility. On 11/25/24 at 3:30 p.m., the Administrator and Regional Nurse Consultant indicated MDS assessments should be completed according to the Resident Assessment Instrument (RAI) guidance. The RAI guidance indicated for Section M-Skin Condition, the medical record was to be reviewed, direct care staff interviewed, and the resident examined to determine if skin conditions were present, the type of skin condition such as related to pressure, and coded appropriately on the MDS assessment. This Citation relates to Complaint IN00447233.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent unsupervised smoking inside the facility and failed to ensure hazardous smoking materials were not accessible to residents who required supervised smoking for 1 of 3 residents reviewed for smoking (Resident B). The Immediate Jeopardy began on 1/30/24 when Resident B was observed with cigarettes and lighter smoking in her room. Unsupervised smoking could result in fire or burn injury to herself and other residents residing in the facility. The Chief Operating Officer (COO), Chief Nursing Officer (CNO), Regional Director of Operations (RDO), and Director of Nursing (DON) were notified of the Immediate Jeopardy on February 13, 2024 at 1:39 P.M. The Immediate Jeopardy was removed on February 14, 2024. Findings include: On 2/12/24 at 12:13 P.M., Resident B's record was reviewed. Diagnoses included Schizoaffective disorder and depression. A quarterly MDS (Minimum Data Set) assessment, dated 11/9/23, indicated the resident did not experience cognitive impairment. The assessment indicated the resident had behaviors of refusing care 4-6 days of the week, was prescribed daily anti-psychotic medications, and ambulated independently without use of assistive devices. Smoking Safety Risk Assessments, dated 11/7/23 and 2/6/24, indicated the resident currently smoked. She had the potential for/history of causing injury to herself or others from smoking in unauthorized areas or careless use of smoking materials. She required supervision and assistance with smoking materials. A care plan, dated 7/27/23 indicated the resident was at risk for impaired safety/injury due to smoking. She was noncompliant with supervised smoking. The goal was for the resident to smoke safely in designated areas and follow all facility safety protocols. Interventions: Inform resident regarding the center's smoking rules dated 8/11/23, designated smoking areas dated 8/10/23, and safe storage of smoking materials 8/11/23. A care plan, dated 2/11/24, indicated the resident was at risk for impaired safety/injury due to smoking. She was noncompliant with supervised smoking. She was re-educated on the facility smoking policy on 2/11/24.The goal was for the resident to smoke safely in designated areas and follow all facility safety protocols. Interventions included: Inform resident regarding the center's smoking rules dated 8/11/23, designated smoking areas 8/10/23, and storage of smoking materials 8/11/23. A progress note, dated 1/30/24 at 11:03 p.m., indicated the CNA (Certified Nurse Aid) confiscated a lighter and cigarettes from Resident B after observing the resident was smoking in her room. The note indicated the CNA re-educated Resident B on the center's smoking rules, the resident began yelling and cursing, and the on call staff person was notified. The note did not include documentation to show the established interventions were effectively implemented or a new, effective intervention was implemented to prevent further events of unsupervised smoking. The care plan for impaired safety/injury due to smoking risk, did not include documentation to show a new, effective intervention to prevent further events of unsupervised smoking were implemented. A progress note, dated 1/31/24 at 9:05 p.m., indicated a CNA notified the nurse the room of Resident B smelled like smoke. The nurse went to the resident's room and observed Resident B with a cigarette and lighter and removed the smoking materials. The resident was yelling and cursing for the nurse to get out of her room. The NP (Nurse Practitioner) and on call staff were notified. The note did not include documentation to indicate how Resident B obtained the smoking materials, to show the established interventions were implemented, or to indicate a new, effective intervention was implemented to prevent further events of unsupervised smoking. There were no new orders from the NP. The progress notes, dated 02/04/24, included the following: - 2:34 a.m.: The nurse was notified by another resident, the smell of cigarette smoke was emanating from Resident B's room. The nurse entered the resident's room and found a cigarette pack with 1 cigarette and lighter in the resident's possession. The cigarette and lighter were removed and secured away from the resident. She was reminded of the smoking policy and educated on dangers of smoking in her room. She was aggressive towards staff, using obscene and offensive language to address staff. The on-call NP, Administrator and DON were updated. -4:11 a.m.: Resident B was awake through the night, was waking other residents up and begging them for cigarettes. There were no new interventions attempted from IDT review. -5:12 a.m.: The resident came to the nurse's station holding a brand-new cigar. Staff were able to retrieve the cigar and put it safely away. The resident continued walking around the hall, speaking profanities to staff. She had not slept all night. - 4:56 p.m.: The nurse went into the resident's room due to smelling cigarette smoke. In the resident's room, smoke was observed in the air. The resident was told she couldn't smoke in the building. The resident replied she hadn't been smoking and someone else had come into her room and smoked. -2/6/24 at 1:07 a.m.: The resident was awake and was begging staff for cigarettes. She was asked to stop begging and told it was past smoke time. The resident started cursing and calling staff profane names. She was unable to be redirected and would be monitored for safety. The notes did not include documentation to indicate the manner in which Resident B obtained the smoking materials, to show the established interventions were implemented, or to indicate a new, effective intervention was implemented to prevent further events of unsupervised smoking. A NP progress note, dated 2/7/24 at 1:13 p.m., indicated the resident was seen by the NP for altered mental status and Nnursing staff reported Resident B had been hoarding items from around the facility in her room. During the visit, the NP observed the resident in her room yelling out at staff. A urinalysis was ordered to check for urinary tract infection. The progress note didn't indicate the resident was found with smoking materials and had been smoking in her room unsupervised. The progress note didn't include documentation to show the NP was aware Resident B was repeatedly found with hazardous smoking materials and smoking unsupervised in her room. A progress note, dated 2/8/24 at 4:06 a.m., indicated the resident had been awake all night. Her room was full of all sorts of items she had picked up from various areas of the facility and was hoarding them in her room. Items littered every corner of the room including her bed and floor. There were items from the activity room, boxes of gloves, a water pitcher from the nurses cart, and cleaning supplies. The resident became aggressive and began cussing at staff. Attempts to redirect the resident were unsuccessful and the Psychiatric NP, Administrator, and DON were updated. The note indicated interventions were intiated for Resident B to be monitored closelyand staff to conduct safety checks every 15 minutes. The note did not include documentation to show the NP was aware Resident B was repeatedly found with hazardous smoking materials and smoking unsupervised in her room. A progress note, dated 2/08/24 at 2:02 p.m., indicatedThe note did not include documentation to indicate the resident had access to hazardous smoking materials or events of unsupervised smoking occurred. Resident B remained on 15 minute checks for safety. A progress note, dated 2/10/24 at 6:34 a.m., indicated the resident was going into other resident's rooms, taking their stuff (remote controls, cigarette lighter, etc), bringing it back to her room and hiding them. Another resident reported to the nurse that Resident B had taken his lighter out of his room. Staff went to her room and questioned her about the lighter. Resident B denied having it and allowed staff to search her room and her person. A lighter was not found. The DON was updated and the resident placed on 1:1 (continuous) supervision. An Indiana IDOH (Indiana Department of Health) incident report, dated 2/11/24, indicated Resident B had been outside smoking with another resident at approximately 6:30 a.m. When the other resident finished smoking, she had placed her cigarette on the ground. Resident B tried to pick up the remains of the cigarette when the other resident told her to stop. Resident B continued to try and pick up the cigarette butt and the other resident pushed her knocking her to the ground. The report didn't indicate Resident B was supervised while smoking. No statements regarding the smoking time were available for review. Progress notes, dated 2/11/24 at 7:30 a.m., 11:00 a.m., and 3:00 p.m., indicated Resident B remained on 1:1 direct staff supervision without any changes in condition.The notes did not include documentation to show new interventions were initiated when the established interventions were ineffective. A progress note, dated 2/12/24 at 8:24 a.m., indicated the resident remained on 1:1 with staff. She continued going into other residents' room, waking them up, asking for cigarettes and asked staff for money for cigarettes. She was heard cursing at another resident when she was told to get out of the resident's room. The note did not include documentation to show new interventions were initiated when the established intervention of continuous observation was ineffective. On 2/12/24 at 1:42 P.M., in a confidential interview with an interviewable resident, cigarettes and a lighter were observed on the resident's bedside table and, cigarettes were observed on the overbed table of the resident's roommate. The smoking materials were observed to be accessible to residents who needed supervision when smoking. The resident indicated on 2/10/24, Resident B had come into his room in the middle of the night and took his lighter. He had been very angry and had reported it to staff. He indicated she would often come into his room, begging for cigarettes. He had asked for a locked box to keep his cigarettes and lighter but hadn't been given one. His roommate, who was present and interviewable, indicated he wore a satchel around his neck to keep his smoking materials in and on his person so Resident B couldn't take his items. The progress notes, dated 2/13/24 indicated the following: -2/13/24 at 8:36 a.m., indicated Resident B was attempting to light a cigarette in her room and the CNA confiscated the lighter from the resident. Resident B was told she could not smoke in her room and had to smoke outside during smoke breaks.The note did not include documentation to show the established interventions were implemented or to indicate a new, effective intervention was implemented to prevent further events of unsupervised smoking. The note did not include documentation to indicate staff was providing continuous supervision or to show the manner in which Resident B obtained the hazardous smoking materials. -2/13/24 at 10:16 A.M., LPN 3 (Licensed Practical Nurse) was interviewed. She indicated CNA 5 had reported to her Resident B had a cigarette and lighter in her room. The CNA had removed the hazardous smoking materials. LPN 3 indicated she didn't know how the resident had gotten the cigarette and lighter as she remained on 1:1 supervision with staff. The note did not include documentation to indicate staff effectively provided continuous supervision or to indicate a new, effective intervention was implemented to prevent further events of unsupervised smoking. - 2/13/24 at 10:20 A.M., in a confidential interview, an interviewable resident indicated prior to 3 days ago, Resident B was always out smoking unsupervised on the smoking patio. He indicated she was always begging for cigarettes from other smokers and would go into other resident's rooms to try and take their smoking materials. He indicated over the past weekend (2/10 and 2/11/24), Resident B had been going into various residents' rooms in the middle of the night asking for cigarettes and a lighter. Residents who lived on the unit were afraid of Resident B because she was always yelling, cursing, and going into other resident's rooms to take cigarettes and lighters. He kept his smoking materials in his bedside drawer and kept the door to his room closed at all times. He indicated staff including the Administrator, DON, and Social Services Director (SSD) were aware of the concerns with Resident B. - 2/13/24 at 10:45 A.M., CNA 5 was interviewed. She was assigned to be 1:1 supervision with Resident B. CNA 5 indicated she reported to work and relieved the night shift CNA, assigned to provide 1:1 care, at 7:00 a.m. CNA 5 indicated the night shift CNA was at the nurse's station upon her arrival and was not effectively providing continuous supervision to Resident B who was in her room and not at the nurse's station. When CNA 5 went into Resident B's room, she observed the resident sitting on the side of her bed. The resident had a cigarette in her mouth, a lighter in her hand and was trying to light the cigarette. She removed the cigarette and lighter and reported it to LPN 3. CNA 5 indicated she had no idea where the resident had gotten the smoking items. - 2/13/24 at 10:50 A.M., CNA 6 and CNA 8 were interviewed. CNA 6 indicated cigarettes and lighters were kept in a smoking box at the nurse's station or front desk and were given out to residents during scheduled smoke times. CNA 8 indicated only residents who required supervision while smoking had their smoking materials kept in the smoke box while residents who did not require supervision to smoke were allowed to keep their smoking materials in their rooms or on their person. Residents who smoked unsupervised were not required to lock up or secure their smoking materials in their rooms. On 2/13/24 at 12:10 P.M., the SSD was interviewed. She indicated Resident B required supervision while smoking and was not allowed to have smoking materials in her room or on her person. She was aware the resident had been observed with smoking materials and smoking in her room while receiving 1:1 supervision from staff. The resident had been reminded of the smoking policy and was not allowed to smoke in her room. The SSD indicated residents who could smoke independently were not required to keep their smoking materials secured. The SSD provided a current copy of the facility's smoking policy, on 2/12/24 at 12:12 P.M. The policy indicated: Purpose: To provide a safe and healthy living environment .It is also the objective of this policy to communicate to each resident that they are responsible for following each rule and on-going compliance with this policy. Guidelines: If smoking, e-cigarette or vaping, the facility will designate areas approved for smoking. The designated area will be outside in accordance with state/local standards. The facility has the right to enforce a policy prohibiting residents from keeping any smoking, e-cigarettes, vape materials in his/her possession for health, safety, and security reasons .Smokers will be evaluated to determine their ability to comply with safety rules and their ability to smoke independently .Residents deemed to be safe independent smokers will smoke in designated areas and adhere to smoking requirements. Individuals who are non-compliant, potentially dangerous, exercise poor judgement, and show a lack of concern for the welfare of others will be counseled accordingly with potential for facility discharge .The facility recognizes the potential harm that may result from careless, hazardous smoking and has implemented this policy to maintain a safe living environment. Violation of this policy will be taken seriously, and appropriate action will be forthcoming The policy did not include documentation of a system to ensure hazardous smoking materials were effectively stored to limit their accessibility to residents who require supervision when smoking. The Immediate Jeopardy that began on 1/30/24 was removed and the deficient practice corrected on 2/14/24 when the facility completed training of staff on the revised facility smoking policy and 1:1 monitoring but will remain at the lower scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy. This tag relates to Complaint IN00427156. 3.1-45(a)

Based on observation, interview, and record review, the facility failed to provide supervision and assistance to prevent accidents for 6 of 20 residents reviewed. The deficit practice resulted in 2 residents having falls with fracture injuries (Resident H and Resident J). This deficient practice also affected 4 of 17 residents that smoked (Resident B, Resident C, Resident K, and Resident L). Findings include: 1. On 6/11/19 at 12:03 P.M., Resident H's record was reviewed. [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 5/14/19, indicated a BIMS (Brief Interview Mental Status) score of 14 which signified the resident was cognitively intact. The resident required extensive assistance from 2 staff members with bed mobility. A care plan, dated 9/29/17, indicated the resident required assistance with ADL's (Activities of Daily Living) related to obesity, diabetes, pain, and weakness. The goal, with a target date of 8/12/19, was Resident H would be clean, dry, and well-groomed through the next review. Interventions included, but were not limited to, bed mobility-2 person extensive assistance required (initiated 9/13/18 and revised on 3/1/19) and repositioning rails-2 repositioning rails up as per physician order [REDACTED]. A care plan, dated 12/13/17, indicated the resident requested side rails. The goal, with a target date of 8/12/19, was her independence would be promoted with bed mobility. Interventions included, but were not limited to, 2- 1/4 side rails up when in bed to assist with mobility and promote independence (revised on 9/23/18). A care plan, dated 3/26/19 and revised on 5/31/19, indicated Resident H was at moderate risk for falls. The goal was she would not sustain serious injury through the review date of 8/12/19. Interventions included, but were not limited to, resident to receive bed frame that fits the current mattress (initiated 5/31/19). 6/10/19 at 12:17 P.M., Resident H, who was identified by the facility as interviewable, was interviewed. During the interview, she was observed lying on her back on a bariatric mattress that was too large for the bed frame. The mattress hung over the bed frame approximately 2 inches on both sides of the bed. Resident H wore a leg brace on her right leg which was elevated on a pillow. When questioned, she indicated she had fallen out of the bed, onto the floor and had broken her right knee. She was being turned in bed by 1 CNA (Certified Nurse Assistant) when she rolled too far, rolled out onto the floor and struck both of her knees. Her bed was observed to have 1- 1/4 bedrail on the right upper side of the bed and no bedrail on the left side. She indicated she wanted a bedrail on the left side but couldn't have one because her mattress didn't fit on the bed frame so a bedrail couldn't be attached. When questioned, she indicated since her fall, 2 CNA's were assisting her with bed mobility. A Fall Initial Occurrence Note, dated 5/30/19 at 12:30 a.m., indicated the resident had a fall from bed while the CNA was assisting her with care in bed. Resident H reached to the bedside table to help pull herself over. She ended up rolling onto the floor and landed on her left side but her right knee hit the floor hard. She complained of pain to the right knee which had 2 - 2 cm (centimeters) contusions-the skin was not broken but there was swelling and bruising observed. She had additional injuries which included, her left upper arm which had a skin tear and purple bruising, her right shoulder which had a 2 inch scratch from the CNA's fingernails as she tried to catch her, and a scrape to the right side of her abdomen that measured 1 by 1 cm. The NP (Nurse Practitioner) was notified and orders received for an x-ray to be done of the right knee. The intervention to prevent future falls was to make sure there were 2 persons to assist her with turning in bed and place a side rail to the left side of her bed. A Fall IDT (Interdisciplinary Team) Note, dated 5/31/19 at 12:42 p.m., indicated the root cause of the residents fall was that her mattress was too big for the bed. The intervention was to obtain a different bed. An NP progress note, dated 6/4/19 at 9:29 a.m., indicated the resident was seen for fall follow-up. Her initial right knee x-ray was negative for fracture but the resident continued to complain of pain when being assisted to turn in bed. The resident had not been out of bed since the fall. A repeat x-ray of the right knee was ordered. An Orthopedic specialist progress note, dated 6/5/19 at unknown time, indicated the resident was seen on this date for pain and an injury in the right and left knee. She had a non-displaced right femur [MEDICAL CONDITION] condyle and a contusion/hematoma to the left knee. The resident was non-ambulatory therefore her right knee was placed in an immobilizer and a recommendation made to repeat x-rays in 2 weeks. On 6/12/19 at 12:29 P.M., the Administrator provided a copy of an invoice for a bariatric bed frame with side rails that was ordered on this date at 11:17 a.m. The Administrator indicated she had thought Resident H's bed frame had already been replaced and she had not been aware that the resident wanted a bedrail on both sides of her bed. 2. On 6/11/19 at 12:20 P.M., Resident J's record was reviewed. [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 3/21/19, indicated the resident had a BIMS score of 9 which signified the resident had moderately impaired cognition. The resident displayed no behaviors such as rejection of care. She required extensive assistance from 1 staff member with transfers and toileting. She was occasionally incontinent of bowel and bladder. A care plan, dated 9/5/17 and revised on 6/4/18, indicated the resident was at risk for falls and injuries related to use of [MEDICAL CONDITION] and pain medications. The resident had a history of [REDACTED]. The goal, with a target date of 6/19/19, was the risk for falls would be minimized and managed. Interventions included, but were not limited to, staff to make checks every hour on the resident to address her needs (initiated on 3/7/19 and revised 6/6/19), Dycem (non-skid material) to the resident's w/c (wheelchair) and recliner (6/12/19), keep call light within reach (non-compliant with using call light) (6/12/19), resident to be toileted before/after meals, upon rising and before bed (6/12/19), and TAB alarm to bed and chair (6/12/19). On 6/10/19 at 12:10 P.M., Resident J, who was identified as not interviewable, was observed propelling herself in a w/c in the hallway. She had some fading yellow to green bruising on her right forehead. Her right forearm/elbow was covered with a fluorescent pink cast which she was using to hold onto the handrail and pull herself along. She indicated she was probably not supposed to do that but she had to get around. When questioned, she indicated she did have pain and was not given pain medication when requested. A Fall Initial Occurrence Note, dated 5/28/19 at 6:55 a.m., indicated the resident had an un-witnessed fall on 5/27/19 at 8:00 p.m. The resident stated on this date, that she had fallen in her bathroom last night. She indicated she had been able to get up from the floor after falling on the right side of her hip. The note indicated the resident had no apparent injuries. The intervention was to increase monitoring. A 72 hour charting post-fall note, dated 5/29/19 at 12:38 p.m., indicated the resident complained of pain to her right elbow, right hip and tailbone. She rated the pain at a 5 out of 10 with 10 being the worst pain. She was administered pain medication. The resident had reddish-purple bruising to her right elbow. A Weekly Skin Observation, dated 5/30/19 at 2:07 p.m., indicated the resident had a bruise on her right elbow. A 72 hour charting post-fall note, dated 5/30/19 at 11:11 p.m., indicated the resident had green and yellow bruising to her right elbow. A Behavior Note, dated 5/31/19 at 1:37 a.m., indicated the resident had not rested at all through the night. She was confused on day and night time and thought she needed to go to the dining room after 8:00 p.m. A Behavior Note, dated 6/1/19 at 12:16 a.m., indicated the resident continued to act confused and needed more direction. She didn't know if it were day or night and talked in confused sentences. A note was left in the Psychiatric NP's book to see if the resident could be assessed for worsening dementia. A Fall IDT Note, dated 6/3/19 at 12:25 p.m., indicated the resident had stated she had gotten up in the middle of the night and had gone to the bathroom where she had a fall on 5/27/19. The resident indicated she got up by herself. It is not believed that she could have gotten herself off the floor without assistance. The root cause of the fall was that she was non-compliant with using the call light and got up on her own. Resident J had no injuries. The IDT was unable to recreate how she fell or got back up. She had a non-compliant care plan in place. There were not further fall interventions put into place and the resident's increased confusion was not assessed. A Fall Initial Occurrence Note, dated 6/5/19 at 1:29 p.m., indicated the resident was found laying on the floor on her right side on her elbow. She had a laceration noted to the right side of her forehead. Resident J indicated she was getting up to go to lunch. The resident was noted to be alert and disoriented per usual baseline. She was lethargic and drowsy which was an acute change from her normal baseline. The resident was transferred to the ER for evaluation and treatment. The intervention was to place non-skid strips in front of her recliner chair. A Fall IDT Note, dated 6/6/19 at 9:58 a.m., indicated the resident was getting up to go to lunch and fell to the floor on 6/5/19. The root cause of the fall was the resident got up without help. The plan was to check the resident every hour for toileting needs. A NP progress note, dated 6/6/19 at 1:14 p.m., indicated the resident was seen as a follow up to the fall she had. The resident had gotten up by herself and had fallen and sustained bruising to her right eyebrow and right elbow fracture. The resident had been seen in the ER and treated for [REDACTED]. The progress note did not indicate the resident had been having an increase in confusion. A Behavior Note, dated 6/9/19 at 12:18 a.m., indicated the resident continued to be confused with night and day time and continued to try and transfer herself. A Behavior Note, dated 6/10/19 at 1:06 a.m., indicated the resident was still very confused at night and did not know if it was day or night. She would put on her call light every 1/2 hour and wanted to get up and go to the dining room. She did not sleep at all. A Psychiatric NP progress note, dated 6/10/19 at 9:25 a.m., indicated the resident was seen for assessment of behaviors and moods. Her medications were reviewed and changed/discontinued due to increased falls. She was noted with progressive cognitive decline and intermittent [MEDICAL CONDITION]. On 6/12/19 at 10:20 A.M., the DON was interviewed. She indicated the care plan was updated on this date to reflect the use of a TABS personal alarm to alert staff to the resident's attempts to get up by herself. On 6/12/19 at 9:57 A.M., the DON provided a current copy of the facility policy titled Fall Prevention Program which indicated the following: Purpose: to assure the safety of all residents in the facility when possible and will determine the individual needs of each resident by assessing the risk of falls and implementing appropriate interventions to provide necessary supervision and assistive devices are utilized .Care plan incorporates: identification of all risk/issue, addresses each fall, interventions are changed with each fall, as appropriate, preventative measures 3. On 6/10/19 at 1:26 P.M., Resident B's record was reviewed. [DIAGNOSES REDACTED]. A Smoking Safety Risk Assessment, dated 4/29/19 at 11:00 a.m., indicated the resident was assessed as requiring supervision only (no assistance) with smoking and was not able to store smoking materials. A care plan, dated 4/28/19, indicated the resident preferred to smoke. The goal was the resident would not suffer injury from unsafe smoking practices. The intervention was to notify the charge nurse immediately if the resident was suspected of violating the facility smoking policy. On 6/10/19 at 4:11 P.M., Resident B was observed in his room, sitting on the edge of his bed with an overbed table in front of him. On the overbed table was a pack of Pall Mall cigarettes sitting out. 4. On 6/10/19 at 3:29 P.M., Resident C's record was reviewed. [DIAGNOSES REDACTED]. A Smoking Safety Risk Assessment, dated 5/27/19 at 11:00 a.m., indicated the resident was assessed as requiring supervision only (no assistance) with smoking and was not able to store smoking materials. A care plan, dated 5/21/19, indicated the resident was a smoker. The goal was the resident would not smoke without supervision. Interventions included, but were not limited to, the resident would participate in smoking assessments as needed and the resident was able to light his own cigarette. On 6/10/19 at 3:20 P.M., Resident C was observed in the hallway outside his room. He was wearing headphones and walking down the hall when he pulled a cigarette out of a pack and placed it in his mouth. He did not light the cigarette but continued walking down the hallway with it in his mouth. 5. On 6/11/19 at 10:30 A.M., Resident K's record was reviewed. [DIAGNOSES REDACTED]. A Smoking Safety Risk Assessment, dated 3/24/19 at 11:30 a.m., indicated Resident K was assessed as requiring supervision only (no assistance) with smoking and was not able to store smoking materials. A care plan, dated 4/9/19, indicated the resident was a smoker. The goal was the resident would not smoke without supervision. Interventions included, but were not limited to, instruct the resident about the facility policy on smoking: locations, times, safety concerns, notify the charge nurse immediately if it is suspected the resident has violated the facility smoking policy, and observe clothing and skin for signs of cigarette burns. On 6/10/19 at 2:50 P.M., Resident K was observed walking out in front of the facility with her rolling walker. She walked to the park bench that was positioned in the grass facing the facility front door. She sat down on the park bench and pulled out a pack of cigarettes and lighter from a basket on her rolling walker, took one out, used the lighter to light it and sat on the bench smoking her cigarette. This area was not a designated smoking area. 6. On 6/12/19 at 10:17 A.M., Resident L's record was reviewed. [DIAGNOSES REDACTED]. A Smoking Safety Risk Assessment, dated 5/27/19 at 7:41 p.m., indicated the resident required supervision only (no assistance) with smoking and was independent with storage of smoking materials. A care plan, dated 5/24/19, indicated the resident was a smoker. The goal was the resident would not smoke without supervision and would not suffer injury from unsafe smoking practices. Interventions included, but were not limited to, instruct the resident about the facility policy on smoking locations, times, and safety concerns, keep smoking materials in a secured location, and keep resident's smoking supplies in a lock box. On 6/11/19 at 3:35 P.M., Resident L was observed walking down the hallway carrying a yellow lighter and cigarettes in his left hand. He walked out to the courtyard where the designated supervised smoking time was occurring. On 6/10/19 at 3:50 P.M., LPN 2 (Licensed Practical Nurse) was interviewed. She indicated all resident cigarettes and lighters were kept in a locked box and given to residents during scheduled supervised smoking times. She indicated residents could smoke 2 cigarettes at each smoking time. On 6/10/19 at 3:55 P.M., the Administrator was interviewed. During the interview, she opened the locked box for smoking materials and it was observed to contain packs of cigarettes but no lighters or matches. The Administrator indicated all lighters were to be kept in the locked box and that no residents were to have smoking materials in there rooms. She did not know why there were no lighters in the locked box. She indicated there had been recurrent issues with residents keeping smoking materials in their rooms and the facility performed 1 to 2 room sweeps per month to remove smoking materials found. On 6/10/19 at 4:31 P.M., the Administrator provided a current copy of the facility policy titled Smoking Safety which stated the following: If smoking is allowed at this facility, the facility will designate areas approved for smoking by residents, visitors and staff .The facility has the right to enforce a policy prohibiting residents from keeping any smoking materials in his/her possession for health, safety and security reasons. A Smoking Safety Assessment will be completed to determine the level of assistance and supervision needed during smoking, the ability to carry and store smoking materials, and if a smoking apron is indicated. The plan of care shall reflect the results of this assessment .Individuals who are non-compliant, potentially dangerous, exercise poor judgement, and how a lack of concern for the welfare of others will be counseled accordingly. The facility maintains the right to limit and restrict access to smoking products, matches, and lighters for persons deemed unsafe This Federal complaint relates to Complaint IN 479. 3.1-45(a)(2)

Based on record review and interviews the facility failed to ensure 1 resident (B) in a sample of 3 residents reviewed, was transferred according to his plan of care which resulted in a fracture. Findings include: On 5/2/17 at 10:45 a.m. review of the clinical record for Resident B indicated he had [DIAGNOSES REDACTED]. Review of the admission MDS (minimum data set) assessment dated [DATE] indicated the resident was alert and oriented, could answer questions appropriately, and required extensive assistance with transfers, dressing and hygiene. Review of the plan of care titled ADL needs dated 4/6/15 indicated the resident required two person physical assistance for transfers. Review of an Incident Investigation for Resident B dated 4/23/17 indicated a CNA (certified nure aide) had transferred the resident by himself without the assistance of another staff person. After the transfer the resident complained of pain to his left knee, and an x-ray obtained indicated the resident had a fracture to his femur. Resident B was transferred to the hospital and required surgery to his femur. A review of the CNA documentation and ADL Needs indicated Resident B was a 2 person lift. Interview with the Director of Nursing on 5/2/17 at 11:25 a.m. indicated the CNA was not to transfer Resident B by himself and he was suspended from work while the investigation of the incident was completed. Interview with Resident B on 5/2/17 at 1:15 p.m. indicated he had asked the CNA to transfer him from his wheelchair to the bed. He indicated when the CNA lifted him his left leg had gotten stuck under the seat of his wheelchair and he twisted his leg. Resident B indicated his knee did not hurt ast the time, but later, his knee began hurting, and he had to go to the hospital. This federal tag is related to complaint IN 370 3.1-45(a)(2)

Based on interview and record review, the facility failed to assess and monitor residents for changes in skin integrity for 2 of 3 residents reviewed for pressure ulcers in a sample of 9 residents (Resident #N and Resident #O). This failure to assess and monitor skin integrity changes resulted in 1 resident's pressure areas increasing in stage from superficial to unstageable. Findings include: 1. Resident #N's record was reviewed 12-5-2014 at 9:33 AM. Resident # N's [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#N had wounds on the right upper thigh on admission. The orders additionally indicated to maintain a Foley catheter for wound healing. physician progress notes [REDACTED].#N had pressure ulcers on the right upper thigh measuring 7.4 cm x 1.6 cm x less than (<) 0.1 cm and 3 cm x 0.8 cm x < 0.1 cm. The note further indicated the areas were superficial, and had a pink wound base. A review of Resident #N's care plans included a potential for pressure ulcer development, interventions included medication administration, lotion to skin, bath per schedule, encourage fluid intake and meal intake, encourage to reposition self, evaluate skin weekly, labs as ordered, pressure reducing cushion in wheel chair and on mattress. An additional care plan for stasis ulcers was initiated an 10-10-2014. The interventions were to document location and characteristics of wounds, medicate as ordered, and document signs of infection. An SBAR #1 dated 11-13-2014 indicated Resident #N had an area on right inner thigh of undetermined depth, due to yellow slough in the wound bed, measuring 7.4 cm x 1.6 cm. There was not a description of the location of the area. The document further indicated there was no drainage to the area, and the wound edges were pink. A review of SBAR #2 indicated there was a second area to the right inner thigh measuring 3 cm x 0.8 cm of undetermined depth due to yellow slough in the wound bed. There was not a description of the location of the area. The document further indicated there was no drainage to the area, and the wound edges were pink. A review of Resident #N's wound tracking indicated there was no wound tracking available for review to indicated the locations, size, or progress of the left upper thigh wounds between 9-18-2014 and 11-13-2014. A review of Pressure ulcer evaluation record dated 11-13-2014 indicated there was a right thigh wound proximal to the thigh/ torso fold, about the middle of the thigh. This wound was described as unstageable due to slough in the wound bed. and measured 7.4 cm x 1.6 cm. There was no depth noted on the document. A review of Pressure ulcer evaluation record dated 11-13-2014 indicated there was a right thigh wound proximal to the thigh/ torso fold, close to the inner part of the leg. This wound was described as unstageable due to slough in the wound bed. and measured 3 cm x 0.8 cm. There was no depth noted on the document. A review of Resident #N's Nurses Notes indicated there were no descriptions of the open areas, or measurements, or characteristics of the open areas between the initial admission assessment on 9-18-2014 on the wound reports dated 11-13-2014. In an interview on 12-5-2014 at 11:24 AM, LPN #1 indicated she had measured the wounds on 11-13-2014 and although the true depth was obscured by the slough in the wounds, the measured depth was 0.1 cm. When asked why this measurement had not been documented, LPN #1 indicated she had been instructed to leave the measurement off the document because of the underlying slough. A current policy titled Skin Integrity Standard dated June 2010 provided by RN Consultant #3 on 12-5-2014 at 9:35 AM indicated "weekly head to toe assessment of all residents by the Licensed nurse with narrative documentation of findings. Narrative findings will include; description of skin turgor, color, and any skin related issue." This Federal tag relates to Complaint IN 064. 3.1-40(a)(1)

Based on interview and record review, the facility failed to assess and monitor a resident for changes in skin integrity for 1 of 3 residents reviewed for pressure ulcers (Resident #N). This failure to assess and monitor skin integrity changes resulted in 1 resident's pressure areas increasing in stage from superficial to unstageable. Findings include: 1. Resident #N's record was reviewed 12-5-2014 at 9:33 AM. Resident # N's [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#N had wounds on the right upper thigh on admission. The orders additionally indicated to maintain a Foley catheter for wound healing. physician progress notes [REDACTED].#N had pressure ulcers on the right upper thigh measuring 7.4 cm x 1.6 cm x less than (<) 0.1 cm and 3 cm x 0.8 cm x < 0.1 cm. The note further indicated the areas were superficial, and had a pink wound base. A review of Resident #N's care plans included a potential for pressure ulcer development, interventions included medication administration, lotion to skin, bath per schedule, encourage fluid intake and meal intake, encourage to reposition self, evaluate skin weekly, labs as ordered, pressure reducing cushion in wheel chair and on mattress. An additional care plan for stasis ulcers was initiated an 10-10-2014. The interventions were to document location and characteristics of wounds, medicate as ordered, and document signs of infection. An SBAR #1 dated 11-13-2014 indicated Resident #N had an area on right inner thigh of undetermined depth, due to yellow slough in the wound bed, measuring 7.4 cm x 1.6 cm. There was not a description of the location of the area. The document further indicated there was no drainage to the area, and the wound edges were pink. A review of SBAR #2 indicated there was a second area to the right inner thigh measuring 3 cm x 0.8 cm of undetermined depth due to yellow slough in the wound bed. There was not a description of the location of the area. The document further indicated there was no drainage to the area, and the wound edges were pink. A review of Resident #N's wound tracking indicated there was no wound tracking available for review to indicated the locations, size, or progress of the left upper thigh wounds between 9-18-2014 and 11-13-2014. A review of Pressure ulcer evaluation record dated 11-13-2014 indicated there was a right thigh wound proximal to the thigh/ torso fold, about the middle of the thigh. This wound was described as unstageable due to slough in the wound bed. and measured 7.4 cm x 1.6 cm. There was no depth noted on the document. A review of Pressure ulcer evaluation record dated 11-13-2014 indicated there was a right thigh wound proximal to the thigh/ torso fold, close to the inner part of the leg. This wound was described as unstageable due to slough in the wound bed. and measured 3 cm x 0.8 cm. There was no depth noted on the document. A review of Resident #N's Nurses Notes indicated there were no descriptions of the open areas, measurements of characteristics of the open areas between the initial admission assessment on the wound reports dated 11-13-2014. In an interview on 12-5-2014 at 11:24 AM, LPN #1 indicated she had measured the wounds on 11-13-2014 and although the true depth was obscured by the slough in the wounds, the measured depth was 0.1 cm. When asked why this measurement had not been documented, LPN #1 indicated she had been instructed to leave the measurement off the document because of the underlying slough. A current policy titled Skin Integrity Standard dated June 2010 provided by RN Consultant #3 indicated "weekly head to toe assessment of all residents by the Licensed nurse with narrative documentation of findings. Narrative findings will include; description of skin turgor, color, and any skin related issue." This Federal tag relates to Complaint IN 064. 3.1-40(a)(1)

Based on observation, interview and record review, the facility failed to monitor skin conditions for 2 of 4 residents with pressure related wounds (Resident #U, and Resident #W) in a sample of 4. The facility further failed to follow treatment recommendations resulting in Resident #U not receiving treatment promptly as recommended by a Nurse Practitioner for a pressure ulcer on the back of the head. Findings include: 1. Resident #U's record was reviewed on 11-12-2014 at 11:03 AM. Resident #U's [DIAGNOSES REDACTED]. A review of Resident #U's most current Minimum Data Sheet (MDS) dated 8-20-2014 indicated Resident #U had Brief Interview for Mental Status (BIMS) score of 14, that indicated Resident #U was alert, oriented, and able to answer questions appropriately. During an observation on 11-12-2014 at 10:55 AM, 2 open areas were observed on the back of Resident #U's head. The first area was approximately the size of a 50 cent piece and had a dressing covering the wound. The area was on the right upper area of the back of the head, approximately 2 fingers from the whorl. The second area was oblong, and was about 2 cm x 2 cm x less than 0.1 cm deep. The area went from right to left at the bottom of Resident #U's head. A review of Resident #U's hospital discharge record dated 9-29-2014 indicated there was a bruised, purple area on the back of Resident #U's head. There was no indication of the size of the area or of a treatment for [REDACTED]. A review of Nurse's Notes dated 9-29-2014 did not indicate there was an area on the back of Resident #U's head. There was no admission nursing assessment dated ,[DATE], or 9-30-2014 available for review. A Nurse's Note dated 10-3-2014 at 3:05 PM indicated Resident #U's area on the back of the head was open and approximately 6 cm (centimeters) x 3.3 cm. There was no depth noted in the Nursing Notes. A Pressure Area Evaluation Record indicated the area was present on admission. The Record indicated the area was not measured on 10-3-2014. The area was first measured on 10-10-2014. The measurements of the area were 5 cm x 5.5 cm with 100% slough in the wound bed. The record further indicated on 10-16-2014, the measurements of the area on the back of Resident #U's head were 4.2 cm x 3.9 cm x 0.1 cm. There were no other measurements in the record until 11-4-2014, that indicated the back of Resident #U's scalp wound had been monitored.. On 11-4-2014 the Nurse Practitioner indicated on the Wound Assessment Form there was a second area on the back of Resident #U's scalp. The area location was not described in the note. The note indicated the oblong area was 6.1 cm x 1.1 cm x 0.1 cm. The note indicated there was a new area just above the oblong area. The measurements for the new area were 4.4 cm x 3.5 cm x 0.1 cm. There was no staging or description of the wound bed. Additionally, the Nurse Practitioner had recommended the use of a head pressure reducing cradle. A review of Nursing Notes did not indicate a new area had been identified. During an observation on 11-12-2014 at 10:55 AM, the rounded area on the scalp was approximately 3 cm x 3 cm x 0.3 cm. There was pink granulation in the wound bed. The edges were pink. There was not a head pressure reducing cradle observed in Resident #U's room. In an interview on 11-12-2014 at 11:02 AM, Resident #U indicated the facility had left his head lay on the head board of the bed without a pillow under his head for an extended length of time on 10-16-2014. He additionally indicated no device for reducing pressure to the back of his head had been in use. A current policy titled Skin Integrity Standard dated March 2005 and updated June 2010, provided 11-13-2014 at 1:20 PM by the Regional Nurse indicated "all new admissions will have a head to toe skin assessment by the licensed nurse no later then 24 hours after resident admission." The policy additionally indicated "Weekly narrative documentation must include: description of skin tissue, color, turgor, rashes, bruising, skin tears, [MEDICAL CONDITION], incision lines, and any other skin related issue." Further, the policy indicated "information required is wound specifics: Location of a wound, size of the wound including length, width, and depth in centimeters." 2. Resident #W's record was reviewed 11-13-2014 at 10:27 AM. Resident #W's [DIAGNOSES REDACTED]. Hospice documentation indicated Resident #W had been admitted to Hospice services in September, 2014. A non pressure skin condition report dated 9-24-2014 indicted Resident #W had a scabbed area approximately 1 X 1 (there was no indication of the unit of measurement on the form) on Resident #W's left hip. The area was later identified as pressure related. During an observation on 11-13-2014 at 9:54 AM, the area on resident #W's right hip was observed to be about 5 cm x 4 cm x 3 cm deep. The area had yellow slough in the wound bed. A Pressure Area Evaluation Record did not indicate the onset of the wound, and indicated the original measurements of the wound had been taken 10-10-2014. On 10-10-2014, the measurements were documented as 2 cm x 3 cm with an undetermined depth. The next measurements were documented on 11-4-2014. The measurements were recorded as 2.1 cm x 3.5 cm and an undetermined depth. the next measurements were documented on 11-12-2014 as 3.8 cm x 2.6 cm x 1.6 cm with undermining of 1.2 cm at 11-4 o clock. A review of Resident #W's Treatment Administration Record (TAR) for September, 2014 did not indicate a treatment had been initiated to the area. A review of Resident #W's Physician orders did not indicate a treatment had been ordered. A review of the Wound Assessment record dated 10-16-2014 indicated the area to Resident #W's right hip was declining. The area now measured 2 cm x 3 cm and was open with slough in the wound bed. There was not a measurement documented for the depth of the wound. The recommendation for treatment was Santyl ointment. There were no other measurements for Resident #W indicated monitoring of the wound had been completed. This Federal tag relates to Complaint IN 970 3.1-40(a)

Based on observation, record review, and interview, the facility failed to supervise and prevent falls with injuries for 2 of 3 residents reviewed for falls. This resulted in Resident #49 falling 10 times and sustaining a hip fracture. Resident # 58 incurred 6 falls, one regarding lack of a gait belt being used, which resulted in injury to the resident. Findings include: A. Resident #49 was observed in a broda chair, in the secure unit dining room, at lunch time on 2/11/14, being assisted by the Hospice nurse to eat. The resident was observed again, at 10:28 a.m., on 2/12/14, sitting in a broda chair with a lap tray across the chair. The record for Resident #49 was reviewed, at 8:10 a.m., on 2/14/14, and again at 8:17 a.m., on 2/17/14. [DIAGNOSES REDACTED]. Review of a fall risk assessment, dated 6/1/13, indicated the resident was a high risk for falls. The Interdisciplinary Team (IDT) Post Occurrence Review documentation was reviewed and revealed the resident had incurred 10 falls, as follows between 5/31/13 and 12/6/13: 5/31/13, 6/4/13, 7/12/13, 8/4/13, 8/11/13, 8/28/13, 9/19/13, 9/24/13, 11/19/13, and 12/6/13. 9 of the 10 falls were listed as unwitnessed falls. Care Plans were reviewed and a care plan originally dated 10/2/12 indicated the resident was at risk for falls and injuries, related to Psychotropic medication, incontinence, cognitive impairment, dementia, poor safety awareness, weakness and history of falls. The care plan was updated on the following dates with interventions including, but not limited to the following: 6/3/12 (sic) Non-compliant with disabling alarms 6/3/12 (sic) ensure resident wore shoes when up in wheelchair 6/3/12 (sic) wedge cushion to wheelchair 6/4/13 non skid slipper socks 6/4/13 non skid strips on the floor by bed 7/12/13 urinalysis and culture and sensitivity to rule out a Urinary tract infection 8/12/13 medication review 8/12/13 Orthostatic Blood pressures every shift for 72 hours 8/12/13 alarms to bed and wheelchair 8/28/13 awaiting therapeutic level of depakote to reach therapeutic level to decrease anxiety 8/28/13 evaluation for anti roll back for wheelchair Another care plan, dated originally on 9/13/13, indicated the resident was at risk for falls related to Psychotropic, cardiovascular, and pain medications, incontinence, unsteady gait, Fracture of hip, pain, cognitive impairment, dementia, poor safety awareness, non-compliance, weakness, and history of falls. The care plan interventions included, but were not limited to: observe for side effects of medications, keep environment clutter free, observe for unsteady gait and balance, assess toileting needs, provide/reinforce use of assistive devices, wheelchair/broda, provide/reinforce use of non-skid foot wear, PT(physical therapy) OT (occupational therapy) ST (speech therapy), pressure sensor pad in bed and wheelchair, mat at bedside when in bed. Additional interventions included, but were not limited to the following: 9/24/13 bolsters to bed 9/24/13 mat to floor 9/24/13 tray on wheelchair when up-for eating meals and drinking 11/19/13 hospice to provide Broda wheelchair 11/21/13 raised edge mattress per hospice 12/8/13 reposition wheelchair back farther to prevent her from sliding out of chair 12/11/13 tray in place to broda chair The IDT Post Occurrence Review documentation and interventions for the falls were reviewed and indicated the following: 1. 6/3/13 - an unwitnessed fall occurred on 5/31/13. The report indicated the resident fell in the hallway in front of the bedroom door. The report indicated the resident was self- ambulating and fell against a linen barrel. Also, the resident was not wearing shoes at the time. The report indicated as a result of the fall the resident incurred a hematoma to the right side of the forehead. IDT recommendations indicated neuro check for 72 hours, monitor hematoma, and make sure the resident wore shoes when up out of bed. The recommendations section also indicated the resident remained noncompliant with disabling alarms, and "wedge cushion w.c.(wheelchair)." Review of a report of incident SBAR(Situation, background, assessment, recommendation) for an actual or suspected fall, dated 5/31/13, indicated the fall occurred at 5:15 p.m., and the resident was attempting to "put on shoes." Also possible contributing factors included: environment: spills/clutter/lighting, and footwear, also alarm failure or device removal. 2. 6/4/13 - an unwitnessed fall at 5:45 a.m. on 6/4/13 with no injury. The report indicated the resident got herself out of bed, was not wearing shoes, and slid to the floor on her buttocks. The IDT recommendations indicated neuro checks were completed for 72 hrs, and slipper socks were to be worn when in bed. An IDT assessment and progress note, dated 6/17/13, indicated the resident required 1 assist for activities of daily living and transfers, used a wheelchair for ambulation, but was non-compliant with not using call light and transferring self, and was identified as a fall risk. 3. Unwitnessed fall on 7/12/13, the resident fell in another resident room, and indicated she was checking on her kids. She tripped on a low bed and fell . Also, the resident ambulated per self, and no injury was noted. Recommendations indicated neuro checks for 72 hours, and a urinalysis with culture and sensitivity to rule out a urinary tract infection. Review of an incident SBAR form for actual or suspected fall, dated 7/12/13, indicated Wandering or pacing behavior, additional circumstances included device removal, and a brief description which indicated the resident was heard yelling, and found lying on the floor on the left side at the foot of the bed . A Verification of Incident investigation/Administrative Summary report, provided by the DNS and Regional Director, at 10:33 a.m., on 2/18/14, and reviewed at this time, indicated the incident occurred at 8:15 p.m., and indicated the resident was to be referred to therapy for an evaluation. Review of an IDT assessment, dated 7/23/13, indicated the resident had delusions and agitation at times but was generally redirectable. Also the resident was at risk for falls, required 1 person assist for ADL and transfers, and the resident used a wheelchair for ambulation and was non- compliant. The note indicated the resident would ambulate without any assistance and went into other residents' rooms. 4. Unwitnessed fall, resident self transferred on 8/4/13. Resident was transferring from a chair and lost her balance and fell . Injury: resident had hematoma on the back of her head. IDT recommendations indicated ice was applied to the back of the head, neuro checks for 72 hours,, and tylenol as needed. Review of a Verification of Incident Investigation/Administrative Summary report, provided by the DNS and Regional Director, at 10:33 a.m., on 2/18/14, and reviewed at this time, indicated the incident occurred at 1:35 a.m., the floor was being stripped and all the residents were asleep. Resident #49 woke up and entered the hallway, slipped, and fell . 5. 8/11/13 Unwitnessed fall on 8/11/13, resident self- ambulated, noted sitting on the floor near her bed and indicated she lost her balance, no injury. IDT recommendations indicated neuro checks for 72 hours, medication evaluation, orthostatic blood pressures, and alarms to bed and wheelchair. Review of a Verification of Incident Investigation/Administrative Summary, provided by the DNS and Regional Director, at 10:33 a.m., on 2/18/14, and reviewed at this time, indicated the incident occurred at 7:15 p.m. 6. 8/28/13 Unwitnessed fall. Resident fell from the wheelchair and incurred a skin tear to the right forearm. The resident indicated she was reaching for an object and slid out of the wheelchair. IDT recommendations indicated neuro checks for 72 hours, Opsite to the skin tear, nurse to follow up on the resident's depakote-( increased had not reached the therapeutic level yet), "falls D/T(due to) agitation", and anti roll back to wheelchair evaluation to be completed. Review of the Incident SBAR for actual or suspected fall, dated 8/28/13, indicated the incident occurred in the dining room, at 2:30 p.m., the resident's depakote had been increased to three times a day in the last 2 weeks, the possible contributing factors included a recent medication change, restlessness or anxiousness, and the wheel chair was unlocked. The description of the incident indicated the resident stated she went to reach for an object and the wheelchair slid out from underneath her causing her to slide to the floor. Review of an Interview/Investigative Record, undated, and provided by the DNS and Regional Director , at 10:33 a.m., on 2/17/14, and reviewed at this time, indicated therapy was trialing a tiltback wheelchair without tray with the resident when the fall occurred on 8/28/13. The resident was sitting at the table doing crafts, the tray was not on, and the resident reached for an object and slid out of the wheelchair. An IDT note, dated 9/3/13, indicated the resident required 1-2 person assist with ADLs and transfer, resident able to voice her needs, and continued to have behaviors. 7. 9/19/13 - unwitnessed fall. The resident fell during ambulation. The resident was ambulating in her room and tripped falling on the floor. The resident was wearing shoes, and the area was clear of debris and was dry. The resident was heard yelling. The CNA (Certified Nursing Assistant) went to the room, and found the resident on the floor . The resident complained of pain in her thigh area. The resident was admitted to the hospital with [REDACTED]. Review of a Report of incident SBAR- actual or suspected fall, dated 9/19/13 at 1:00 p.m., indicated the resident was noted to be on the floor, lying on her back, with her feet at the end of the bed and head near the bathroom door. Review of a nurse's note, without a resident's name on it, provided by the DNS and Regional Director, at 10:33 a.m., on 2/18/14, indicated the following: "9/19/13 LPN #6 - Resident was anxious and walking around the hall yelling and was uncooperative. Resident would not use her w/c(wheelchair). Resident was in a w/c when she was too weak to ambulate but otherwise she ambulated per self. " Another note on the same form indicated the following: "9/19/13 CNA #14 - Resident was up ambulating thru the hallway. She was not using the w/c. she would dismantle her alarm to bed and w/c. CNA was in helping another resident lay down. " 8. 9/24/13 Unwitnessed fall from wheelchair. The resident was sitting in her wheelchair , attempted to get up and fell to floor bumping the side of her head. The resident had just returned from the hospital on [DATE]. She had a right hip fracture, and was on heparin therapy. IDT recommendations indicated the resident was sent to the emergency room for evaluation and treatment, and facility would follow up with orders upon return. Plans included bolsters to bed, pad on floor beside bed, and a lap tray when up in the wheelchair. Review of a Verification of Incident Investigation/Administrative Summary, provided by the DNS and Regional Director, at 10:33 a.m., on 2/18/13, and reviewed at this time, indicated the incident occurred at 2:00 p.m., the resident was trying to get out of her bed, the CNA got her up and she fell from the wheelchair.. Also, the resident attempted to ambulate, had just returned from the hospital on [DATE] due to hip fracture and surgery. The resident fell from her wheelchair and bumped the right side of her head causing a hematoma. She was sent to the emergency room for evaluation. A nurse's note, without a resident's name, provided by the DNS and Regional Director, at 10:33 a.m., on 2/18/14, indicated the following: "9/24/13 Writer was called to West Hall because nurse was trying to finish medpass and (Resident #49) would not stay in w/c and was out at nurse's station. Writer was walking down the hall when alarm sounded. Writer ran down hall and found resident lying on floor in front of w/c c (with) hematoma to head. " This note was signed by The Assistant Director of Nursing Services. Review of an IDT assessment, dated 9/25/13, indicated a behavior review was completed, the resident was taking an antidepressant, and antipsychotic for schizoaffective disorder, and behaviors included verbal aggression and noncompliance. The resident returned from the hospital on [DATE] from surgery due to right hip fracture, had a fall on 9/24/13, and interventions included a lap tray on the wheelchair, bolster on bed, and a mat on the floor. On 9/24/13, the resident was In the wheelchair, attempted to transfer self and fell . She had a hematoma to the right side of the head, sent to the emergency room for evaluation and was returned to the facility. Resident required one assist for ADL's and transfers and was able to voice her needs. Staff also meets her needs. Pursuant IDT notes, dated on 9/30/13 and 10/4/13 indicated a behavior and medication review, the resident required 1-2 person assist for ADLs and transfers, and a safety review - chair and bed alarm, continue with therapy, the resident becomes anxious, and had a recent medication change. The resident was on an antidepressant, antipsychotic, antianxiety medication, was on Physical and Occupational therapy, was a fall risk, and had bed and chair alarms. IDT notes on 11/14/13 and 11/18/13, indicated the resident propelled her wheelchair for ambulation, was combative with care, had a weight loss, was refusing food, and was being placed on hospice. Also, the resident had frequent behaviors, yelling out, cursing and hitting staff, and a decline in all areas of ADLs. The note indicated, "sometimes requires" staff to monitor her frequently, and the family wanted therapy stopped so hospice could evaluate the resident. 9. 11/19/13 Witnessed Fall - Resident fell from wheelchair, was sitting by a staff member, was reaching for eggs , stood up and fell from the wheelchair. No injury, Resident to start Hospice. IDT recommendations indicated Hospice was to provide a new wheelchair. Review of an incident SBAR-actual or suspected fall form, dated 11/19/13, at 8:45 p.m., indicated the resident was in the wheelchair near staff in the dining room, and wanted to go get some eggs. The resident stood up, the wheelchair slid out behind the resident causing the resident to fall to the floor. Review of a Verification of Incident Investigation/Administrative Summary, provided by the DNS and Regional Director, at 10:33 a.m., on 2/18/13, and reviewed at that time, indicated the resident fell from the wheelchair, attempted to ambulate and her knees gave out, and there was no injury. Follow up actions taken indicated the resident was going to get a new wheelchair from hospice, and to continue with a lap buddy at this time until the wheelchair was replaced. 10. 12/6/13 - Unwitnessed fall. The resident slid out of the wheelchair on to the floor. She had leaned forward to reach an object-slid out of chair. IDT recommendations indicated neuros checks for 72 hours, ice applied to side of forehead, and to make sure wheelchair positioned back farther to prevent resident from sliding out of chair. Review of a report of incident SBAR- actual or suspected fall, dated 12/6/13, at 1:00 p.m., indicated the resident slid out of her chair on the floor in the dining room. The resident had a small abrasion on the left side of the forehead, some swelling. Possible contributing factors indicated "sliding or positioning issue. " The Director of Nursing Services (DNS) and Administrator were interviewed, at 11:30 a.m., on 2/17/14 regarding the falls the resident had incurred. The DNS indicated the Interdisciplinary Team (IDT) met after each resident fall and reviewed the fall and made recommendations and interventions which were added to the care plan. The DNS indicated at the time of the fall in June, 2013, the resident was self-ambulating. She indicated after the first fall, a wedge cushion was added to the wheelchair. The Administrator indicated the wedge cushion sloped in the back and rose in the front so made it more difficult for the resident to get up from the wheelchair. She indicated there were also alarms on the bed and wheelchair at this time. The DNS indicated slipper socks in bed were also utilized after this fall. The DNS indicated on 7/12/13, the resident wandered into another resident's room, still ambulated by herself, was confused, and tripped on the resident's bed. She indicated a urinalysis was completed after this fall. The Administrator indicated the resident was in therapy after the fall on 7/12/13, and she provided a copy of the Physical therapy plan of care at 11:45 a.m., on 2/17/14. The Physical therapy(PT) Plan of care assessment, dated 7/17/13, was reviewed, at 11:45 a.m., on 2/17/14. The PT assessment indicated the following: "PT (physical therapy) impression: patient's cause of fall on 7/12/13 was due to tripping from moderately impaired safety awareness. PT has instructed nursing staff to always provide supervision, because she is not an independent ambulation and her safety awareness does not allow this level anymore. There is, however, decreased strength on BLE (bilateral lower extremities)and decreased balance, which along with her postural deficits, cause increased gait deviation compared to previous discharge from PT program. These deficits, when managed, will aid in reducing fall risk associated with functional ambulation but expectations at discharge remain for patient to require supervision due to her cognitive impairments. " The DNS indicated a medication review was completed on 8/17/13 and medication changes were made, also orthostatic(lying, sitting, standing) blood pressures were checked because the resident had gotten up and lost balance, and the resident was seen by a psychiatrist and a psychologist. The DNS indicated the resident's family wanted to buy an anti-roll back for the resident's wheelchair, which were like a brake for the wheelchair. The DNS indicated an intervention was added to the care plan on 8/28/13 for an evaluation for the anti roll back for the wheelchair, but she was not sure what resulted from this evaluation. She indicated the Medical Records LPN would know what occurred regarding this. The Medical Records LPN was interviewed, at 12 noon on 2/17/14, and indicated she had given the price of the anti roll back to the resident's daughter, but had not ordered it herself. The DNS indicated there was always staff in the dining room on the secure unit, and the falls listed as unwitnessed only meant someone did not actually see the fall, but could have been in the same room with the resident. The DNS and the RN Regional Director were interviewed, at 10:33 a.m., on 2/18/14, and indicated the resident had seen a psychiatrist on 8/17/13 for her behaviors and delusions, and the resident would remove alarms and hide them. They indicated staff tried to redirect the resident with such things as movies and snacks, would walk with the resident at times, but she would become verbally and physically aggressive. She was also seen by a psychologist on 8/15/13, who had recommended trying to redirect, and avoid confrontation. The DNS and Regional Director provided additional information about the falls as follows: 6/3/13 - In addition to information already given, the resident was refusing to use her wheelchair and disabled her alarms on her wheelchair and bed. When staff attempted to intervene, the resident indicated she didn't need help and she could walk by herself. 6/4/13 - additional interventions for the care plan included non -skid strips on the floor next to bed. 7/12/13- The intervention from IDT regarding the urinalysis was not an order, but a nursing intervention. The DNS indicated the nurses could do dipsticks to check for a urine infection. She indicated she thought this had been done as per IDT recommendations after this fall on 7/12/13, but could find no documentation it had been done. 8/28/13 The Regional Director indicated at the time of this fall, the resident was in a tilt back wheelchair, which therapy had provided. She indicated there was no documentation regarding the tilt back wheelchair but LPN #6 had told the Regional Director this, and documented a note regarding this. The DNS indicated on 8/28/13 the resident was sitting at the dining room table doing an activity, and the wheelchair was not locked. She indicated the intervention was to remind staff to lock the wheelchair. She indicated she inserviced staff on the secure unit who were involved in the incident, but indicated the facility also had annual fall inservices with all staff. The DNS indicated the family were going to purchase an anti roll back for the wheelchair, and the Medical Records person had looked up pricing and reported to the family. The daughter and grand-daughter were not sure what kind to get, but ended up not getting the anti roll back because they were debating whether to place the resident on hospice. The DNS indicated she could not find any documentation regarding the anti roll back. She indicated the resident was admitted to hospice on 11/20/13. 9/19/13 The Regional Director indicated there was additional information from nursing notes, which indicated the nurse stated the resident was anxious and walking around the unit. She was uncooperative and would not sit in her wheelchair, and was yelling in the hallway. Staff attempted to redirect with snacks, puzzles, movies, cards, and coffee without success. 9/24/13 The Regional Director indicated the resident returned from the hospital on [DATE] and was placed on the West wing, which is the rehab unit. She had alarms to the bed and wheelchair. On 9/24/13, the resident was sitting in the wheelchair by the nurse's station. The Assistant DNS was coming down to the hall and heard her alarm sounding and found the resident laying on the floor. She indicated the ADNS was called down to the unit to help staff keep an eye on the resident because the nurse was going to lunch. She indicated the aide had just stepped away to answer a call light. Review of a PT progress and discharge summary, dated 7/30/13 (end of care), and provided by the DNS and Regional Director during this meeting, indicated the resident was admitted to therapy on 7/17/13 and discharged on [DATE]. The progress note indicated the resident was referred to therapy for strengthening and balance improvement to reduce fall risk associated with gait in memory care unit. Over the course of the two week program, the resident was able to tolerate progression of resistance exercises and balance tasks. At the time of discharge, expectation for supervised level of ambulation had been met. This, however, may change to Stand by assist as the resident could get less alert on some days. Staff had been advised of downgrading to this latter level of assistance as needed. The resident was discharged to the memory care unit , stand by assist to supervision for ambulation without assistive devices, and to have a restorative nursing program. B. The record for Resident #58 was reviewed, at 1:37 p.m., on 2/17/14, and indicated he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Interdisciplinary Team Post-Occurrence Review notes indicated the following: 1. 6/23/13 Witnessed fall, The resident was assisted to the bathroom by a CNA and assisted off of the toilet. The resident insisted on fastening his own pants, tried twice, then leaned forward, lost his balance, and fell to his knees, hitting the top of his head on the sink faucet causing a laceration. The report also indicated the resident incurred a skin tear to the right elbow, IDT recommendations indicated the physician was notified, the resident was sent to the emergency room for evaluation and treatment, surgical glue was applied to the top of the head, and an inservice was given on use of gait belts. The DNS was interviewed, at 11:20 a.m., on 2/18/14, and indicated the resident was residing on the rehabilitation wing at the time the incident occurred. She indicated the CNA involved was not using a gait belt on the resident when the incident occurred, and if the CNA had used the gait belt, the resident probably would not have fallen forward. She indicated she did an one on one inservice with the CNA following this incident, but did not document this. 2. 7/15/13 Unwitnessed fall - the resident took himself to the bathroom, was transferring to his wheelchair, and fell in the bedroom. The alarm was activated. The resident was found on his right side, complained of hip and joint pain, and incurred a small skin tear to the right lateral hand. IDT recommendations indicated neuro checks for 72 hours, Opsite to the skin tear, the resident was non-compliant with using the call light and waiting for assistance, and the staff were inserviced on not leaving the resident alone in the bathroom. The DNS was interviewed, at 11:20 a.m., on 2/18/14, and indicated the resident was still residing on the rehabilitation hall at the time of this fall. She indicated the resident was a one person assist for ADLs, but the resident had taken himself to the bathroom, so staff was unaware. She indicated she did an inservice just to make sure if staff accompanied the resident to the bathroom, they would stay with him. 3. 10/25/13 Unwitnessed fall - the resident attempted to get out of bed, and fell to the floor. The resident had removed his alarms. He bumped his forehead and incurred a laceration to the bridge of his nose. IDT recommendations indicated the resident was sent to the emergency room , bolsters were placed on the bed, the alarm replaced, and he was to continue with therapy. 4. 10/27/13 Unwitnessed fall - 8:30 p.m., the resident was noted to be on the floor beside his bed. He had attempted to self- transfer, and incurred a small abrasion to his forehead. IDT recommendations indicated steri strips were applied to the forehead, and a mat was placed on the floor beside his bed. 5. 11/6/13 Witnessed fall - the resident was taken to the bathroom, was aggressive with staff grabbing and punching them. He was continuing to attempt to get out of his wheelchair, pulled his alarm off and stood up from the wheelchair, then slid down to the floor. IDT recommendations indicated the resident was placed on 15 minute checks for 72 hours, and there was no injury. 6. 12/29/13 Unwitnessed fall- the resident stood up from his wheelchair, and lost his balance, no injury. The review of safety device section indicated there was an alarm failure. IDT recommendations indicated the alarm battery was replaced, and the resident was referred for therapy. The DNS was interviewed, at 11:30 a.m., on 2/18/14, and indicated the resident had been in therapy but discharged earlier, and now was being referred again. She also indicated alarms were checked by staff every shift for functioning, but the battery had to be replaced on this one. 7. 2/7/14 Unwitnessed fall - the resident was in the dining room (on the secure unit), in his wheelchair. The nurse was in the dining room, talking to the hospice nurse when the resident called" hey", and was noted to be on the floor. The resident had a tab alarm on, but the clip did not hold. IDT recommendations indicated a new clip was placed on the alarm cord, the resident continued in therapy, and the alarm was changed to a sensor pad. Care plans were reviewed for Resident #58 and indicated the following: The resident had dementia with delusions, anxiety, behavior disturbances, was exit seeking, and verbally and physically aggressive. A restorative care plan, dated 12/2/13 indicated joint mobility decline, weakness, and ambulation with a rolling walker 10-20 feet daily. This was updated to March 2014, and indicated the resident walked with assistance of one staff, had a self care deficit, staff were to provide cues, the resident had impaired decision making, was an extensive assist of one person for transfer and ambulation, had one side rail used on bed, and had a wheelchair alarm. The care plan also indicated the resident was at risk for falls due to psychotropic, cardiovascular, and pain medications, incontinence, seizures, dementia, Cerebral Vascular Accident, weakness, and a history of falls. Interventions indicated the call light was to be kept in reach, monitor for unsteady gait, PT and OT evaluations, referral to therapy on 12/20/13, alarms, pressure sensor pad on bed, bolsters, and a mat on the floor. The resident was observed in his bed, at 1:57 p.m., on 2/17/14, one side rail on the wall side, a mat on the floor, and a bolster pad on the other side of the bed nearest the door. The call light was within reach. LPN #6 was interviewed, at 9:37 a.m., on 2/18/13, and indicated the resident was presently receiving speech therapy and Occupational therapy, which was helping him. She indicated he had quit feeding himself, but now was better. Review of gait belt use policy, dated 2008, and provided by the DNS, at 12 noon on 2/18/14, and reviewed, at 12:20 p.m., on 2/18/14, indicated, "It is the policy of this facility that staff will help control and balance (by using a gait belt) residents who require assistance with ambulation and transfer." Review of the Falls Management Policy, dated October 2010, and provided by the DNS, at 12 noon on 2/18/14, and reviewed at 12:20 p.m., on 2/18/14, indicated the fall prevention procedure: "1. Evaluate risk factors for sustaining falls upon admission, with comprehensive assessments, and while conducting interdisciplinary care plan reviews. 2. Initiate a fall prevention care plan when appropriate with strategies to minimize risk and potential for injuries. 3. Regularly review, revise, and evaluate care plan effectiveness at minimizing falls and injuries." 3.1-45(a)(2)