Every finding on record at Wellbrooke of Carmel

Based on interview and record review, the facility failed to ensure a resident's representative and physician were notified when a resident's weight was obtained, documented, and showed a loss for 1 of 2 residents reviewed for notification of change. (Resident 23)Findings include:The clinical record for Resident 23 was reviewed on 1/14/26 at 1:56 p.m. The diagnoses included, but were not limited to, type 2 diabetes, vitamin D deficiency, and dehydration.A current care plan, dated 11/29/23, indicated to monitor and record weight and to notify the physician and family of weight loss.The vitals tab in the electronic medical record for Resident 23 indicated the following:On 3/8/25, the resident weighed 155 pounds.On 4/10/25, the resident weighed 157.4 pounds.On 5/6/25, the resident weighed 144.2 pounds.This was a documented 8.39% weight loss in under 30 days.A facility report, dated 5/14/25, indicated Resident 23 had a 5% weight change in 30 days.There was no documentation to indicate the physician was notified until eight days after the weight loss was documented.There was no documentation to indicate the resident's family was notified of the weight loss until 5/28/25 which was 22 days after the weight loss was documented.During an interview, on 1/16/26 at 11:51 a.m., Clinical Support 1 indicated the facility should have notified the physician and family of the weight loss. A current facility policy, titled Physician- Provider Notification Guidelines, last revised on 12/8/25 and received from the Executive Director on 1/20/26 at 3:35 p.m., indicated .To ensure the resident's physician or practitioner (may include NP, PA, or clinical nurse specialist) is aware of all diagnostic testing results or change in condition in a timely manner to evaluate condition for need of provision of appropriate interventions for care.Resident assessments for change in condition, suspected injury, event of unknown origin or ordered lab and/or other diagnostic tests should be completed in a timely manner.Attempts to notify the physician/provider and their response should be documented in the resident electronic health record. The 24-Hour report shall be utilized for nurse to nurse communication regarding the status of notification and response back.3.1-5(a)(2)3.1-5(a)(3)

Based on interview and record review, the facility failed to ensure a Preadmission Screening and Record Review (PASARR) was accurate for a resident with mental health diagnoses for 1 of 2 residents reviewed for PASARR. (Resident 14)Findings include:The clinical record for Resident 14 was reviewed on 1/14/26 at 2:29 p.m. The diagnoses included, but were not limited to, major depressive disorder, generalized anxiety disorder, and depression.A PASARR level I screen, dated 4/27/25, indicated a PASARR level II was not required. Resident 14 did not have a suspected mental illness, intellectual disability, or related condition. The level I screen did not show there was any serious mental illness.The PASARR level I screen did not include Resident 14's major depressive disorder, generalized anxiety disorder, or depression.During an interview, on 1/20/26 at 11:44 a.m., the Social Services Director (SSD) indicated major depressive disorder should have been on the PASARR. If the facility noted a discrepancy with a PASARR, a new PASARR should be submitted.A current facility policy, titled Indiana PASRR, undated and received from the Executive Director on 1/20/26 at 3:35 p.m., indicated .PASRR required that 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental illness.Change in status.PASRR Level 1 completed for change in status.3.1-16(d)(1)(A)3.1-16(d)(1)(B)

Based on interview and record review, the facility failed to ensure tuberculosis tests were administered according to the acceptable standard of practice for 2 of 5 residents reviewed for infection control. (Resident 1 and 62)Findings include:1. The clinical record for Resident 1 was reviewed on 1/16/26 at 2:18 p.m. The diagnoses included, but were not limited to, cervical region spinal stenosis, lumbar region fusion of the spine, chronic diastolic congestive heart failure, essential primary hypertension, and type 2 diabetes mellitus without complications.Tuberculosis test documentation, dated 12/24/25, indicated the test was administered in the left forearm at 10:05 p.m.Tuberculosis test documentation, dated 12/26/25, indicated the test was read as negative at 4:46 p.m. (less than 48 hours after the test was administered).Tuberculosis test documentation, dated 1/7/26, indicated the test was administered in the left forearm at 9:25 p.m.Tuberculosis test documentation, dated 1/9/26, indicated the test was read as negative at 3:15 p.m. (less than 48 hours after the test was administered).2. The clinical record for Resident 62 was reviewed on 1/15/26 at 11:38 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), dementia, hypertension, and osteomyelitis.Tuberculosis test documentation, dated 1/9/26, indicated the test was administered in the left forearm at 10:00 p.m.Tuberculosis test documentation, dated 1/11/26, indicated the test was read as negative at 5:09 p.m. (less than 48 hours after the test was administered).During an interview, on 1/21/26 at 11:14 a.m., the DON (Director of Nursing) indicated tuberculosis skin tests were supposed to be read within 48 to 72 hours. The IP (Infection Preventionist) indicated the facility needed to change the timing of the tuberculosis orders on the Medication Administration Record to ensure proper spacing between administering and reading the tests.A current facility policy, titled Guidelines for TB Control Plan for Residents-Indiana, dated as last reviewed 12/16/25 and provided by the Executive Director on 1/20/26 at 10:15 a.m., indicated .Upon admission a baseline two-step TST shall be completed.A current CDC healthcare education document, titled Mantoux TB Skin Test, downloaded from https://www.cdc.gov/tb/education/mantoux/pdf/ on 1/21/26 at 4:35 p.m., indicated .The skin test should be read between 48 and 72 hours after administration.3.1-18(e)

Based on observation, interview and record review, the facility failed to ensure a resident's comprehensive plan of care was followed and supervision was provided which resulted in unwitnessed falls for 1 of 3 residents reviewed for accidents. (Resident B) This deficient practice resulted in Resident B sustaining multiple injuries, including, but not limited to a fractured femur, hip, and multiple lacerations, some requiring sutures. Findings include:During a telephone interview, on 12/2/25 at 12:10 p.m., a family member indicated Resident B had five (5) falls in the last six months. Resident B had glass removed from her eye and face and sutures placed during the last fall. She was left alone in her room, and she was not supposed to be because of other falls. In September 2025, she was alone in her bathroom and fell. In November 2025, she was alone in her room and fell. During a telephone interview, on 12/2/25 at 1:48 p.m., a family member indicated she was concerned with Resident B's frequent falls and being left alone in her room. After talking with management, she was told Resident B's frequent falls were due to being alone in her room and she would not be left by herself. She was left in her room by herself by a staff member and had another fall. During an observation, on 12/2/25 at 2:49 p.m., Resident B had purplish/red colored scattered bruises under both her eyes and on her right forehead. She had a laceration above her right eye with seven sutures. She had a laceration under her right eye on her right cheekbone with two sutures. The clinical record for Resident B was reviewed on 12/1/25 at 2:30 p.m. The diagnoses included, but were not limited to, dementia, periprosthetic fracture around an internal prosthetic of the left hip joint, repeated falls, major depressive disorder, and cognitive communitive deficit.A care plan, dated 11/27/23, indicated Resident B was at risk for falls. The long-term goal was Resident B would remain free from falls with major injury. The clinical record for Resident B indicated she had five (5) falls in six (6) months and an injury with every fall. The injuries ranged from skin tears, bruises, lacerations, a fractured left hip and a periprosthetic fracture around an internal prosthetic left hip joint.1. A nursing progress note, dated 5/13/25 at 9:48 p.m., indicated Resident B had an unwitnessed fall, at 8:25 p.m., and sustained a skin tear to her left upper arm. She was observed on the floor in her room. She hit her head. The new intervention placed was to rearrange her room, to place Dycem to her chair, to apply moisturizer to keep her skin supple, and to encourage her to wear long sleeve shirts.A progress note, dated 5/13/25 at 10:07 p.m., indicated Resident B was observed lying face down with her left arm under her body and her legs extended out. Her wheelchair was positioned behind her. Resident B received a hematoma to her forehead, a skin tear to her left upper arm, and a bruise to her left knee. Resident B indicated she leaned over to get something off the floor and fell. 2. A progress note, dated 6/27/25 at 7:30 p.m., indicated Resident B had an unwitnessed fall. The resident was found on the floor in front of her wheelchair in the prone position. She was assessed and blood was coming from a laceration to her forehead. Resident B indicated she was using her grabber tool to pick up an item off the floor and fell over. The resident was asked to use her call light and to allow staff to assist her with picking up items from the floor.A facility incident report, dated 6/28/25 at 1:15 a.m., indicated Resident B had an unwitnessed fall in her room, on 6/27/25 at 7:30 p.m. She sustained a laceration during the fall. An intradisciplinary team note, dated 7/3/25 at 9:54 p.m., indicated Resident B was found on the floor, on 6/27/25 at 7:30 p.m. She was severely cognitively impaired. She indicated she was attempting to get something off the floor with her grabbing tool when she fell over. She had a laceration to the middle of her forehead. The intervention placed was to have a physical and occupational therapy evaluation to determine appropriate assistive devices. 3. A facility incident report, dated 9/4/25 at 8:02 p.m., indicated Resident B had an unwitnessed fall in her bathroom, on 9/4/25 at 7:30 p.m. She complained of pain in her left hip. Prior to the fall, Resident B was transferring herself from her wheelchair to use the restroom and fell. An intradisciplinary team note, dated 9/8/25 at 2:55 p.m., indicated Resident B had an unwitnessed fall, on 9/4/25. The resident was found on her restroom floor and complained of left hip pain. She was attempting to self-transfer to the toilet. Resident B was severely cognitively impaired and displayed an increase in anxiety after the fall. The new intervention placed was Resident B was not to be left unattended in the bathroom by herself.A nursing progress note, dated 9/8/25 at 4:42 p.m., indicated the x-ray company confirmed a subacute fracture at the lateral aspect of the proximal femur with no displacement. A nursing progress note, dated 9/12/25 at 10:27 p.m., indicated Resident B arrived back at the facility by ambulance. She had suffered a fracture of her left femur. She was non-weight bearing. She screamed with movement and was very anxious. Fall precautions were put into place.4. A facility incident report, dated 11/6/25 at 6:41 p.m., indicated Resident B had an unwitnessed fall in her room, on 11/6/25 at 6:15 p.m. It was unknown what Resident B was doing at the time of the fall. The resident was hospitalized .A hospital history and physical, dated 11/7/25 at 3:31 a.m., indicated Resident B fell from her wheelchair. There was a scalp hematoma, and her pelvic CT (Computerized Tomography) report showed a periprosthetic fracture of the left hip with suspected focal hardware loosening. An orthopedic surgeon was consulted. An intradisciplinary team note, dated 11/7/25 at 8:16 a.m., indicated Resident B had an unwitnessed fall, on 11/6/25. She was found on the floor in her room. She had a laceration on her head which was bleeding. She was unable to state what she was doing or attempting to do prior to the fall and had increased anxiety and agitation. The new intervention placed was to keep the resident out of her room unattended unless she was in bed. She would be placed at the nurses' station for supervision while out of her bed and during periods when meals were not being served and activities were not taking place.5. A nursing progress note, dated 11/24/25 at 7:34 p.m., indicated Resident B was placed in the bathroom to wash her face while the CNA stepped out to get supplies. The nurse heard a scream and found the resident on the floor face first by her dresser. She had bleeding coming from the right side of her face and a large gash on her right forehead. She was transported to the hospital for evaluation and treatment.A facility incident report, dated 11/24/25 at 7:48 p.m., indicated Resident B had an unwitnessed fall with a head injury, on 11/24/25 at 7:00 p.m. Prior to the fall, she was washing her face in the bathroom.A nursing progress note, dated 11/25/25 at 1:36 a.m., indicated Resident B returned from the hospital with sutures to the right side of her face. An intradisciplinary team note, dated 11/25/25 at 2:32 p.m., indicated Resident B had an unwitnessed fall, on 11/24/25. The nurse heard yelling, went to her room, and found her on the floor in the prone position next to the dresser. The nurse observed bleeding from the right side of her face near her cheekbone and a large gash on the right side of her forehead. The resident could not indicate what happened. She was in the bathroom brushing her teeth and the CNA went to quickly grab some more supplies. The resident's wheelchair was locked. The resident unlocked her wheelchair, rolled herself into her room, and fell. The new intervention was to place anti-rollbacks on her wheelchair.A facility document, titled Resident Profile (a document used to communicate how residents were to be cared for), dated 12/2/25 at 10:55 a.m., included, but were not limited to, the following approaches: 9/10/25, the resident was not to be left unattended while in the bathroom. 11/11/25, the resident would be placed at the nurses' station for supervision while out of bed and when meals were not being served and activities were not taking place.A facility document, titled Teachable Moment, dated 11/25/25, indicated CNA 1 was given a teachable moment after assisting Resident B with care in the bathroom, on 11/24/25. Resident B had a fall intervention in place prior to this fall, to not leave her in her room unattended while in her wheelchair. CNA 1 left the resident's room to quickly gather some more supplies, when she heard yelling from the resident's room. She went to the resident's room and observed her on the floor near the dresser in her room. CNA 1 indicated she did not know about the resident's fall intervention and had not worked in the last couple of weeks. The Executive Director and the Director of Health Services reminded CNA 1 about looking at the resident profiles, which were located at all the nurses' stations and the importance of doing thorough rounding during shift report. During an interview, on 12/2/25 at 3:15 p.m., the Executive Director indicated the CNA who left the resident alone in her room when she fell, on 11/24/25, was given a teachable moment education. They had not educated the nursing staff members related to leaving residents alone in their rooms who were fall risks or educated the nursing staff on following care plan interventions and resident profile trackers as of this date.A current facility policy, titled Fall Management Program Guidelines, dated as revised on 5/17/17 and provided by the Clinical Support on 12/2/25 at 1:27 p.m., indicated .when a resident is found on the floor, a fall is considered to have occurred.The resident care plan should be updated to reflect any new or change in interventions.Discuss risks and interventions with resident and/or responsible party and communicate interventions during shift report.A current facility policy, titled Comprehensive Care Plan Guidelines, dated 5/22/18 and provided by the Clinical Support staff on 12/2/25 at 1:27 p.m., indicated .Care plan interventions should be reflective of risk area(s) or disease processes that impact the individual resident. c. Should new identified areas of concern arise during the resident's stay, they should be addressed on the care plan.Pertinent care plan approaches are communicated to the nursing staff per the 24-hour CRCA (Certified Resident Care Associate) assignment or the care tracker profile dependent on campus preference.Comprehensive care plans need to remain accurate and current.This citation relates to Intake 2663555.3.1-45(a)(1)3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a resident was ordered and provided with the proper dose of a medication for 1 of 3 residents reviewed for pharmaceutical services. (Resident B)Findings include:The clinical record for Resident B was reviewed on 10/2/25 at 10:13 a.m. The diagnoses included, but were not limited to Parkinson's disease, history of stroke, and weakness.A physician's order, dated 8/11/25 and discontinued 8/12/25, indicated to administer Rytary (a medication used to treat symptoms of Parkinson's disease) extended release 48.75-195 milligrams (mg) one (1) capsule four (4) times per day.A physician's order, dated 8/12/25 and discontinued 8/30/25, indicated to administer Rytary extended release 48.75-195 mg four (4) capsules four (4) times per day.A physician's order, dated 8/30/25 and discontinued 9/11/25, indicated to administer Rytary extended release 48.75-195 mg one (1) capsule four (4) times per day.Resident B admitted to the assisted living section of the facility on 9/11/25.A physician's order, dated 9/11/25 and discontinued 9/17/25, indicated to administer Rytary extended release 48.75-195 mg one (1) capsule four (4) times per day.A physician's order, dated 9/17/25 and discontinued 10/1/25, indicated to administer Rytary extended release 48.75-195 mg two (2) capsules four (4) times per day.During an interview, on 10/2/25 at 11:40 a.m., the Director of Nursing (DON) indicated the resident was supposed to receive four (4) capsules instead of 1 capsule. A weekend nurse had questioned the medication dosage, and when pharmacy looked at the dosage, they changed the medication back to one (1) capsule four (4) times per day.During an interview, on 10/2/25 at 2:00 p.m., the DON indicated the admitting nurse had incorrectly entered the order for one (1) capsule and had quickly changed it back to the correct dosage of four (4) capsules. When the pharmacy reviewed the medication, on 8/30/25, they had looked at an older resident profile which led to the pharmacy changing the order back to one (1) capsule which was an incorrect dosage. When the issue was finally caught, the physician ordered the Rytary for two (2) capsules to titrate Resident B back up to the correct dose.An email from the Executive Director (ED), on 9/22/25 at 3:40 p.m., indicated, on 8/30/25, the weekend supervisor was verifying orders and had spoken to the pharmacist regarding the medication. The pharmacist reported the medication dosage should be changed from four (4) capsules to one (1) capsule. The facility indicated the pharmacy may have looked at an older profile for Resident B.During an interview, on 10/3/25 at 10:45 a.m., Clinical Support Nurse 1 indicated if the facility requested an immediate pharmacy review, they expected the pharmacy would had reviewed the medications and gave recommendations accurately.A current facility policy, titled CONSULTANT PHARMACIST REPORTS, dated as last revised in November 2018 and received from Clinical Support Nurse 1 on 10/3/25 at 10:30 a.m., indicated .Pharmacy will provide facilities with an Immediate Medication Regimen Review (IMRR) upon request.The facility may request that a licensed pharmacist perform an IMRR.This citation relates to Intake 2628099.3.1-25(e)(1)

Based on interview and record review, the facility failed to ensure pain assessments were completed prior to and after the administration of narcotic pain medication for 2 of 3 residents reviewed for quality of care. (Resident B and C)Findings include:1. The clinical record for Resident B was reviewed on 9/12/25 at 3:00 p.m. The diagnoses included, but were not limited to, dementia, chronic kidney disease, malignant melanoma of the skin, anxiety disorder, and chronic degeneration of the lumbar region.A physician's order, dated 3/17/25, indicated to administer Oxycodone (a narcotic pain medication) 5 mg (milligrams) once a day as needed for pain. The Electronic Medication Administration Record (EMAR) indicated a pain assessment was to be completed prior to administering the medication and to follow-up on the effectiveness of the medication after it was administered.A pain assessment was not documented on the EMAR prior to or after the medication was administered on the following dates and times:a. On 7/18/25 at 12:00 a.m.b. On 7/23/25 at 12:25 a.m.c. On 7/24/25 at 12:00 a.m.d. On 7/27/25 at 8:00 p.m.e. On 8/5/25 12:00 a.m.f. On 8/6/25 at 9:00 p.m.g On 8/19/25 at 9:30 p.m. 2. The clinical record for Resident C was reviewed on 9/12/25 at 3:15 p.m. The diagnoses included, but were not limited to, dysarthria following cerebral infarction, stiffness of the right shoulder, type II diabetes mellitus with diabetic neuropathy, and major depressive disorder.A physician's order, dated 5/31/24, indicated to administer Oxycodone 5-325 mg as needed every six hours for moderate to severe pain. The Electronic Medication Administration Record (EMAR) indicated a pain assessment was to be completed prior to administering the medication and to follow-up on the effectiveness of the medication after it was administered.A pain assessment was not documented on the EMAR prior to or after the medication was administered on the following dates and times:a. On 8/15/25 at 1:15 a.m.b. On 8/19/25 at 11:00 p.m. During an interview, on 9/12/25 at 12:40 p.m., Resident B indicated she had not asked for pain medication over the last few weeks, except for one day last week for pain in her shoulder.During an interview, on 9/12/25 at 2:11 p.m., Resident C denied asking for pain medication over the last few weeks. Resident C's daughter was present during the interview and indicated her Resident C would not have asked for the strong pain medication, she preferred Tylenol if she needed something for pain. During an interview, on 9/12/25 at 3:34 p.m., the Executive Director indicated LPN 2 should have completed a pain assessment prior to administering narcotic pain meds to Resident B and C. LPN 2 should have also completed a follow-up pain assessment after the administration of the narcotic pain medication to assess how effective the pain medication was for each resident.This Citation was related to Intake 2598338.3.1-37(a)

Based on interview and record review, the facility failed to ensure narcotic pain medications were documented as administered on the medication administration record for 2 of 3 residents reviewed for controlled medications. (Resident B and C) The deficient practice was corrected on 8/22/25, prior to the start of the survey, and was therefore past noncompliance.Findings include:A facility reported incident, dated 9/4/25, indicated there was an irregularity noted in the narcotic sign out sheets for Residents B and C. When both residents were interviewed, they indicated they had not requested the as needed narcotics which were signed out on 8/19/25 and 8/20/25.1. The clinical record for Resident B was reviewed on 9/12/25 at 3:00 p.m. The diagnoses included, but were not limited to, dementia, chronic kidney disease, malignant melanoma of the skin, anxiety disorder, and chronic degeneration of the lumbar region.A physician's order, dated 3/17/25, indicated to administer Oxycodone (a narcotic pain medication) 5 mg (milligrams) once a day as needed for pain. Resident B's narcotic count sheet indicated Oxycodone was given on the following dates and times, but there was no signature on the electronic medication administration record (EMAR) to indicate the resident had received the medication.a. On 7/18/25 at 12:00 a.m.b. On 7/23/25 at 12:25 a.m.c. On 7/24/25 at 12:00 a.m.d. On 7/27/25 at 8:00 p.m.e. On 8/5/25 12:00 a.m.f. On 8/6/25 at 9:00 p.m.g On 8/19/25 at 9:30 p.m. 2. The clinical record for Resident C was reviewed on 9/12/25 at 3:15 p.m. The diagnoses included, but were not limited to, dysarthria following cerebral infarction, stiffness of the right shoulder, type II diabetes mellitus with diabetic neuropathy, and major depressive disorder.A physician's order, dated 5/31/24, indicated to administer Oxycodone 5-325 mg as needed every six hours for moderate to severe pain. Resident C's narcotic count sheet indicated Oxycodone was given on the following dates and times, but there was no signature on the EMAR to indicate the resident had received the medication. a. On 8/15/25 at 1:15 a.m.b. On 8/19/25 at 11:00 p.m. During an interview, on 9/12/25 at 12:40 p.m., Resident B indicated she had not asked for pain medication over the last few weeks, except for one day last week for pain in her shoulder.During an interview, on 9/12/25 at 2:11 p.m., Resident C denied asking for pain medication over the last few weeks. Resident C's daughter was present during the interview and indicated her Resident C would not have asked for the strong pain medication, she preferred Tylenol if she needed something for pain. During an interview, on 9/12/25 at 3:34 p.m., the Executive Director indicated LPN 2 should have documented the narcotics she administered to Resident B and C on the EMAR's as well as the narcotic sign out sheets.A current facility policy, titled The 6 Rights of Medication Administration, undated and provided by the Executive Administrator on 9/12/25 at 2:00 p.m., indicated .Right Documentation: Record the administration of a medication after you give it to your individual. Follow your agency policy for proper documentation.The deficient practice was corrected by 8/22/25, after the facility implemented a plan which included a thorough investigation, staff and resident interviews, staff education and narcotic medication audits.This citation relates to Intake 2598338.3.1-25(b)(3)

Based on interview and record review, the facility failed to ensure the suprapubic catheter urine output was accurately recorded for 2 of 3 residents reviewed for urinary catheters. (Resident 20 and 1) Finding includes: 1. The clinical record for Resident 20 was reviewed on 1/15/25 at 2:40 p.m. The diagnoses included, but were not limited to, obstructive and reflux uropathy (hindrance of normal urine flow), feeling of incomplete bladder emptying, retention of urine, and the presence of urogenital implants (helps provide normal urine flow). A care plan, dated 2/9/23, indicated the resident had a suprapubic catheter (a tube which drains urine from the bladder through a small incision in the lower abdomen). Interventions included, but were not limited to, record the resident's urinary output and assist with catheter care. A physician's order, dated 2/24/23, indicated to monitor catheter output every shift. A Treatment Administration Record (TAR), dated 12/28/24 through 1/15/25, indicated to empty the catheter every shift and document the output. The following was documented: On 12/29/24 at 8:46 p.m., large was recorded. On 12/30/24 at 2:40 a.m., medium was recorded. On 12/30/24 at 12:00 p.m., medium was recorded. On 12/31/24 at 6:53 a.m., medium was recorded. On 1/1/25 at 9:20 a.m., large was recorded. On 1/2/25 at 8:57 p.m., large was recorded. On 1/3/25 at 1:37 p.m., large was recorded. On 1/4/25 at 8:52 p.m., large was recorded. On 1/5/25 at 9:18 p.m., large was recorded. On 1/5/25 at 11:01 p.m., medium was recorded. On 1/6/25 at 2:16 p.m., medium was recorded. On 1/8/25 at 1:31 p.m., medium was recorded. On 1/9/25 at 12:51 p.m., large was recorded. On 1/9/25 at 1:30 p.m. large was recorded. On 1/12/25 at 1:58 p.m., medium was recorded. On 1/14/25 at 1:39 p.m., medium was recorded. On 1/15/25 at 5:31 a.m., large was recorded. On 1/15/25 at 11:53 a.m., large was recorded. On 1/15/25 at 3:22 p.m., large was recorded. During an interview, on 1/16/25 at 10:38 a.m., Licensed Practical Nurse (LPN) 5 indicated the Certified Nursing Assistant (CNA) normally charted the urine output. If they did not have time, she would add them into the electronic medical record. The urine output should have been documented as milliliters. During an interview, on 1/16/25 at 10:51 a.m., CNA 6 indicated she did not know why the exact urine amount was not documented when the CNA emptied the catheter into the graduated cylinder. When she charted the amount of urine, she would add the amount in milliliters. When the bag was full to the top, she would consider the amount large, halfway would be medium and small would be hardly anything in the bag. During an interview, on 1/16/25 at 11:02 a.m., CNA 7 indicated staff should not chart the catheter outputs by using small, medium, and large for the amounts. 50901 2. The clinical record for Resident 1 was reviewed on 1/14/25 at 3:32 p.m. The diagnoses included, but were not limited to, sepsis (a life-threatening complication of an infection), urinary tract infection (UTI), urethral stricture (a condition which blocks the flow of urine), and urinary retention. A physician's order indicated Resident 1 had a suprapubic catheter (a tube which drains urine directly from the bladder through a small incision in the lower abdomen) due to urethral stricture. A physician's order, dated 5/16/24, indicated to monitor Resident 1's urinary output three times a day, every shift. A Treatment Administration Record (TAR), dated 12/1/24 through 1/15/25, indicated the following documented urinary outputs: On 12/1/24 between 6:00 a.m. to 2:00 p.m., medium was recorded. On 12/1/24 between 2:00 p.m. to 10:00 p.m., medium was recorded. On 12/3/24 between 6:00 a.m. to 2:00 p.m., medium was recorded. On 12/3/24 between 2:00 p.m. to 10:00 p.m., medium was recorded. On 12/17/24 between 6:00 a.m. to 2:00 p.m., large was recorded. On 12/17/24 between 2:00 p.m. to 10:00 p.m., large was recorded. On 12/18/24 between 6:00 a.m. to 2:00 p.m., large was recorded. On 12/19/24 between 6:00 a.m. to 2:00 p.m., medium was recorded. On 12/20/24 between 6:00 a.m. to 2:00 p.m., medium was recorded. On 12/20/24 between 10:00 p.m. to 7:00 a.m., large was recorded. On 12/21/24 between 6:00 a.m. to 2:00 p.m., large was recorded. On 12/23/24 between 6:00 a.m. to 2:00 p.m., medium was recorded. On 12/30/24 between 6:00 a.m. to 2:00 p.m., medium was recorded. On 1/4/25 between 2:00 p.m. to 10:00 p.m., large was recorded. On 1/4/25 between 2:00 p.m. to 10:00 p.m., large was recorded. On 1/5/25 between 6:00 a.m. to 2:00 p.m., medium was recorded. On 1/5/25 between 2:00 p.m. to 10:00 p.m., medium was recorded. On 1/6/25 between 6:00 a.m. to 2:00 p.m., large was recorded. On 1/6/25 between 2:00 p.m. to 10:00 p.m., large was recorded. On 1/8/25 between 6:00 a.m. to 2:00 p.m., medium was recorded. On 1/10/25 between 6:00 a.m. to 2:00 p.m., medium was recorded. On 1/10/25 between 2:00 p.m. to 10:00 p.m., large was recorded. On 1/11/25 between 6:00 a.m. to 2:00 p.m., large was recorded. On 1/13/25 between 6:00 a.m. to 2:00 p.m., medium was recorded. During an interview, on 1/16/25 at 11:03 a.m., Certified Nursing Assistant (CNA) 4 indicated to measure urinary output from a catheter, the catheter bag would be emptied into a urinal and the amount would be documented in mL (milliliters). CNAs document the output in the Matrix (a facility charting platform). The catheter bag would be emptied at least once a shift, or when the catheter bag looked like it needed emptied. During an interview, on 1/16/25 at 11:16 a.m., LPN 5 indicated the nurse would obtain the urinary outputs from the CNAs and document the output in the Treatment Administration Record (TAR). The urinary output amount should be documented in milliliters. During an interview, on 1/16/25 at 12:16 p.m., Clinical Support Nurse 3 indicated the facility did not have a policy regarding documentation of intake and outputs. The Indiana State Department of Health Nurse Aide Curriculum, revised 11/19/15, indicated .Resident Care Procedure (RCP) 50 .Empty Urinary Drainage Bag .Detach spout (if bag has one) and point the drainage tube into center of graduated cylinder without letting tube touch sides .Unclamp spout and drain urine .Check urine for color, odor, amount and characteristics and report unusual findings to nurse .Changes may be first signs of medical problem. By alerting the nurse you ensure that the resident receives prompt attention .Measure and accurately record amount of urine .Accuracy is necessary because decisions regarding resident ' s care may be based on your report 3.1-41(a)(2)

Based on interview and record review, the facility failed to ensure a blood pressure medication was held according to the physician's ordered hold parameter and to ensure the physician was notified for an elevated blood sugar level according to the call parameter for 3 of 3 residents reviewed for quality of care. (Resident 194, 4 and 2) Findings include: 1. The clinical record for Resident 194 was reviewed on 1/15/25 at 11:29 a.m. The diagnoses included, but were not limited to, metabolic encephalopathy, hypotension, anemia, dementia, and type 2 diabetes mellitus. A physician's order, dated 1/9/25, indicated to give midodrine (a medication used to treat orthostatic hypotension) 5 milligrams (mg) twice a day with special instructions to hold the medication for a systolic blood pressure greater than 120. A review of the January 2025 Medication Administration Record, dated January 8 through 17, 2025, indicated the medication was administered to Resident 194 when the systolic blood pressure was greater than 120 on the following days: On 1/9/25, the resident's systolic blood pressure was 122 in the morning and 126 in the evening, and the medication was administered. On 1/10/25, the resident's systolic blood pressure was 132 in the morning and 129 in the evening, and the medication was administered. On 1/11/25, the resident's systolic blood pressure was 128 in the evening, and the medication was administered. On 1/12/25, the resident's systolic blood pressure was 126 in the morning, and the medication was administered. On 1/13/25, the resident's systolic blood pressure was 130 in the morning and 129 in the evening, and the medication was administered. On 1/14/25, the resident's systolic blood pressure was 130 in the morning and 135 in the evening, and the medication was administered. On 1/15/25, the resident's systolic blood pressure was 136 in the morning and 132 in the evening, and the medication was administered. On 1/16/25, the resident's systolic blood pressure was 137 in the morning and 136 in the evening, and the medication was administered. On 1/17/25, the resident's systolic blood pressure was 134 in the morning, and the medication was administered. The electronic medical record did not include documentation of notification to the physician of the medication being administered outside the ordered hold parameters. During an interview, on 1/15/25 at 3:11 p.m., LPN 2 indicated the staff member's initials were in parenthesis when a medication was held. When there was no parenthesis, the medication was administered. During an interview, on 1/16/25 at 12:06 p.m., the Clinical Support Nurse 3 indicated the nurse should follow the ordered hold parameters and not administer the medication. 2. The clinical record for Resident 4 was reviewed on 1/14/25 at 3:42 p.m. The diagnoses included, but were not limited to, hypertension, hyperlipidemia (high cholesterol), and type 2 diabetes. A physician's order, dated 5/29/24, indicated to give carvedilol (an antihypertensive medication) 12.5 milligrams twice a day. The order had special instructions to hold the medication if the systolic blood pressure was less than 100 or if the heart rate (pulse) was less than 65 beats per minute. A review of the November 2024 Medication Administration Record indicated the medication was administered to Resident 4 when her heart rate was less than 65 beats per minute on the following days: On 11/05/24, the resident's heart rate was 64 in the morning, the medication was administered. On 11/11/24, the resident's heart rate was 64 in the morning, the medication was administered. On 11/20/24, the resident's heart rate was 64 in the evening, the medication was administered. A review of the December 2024 Medication Administration Record indicated the medication was administered to Resident 4 when her heart rate was less than 65 beats per minute on the following days: On 12/09/24, the resident's heart rate was 60 in the morning, the medication was administered. On 12/13/24, the resident's heart rate was 64 in the morning, the medication was administered. On 12/14/24, the resident's heart rate was 62 in the morning, the medication was administered. On 12/15/24, the resident's heart rate was 63 in the morning, the medication was administered. On 12/16/24, the resident's heart rate was 63 in the morning, the medication was administered. On 12/20/24, the resident's heart rate was 63 in the morning, the medication was administered. On 12/23/24, the resident's heart rate was 61 in the morning, the medication was administered. On 12/24/24, the resident's heart rate was 60 in the morning, the medication was administered. On 12/24/24, the resident's heart rate was 63 in the evening, the medication was administered. On 12/30/24, the resident's heart rate was 64 in the evening, the medication was administered. A current care plan, dated as last revised on 12/17/24, indicated the resident had a potential for cardiovascular distress due to a diagnosis of hypertension and to administer medications as ordered. During an interview, on 1/16/25 at 10:12 a.m., LPN 1 indicated she followed the physician's order and would not give the carvedilol medication if the heart rate was less than 65. 44598 3. The clinical record for Resident 2 was reviewed on 1/15/23 at 10:29 a.m. The diagnoses included, but were not limited to, diabetes mellitus, hypertensive, anxiety disorder, major depressive disorder, and acute kidney failure. A care plan indicated the resident was at risk for hypoglycemia and hyperglycemia related to diabetes mellitus. Interventions included, but were not limited to, give medication per the physician's order and monitor blood sugars per the physician's order. A physician's order, dated 6/13/24, indicated to give Humalog U-100 Insulin solution subcutaneously before meals per the sliding scale. If the blood sugar was less than 70, call the physician. If the blood sugar was 151 to 200, give 0 units. If the blood sugar was 201 to 250, give 4 units. If the blood sugar was 251 to 300, give 6 units. If the blood sugar was 301 to 400, give 10 units. If the blood sugar was greater than 400, call the physician. The Medication Administration Record indicated the resident's blood sugar was 576 on 7/11/24. There was no documentation the physician was notified of the blood sugar greater than 400. During an interview, on 1/16/25 at 8:58 a.m., the Director of Nursing (DON) indicated there was no notification to the physician on 7/11/24 for the 576-blood sugar reading. The nurse did not notify the physician of the blood sugar and should have. During an interview, on 1/16/25 at 11:12 a.m., Licensed Practical Nurse (LPN) 5 indicated if the resident's blood sugar was out of range, she would give the highest amount on the sliding scale and call the doctor to ask if any additional insulin was needed. The facility did not have a policy for blood glucose monitoring. A current facility policy, titled Medication Administration-General Guidelines, dated as revised 1/2017 and received from the Clinical Support Nurse 3 on 1/17/25 at 10:25 a.m., indicated .Medications are administered in accordance with written orders of the prescriber 3.1-37(a)

Based on interview and record review, the facility failed to ensure a care plan meeting was offered or held for 3 of 3 residents reviewed for care plan meetings. (Resident 23, 29 and 30) Findings include: 1. The clinical record for Resident 23 was reviewed on 1/15/25 at 2:20 p.m. The diagnoses included, but were not limited to, depression, anxiety disorder, and Alzheimer's disease. The record for Resident 23 did not have a quarterly care plan meeting documented between 4/17/24 and 12/4/24. During an interview, on 1/17/25 at 10:03 a.m., the Clinical Support Nurse 3 indicated the resident had a care plan meeting on 4/17/24 and 12/4/24, but nothing in between. 50901 2. The clinical record for Resident 29 was reviewed on 1/14/25 at 3:29 p.m. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, insomnia, and visual hallucinations. A review of the Resident First Meeting Minutes indicated the facility had not conducted a care plan meeting for Resident 29 since 5/30/24. The resident had not had a quarterly care plan meeting held since that time. A nursing progress note, dated 10/11/24, indicated Resident 29 had been experiencing intermittent hallucinations. A psychiatry note, dated 10/16/24, indicated Resident 29 had been experiencing visual hallucinations since her husband's death in April 2024. The hallucinations had started to occur more frequently, and Resident 29 was started on Risperidone (an antipsychotic medication) for the visual hallucinations. During an interview, on 1/16/25 at 3:01 p.m., the Clinical Support Nurse 3 indicated the facility had not held a care plan meeting for Resident 29 since 5/30/24 and the last quarterly meeting had been missed. 3. During an interview, on 1/13/25 at 11:37 a.m., Resident 30 indicated she had not been invited to attend a care plan meeting in a long time. The clinical record for Resident 30 was reviewed on 1/14/25 at 3:37 p.m. The diagnoses included, but were not limited to, malignant neoplasm of upper lobe, left bronchus or lung, severe protein-calorie malnutrition, and muscle weakness. A review of the Resident First Meeting Minutes indicated the facility had not conducted a care plan meeting for Resident 30 since 7/15/24. During an interview, on 1/16/25 at 3:01 p.m., the Clinical Support Nurse 3 indicated the facility conducted a care plan meeting in January 2025, but it was after the last quarterly care plan meeting was due. She indicated the facility had significant employee turnover and had focused on conducting care plan meetings for the rehab residents. A current facility policy, titled Resident's First Meeting Guidelines, dated as last reviewed on 12/17/24 and received from the Clinical Support Nurse 3 on 1/16/25 at 2:59 p.m., indicated .To facilitate communication and participation regarding the residents plan of care, medical condition and care needs between the resident, family, resident representative and care givers .Subsequent meetings for non-Medicare residents should be conducted at a minimum of quarterly and with significant change .Subsequent meetings for Medicare residents should be conducted minimally quarterly .Director of Social Services or designee should send invitations to the resident and/or representative notifying them of the date and time of the conference as far in advance as possible .Prior to the meeting the interdisciplinary team members should: Review the resident's condition since the last assessment .Review recent changes in medications and physician's orders .Make sure issues related to Falls, Restraints, Skin breakdown, Psychotropic medications, and Weight loss/gain are discussed and that reasonable, measurable goals and effective interventions are implemented and documented .The Resident First Meeting is a time to communicate information related to care needs and medical condition and seek input from the resident or representative .Review the residents condition since the last meeting. Recent changes in medications and physician's orders, problems, and any areas of concern should be discussed with the team, family, and resident .Discuss additions or changes that may be needed to goal areas or care routine allowing input from the resident and/or representative 3.1-35(a) 3.1-35(b)(1) 3.1-35(d)(2)(B) 3.1-35(e)

Based on interview and record review, the facility failed to ensure medication administration or reason medication was not given was documented in the Medication Administration Record for 1 of 7 residents reviewed for documentation. (Resident 30) Finding includes: The clinical record for Resident 30 was reviewed on 1/14/25 at 3:43 p.m. The diagnoses included, but were not limited to, adjustment disorder with mixed anxiety and depressed mood, constipation, and bilateral pulmonary embolism (a clot in the lungs). The Medication Administration Record (MAR) was missing documentation of medication administration or lack of administration on the following days: A physician's order for buspirone (an anxiety medication) 5 milligrams (mg) was to be given twice a day for an adjustment disorder. There was no documentation, on 12/12/24, to indicate the evening dose was administered. A physician's order for cholecalciferol (a supplement) 50 micrograms (mcg) was to be given once a day. There was no documentation, on 12/12/24, to indicate the dose was administered. A physician's order for Cymbalta (an antidepressant) 20 mg was to be given once a day for an adjustment disorder. There was no documentation, on 12/12/24, to indicate the dose was administered. A physician's order for docusate sodium (a stool softener) 100 mg was to be given twice a day for constipation. There was no documentation, on 12/12/24, to indicate the morning dose was administered. A physician's order for gabapentin (a medication used to treat nerve pain) 300 mg was to be given three times a day for neuropathy. There was no documentation, on 12/12/24, to indicate the morning or afternoon dose was administered. There were seven (7) additional missed medication administration documentation opportunities found in the December MAR. During an interview, on 1/17/25 at 9:24 a.m., the Corporate Support Nurse 3 indicated medications were to be documented after they were given. A current facility policy, titled PREPARATION AND GENERAL GUIDELINES, dated as revised January 2017 and received from the Corporate Support Nurse 3 on 1/17/25, indicated .If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time .it is documented on MAR or in the EHR (electronic health record) 3.1-50(a)(2)

Based on interview and record review, the facility failed to ensure a resident's code status was changed when an out of hospital do not resuscitate declaration and order was received for 1 of 3 residents reviewed for advanced directives. (Resident 9) Finding includes: The clinical record for Resident 9 was reviewed on [DATE] at 2:35 p.m. The diagnoses included, but were not limited to, Alzheimer's disease, hypertension, attention-deficit hyperactivity disorder, anxiety disorder, depressive disorders, bipolar II disorder, and chronic kidney disease. A physician's order, dated [DATE], indicated the resident's code status was a full code. An out of hospital do not resuscitate declaration and order form, dated [DATE], was signed by the resident on [DATE]. The physician signed the form on [DATE]. It was scanned into the electronic medical record on [DATE]. The physician did not sign the form until 6 days after the resident signed the form. A social service note, dated [DATE] at 9:57 a.m., indicated the resident's code status was reviewed and updated to do not resuscitate during her care plan meeting. A physician's progress note, dated [DATE] at 1:03 p.m., indicated the resident was a full code. A physician's progress note, dated [DATE] at 12:15 p.m., indicated the resident was a full code. On [DATE] at 11:35 a.m., the resident was listed as a full code at the top of her electronic medical record and on her face sheet. On [DATE] at 3:54 p.m., Resident 9 was listed as a full code in the information banner of the electronic medical record. During an interview, on [DATE] at 2:53 p.m., the Director of Nursing (DON) indicated the signed form was scanned into the resident's medical record, but the facility was just now updating their charting system with the correct order and changing it in the electronic medical record. It had been missed and was listed incorrectly until now. During an interview, on [DATE] at 3:11 p.m., LPN 2 indicated in an emergency, staff would check the computer and look at the resident's top banner information to find out if they should start CPR or if resident wished to be a DNR. A current facility policy, titled Guidelines for Advanced Directives, dated as revised on [DATE] and provided by the Clinical Support Nurse 3 on [DATE] at 10:25 a.m., indicated .To ensure facility staff obtains and follows resident's advanced directives regarding end-of-life care .The nursing staff will confirm the desired code status and obtain an order from the physician .Designation of code status and obtainment of physician order will be part of the medical record. 3XXX,d+[DATE](f)(5)

Based on observation, interview and record review, the facility failed to ensure a resident's credit card was kept safe and secure during her admission for 1 of 3 residents reviewed for misappropriation of property. (Resident B) The deficient practice was corrected on 7/18/24, prior to the start of the survey, and therefore was past noncompliance. Finding includes: A document, titled Indiana State Department of Health Survey Report System, dated 7/18/24, indicated Resident B reported missing a credit card which had charges on it she was not responsible for. The card was deactivated. The local police were notified, and an investigation was started. A staff member was terminated for stealing Resident B's credit card. The clinical record for Resident B was reviewed on 8/1/24 at 10:13 a.m. The diagnoses included, but were not limited to, chronic kidney disease stage 3, dependence on dialysis, hypertension, type II diabetes mellitus, and personal history of thrombus and embolism. The employee record for Housekeeper 1 was reviewed, on 8/1/24 at 11:45 a.m. The record included, but were not limited to, the following documents: a. An Indiana State Police screening report indicated Housekeeper 1's information provided inclusive results, and it was recommended to obtain her fingerprints. b. A document, titled Personal Action Form, dated 7/16/24, indicated Housekeeper 1 was suspended on 7/15/24, due to being involved in a theft investigation. She left on her lunch break and never returned. c. A document, titled Personal Action Form, dated 7/18/24, indicated Housekeeper 1 was terminated from the facility, on 7/18/24, for quitting without notice and no call no show. The comment section indicated Housekeeper 1 was involved in a theft investigation. She was asked to give her statement. On 7/15/24, she left for her lunch break and never returned. She did not answer calls or respond to texts from the facility. She was a no call no show for her 7/16/24 and 7/17/24 shifts with no response to her supervisor or the Executive Director (ED). The police were investigating the theft of Resident B's credit card. The facility investigation of Resident B's credit card included, but were not limited to, the following documents: a. A document, titled Investigation Summary, indicated on 7/13/24 at 5:00 p.m., Resident B reported her credit card was missing with charges she was not responsible for. The resident indicated her credit card was in her phone case wallet at approximately 9:00 a.m. She left her room around 10:00 a.m., to go do an activity, then went to physical therapy in the gym then to lunch at approximately 12:50 p.m. After the resident returned to her room, she picked up her phone case wallet and noticed her credit card was not in her wallet. She called her bank and reported the credit card missing. She found the credit card had an unknown transaction at a McDonald's at 12:30 p.m. The card was deactivated, and she reported the stolen credit card to the nurse on duty. Her credit card came up missing between the timeframe of 10:00 a.m. and 1:40 p.m., on 7/13/24. b. A typed statement by Housekeeper 3, dated 7/16/24, indicated she was training Housekeeper 1 on 7/13/24. Housekeeper 3 asked Housekeeper 1 if she needed a break and she indicated Yes, so they left and went on a lunch break. Housekeeper 1 mentioned to Housekeeper 3 she was going to her car, and she would be back. When Housekeeper 3 went to the employee break room to grab her iPad, she observed Housekeeper 1 eating McDonalds. Housekeeper 1 told Housekeeper 3 her husband had gotten her some food to eat for lunch. Housekeeper 1 disappeared randomly at approximately 2:00 p.m. During an interview, on 8/1/24 at 11:00 a.m., Resident B was observed sitting in her standard wheelchair in the therapy room. She indicated she had opened her phone wallet case where her credit card was kept prior to getting her morning care and her credit card was there. She received her morning care at approximately 9:00 a.m., then went to an activity at approximately 10:00 a.m. She went straight to therapy from the activity, then went to lunch and went back to her apartment at approximately 12:50 p.m. She opened her phone wallet case to look for something and noticed her credit card was missing. She called the bank and deactivated her credit card. At that time, she found out her credit card had been used at a McDonalds to buy food for $10.50 at approximately 12:30 p.m. The person who stole it had also tried to use it at a store and it was denied three times due to the card being deactivated. She reported to a nurse her credit card had been stolen. The Executive Director (ED) told her a housekeeper was the staff member who stole her credit card. She received her $10.50 back from the bank. The police officers were investigating the theft. A current policy, titled Abuse and Neglect Procedural Guidelines, dated as revised July 2, 2024, and provided by ED on 8/1/24 at 11:11 a.m., indicated .has implemented processes in an effort to provide a comfortable and safe environment .Definitions .Misappropriation of Property-means the deliberate misplacement, exploitation or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent The deficient practice was corrected by 7/18/24, after the facility implemented a systemic plan which included a thorough investigation with police involvement, all alert and oriented residents were interviewed, Housekeeper 1 was terminated, and all staff members were educated on abuse and misappropriation of property along with resident rights. This citation relates to Complaint IN00438719. 3.1-28(a)

Based on interview and record review, the facility failed to ensure a staff member had the appropriate qualifications and current certification to perform the duties of a Certified Nursing Assistant (CNA) and a Qualified Medication Aide (QMA) during the 34 day time period he was hired at the facility and failed to ensure a job specific orientation checkoff list for his CNA was completed and signed by the trainer prior to working alone on the floor as a CNA for 1 of 5 employees reviewed. (Employee 1) The deficient practice was corrected on 5/18/24, prior to the start of the survey, and was therefore past noncompliance. Findings include: 1. An anonymous complaint was sent to the Indiana Department of Health, which indicated Employee 1 was working as a Licensed Practical Nurse (LPN) without a license at the facility. Employee 1's employee record was requested during the entrance conference on 5/29/24 at 10:20 a.m. During an interview, on 5/29/24 at 12:30 p.m., the Executive Director (ED) and the Nursing Clinical Specialist (NCS) were in attendance. The ED indicated Employee 1 worked at the facility as a Certified Nursing Assistant (CNA) and Qualified Medication Aide (QMA). He worked at the facility, from 11/15/23 to 12/20/23, for a total of 34 days. One week of the 34 days he did not work due to COVID-19 and one week he was suspended for a staff-to-staff incident, then he was terminated for poor job performance. He worked a total of 14 shifts while employed at the facility. A news reporter was outside on the facility property, on 5/17/24, and reported Employee 1 had worked at the facility as an LPN without a license. At that time, the facility discovered he had worked as a QMA and CNA under the name of another person. He was not working at the facility at the present time, he had been terminated for poor job performance in December 2023. On 5/29/24 at 2:30 p.m., the employee file of Employee 1 was requested and received. On 5/30/24 at 11:48 a.m., Employee 1's CNA certification was provided by the ED, which had a different last name than the last name the employee was hired by. When the ED was asked why Employee 1's name was different on his certification then on his employment records, she indicated he told the facility when asked why his names were different on his CNA and QMA certification than his driver's license and social security card, that he had gotten married. A document, titled Investigation Summary, dated 5/18/24, indicated on 5/17/24 at 10:00 p.m., Channel 13 News aired a live report from in front of the facility at 6:00 p.m. The news report indicated a hospice company had an employee using someone else's LPN license to practice. The news report indicated he was a former employee of the facility and there were licensure concerns when this employee worked at the facility. The Summary of the Investigation indicated Employee 1 was employed at the facility from 11/15/23 and terminated on 12/20/23, due to unsatisfactory performance and poor interactions with staff. He was hired at the facility under one name and indicated his name was another name due to him getting married and he had changed his last name. He provided the CNA and QMA certification under his [NAME] name and the payroll person noted the name was his [NAME] name on top of his certifications. There was no marriage license found in his employee file. 2. On 5/30/24 at 1:15 p.m., Employee 1's file was reviewed and there were no completed and signed job specific orientation checklists signed by the trainer and employee, for his CNA or QMA job titles. Those job specific orientation checklists were requested from the Nursing Clinical Specialist. An employee profile indicated, on 11/15/24, he was hired as a Certified Resident Care Associate or a CNA. An employee profile indicated, on 11/21/24, his job was reclassified to a Certified Resident Medication Assistant or a QMA An employee profile indicated, on 12/20/24, he was terminated for unsatisfactory Medication Assistant performance. Employee 1's IN Licensed Package background check had his name on it. There was a red flag on the subject data which indicated he went by another name as well. That name he went by was also on his social security card. All the other areas of the background check he passed with his name and social security number, including the Professional Licensing section. Under the Professional Licensing section there were some research history notes, which were as follows: Tuesday 11/7/23 at 6:29 a.m., problem notification sent to client/applicant services Wednesday 11/8/23 at 11:48 a.m., organization uses automated system-processing request Wednesday 11/8/23 at 11:48 a.m., quality control review A document, titled Employee Corrective Action Form, dated 12/5/23 and signed on 12/7/23, indicated Employee 1 was being given a verbal warning for his job performance. On 12/5/23, after he left the facility for the day, it was brought to the Director of Nursing and the Executive Director's attention Employee 1 failed to perform his duties as a CNA, worked within his scope of practice only, and followed the direction of the nurse on duty or any other member of management and nursing supervision. He was expected to pick up room trays, linens, and trash at the end of each shift, per policy. Failure to do so would result in further corrective, progressive disciplinary action, up to and including termination from employment with the campus. A document, titled Personnel Action Form, dated 12/14/23, indicated Employee 1 was suspended due to poor interaction with peers, poor patient care, and poor job performance. A document, titled Personnel Action Form, dated 12/21/23, indicated Employee 1 was terminated for unsatisfactory performance and he was not eligible for rehire. On 5/30/24 at 1:37 p.m., the Nursing Clinical Specialist provided a blank copy signed by Employee 1 of the Job Specific Orientation Checklist for the QMA position at that time. She indicated this copy had been uploaded onto the computer, so it was not in his employee file. The facility did not have the signed copy with the trainer's initials showing what he had been checked off on thus far because the employees kept the signed original copies with them until the orientation was complete. When they were all checked off, their trainer signed his or her name and the employee handed the paper in to be uploaded to their file. All new employees signed a blank job specific orientation checklist for each job description when they were hired, then it was uploaded into the computer in their file. There was no CNA job specific orientation checklist provided at that time. The deficient practice was corrected by 5/18/24, after the facility implemented a systemic plan that included the following actions: A house wide audit of all employees' records checking all licenses and certifications back to 11/15/23 was completed. An audit was to be completed by the ED on 5 new employee records, if available, to ensure licenses and certifications and names matched. The payroll person would audit 100% of new hires for valid and matching names with certifications and licenses and any concerns will be brought to the ED. This citation relates to Complaint IN00435005. 3.1-14(s)

Based on interview and record review, the facility failed to ensure staff followed the physician's order for a resident on a mechanical soft diet when the wrong texture of the diet was provided and failed to provide assistance with meals which resulted in a resident choking for 1 of 4 residents reviewed for dietary requirements. (Resident B) This deficient practice resulted in Resident B's death. The Immediate Jeopardy began on [DATE], when it was identified Resident B was provided a regular diet in place of a mechanical soft diet. Resident B choked on her dinner, was provided the Heimlich Maneuver, lost consciousness, and expired in the facility. The Executive Director (ED), Director of Health Services (DHS), and the Clinical Support Nurse were notified of the immediate jeopardy on [DATE] at 11:48 a.m. The Immediate Jeopardy was removed and the deficient practice corrected on [DATE] prior to the start of survey and therefore was past non-compliance. Finding includes: An Indiana Department of Health (IDOH) incident report, dated [DATE], indicated Resident B experienced a change in condition upon leaving the dining room, on [DATE]. The report indicated the resident appeared to be blue in color and was alert and able to speak with staff prior to the event. The resident choked on food during the evening meal, the Heimlich Maneuver (a first-aid procedure for dislodging an obstruction from a person's windpipe) was unsuccessfully performed, the resident lost consciousness, and emergency services (EMS) was contacted. The clinical record for Resident B was reviewed on [DATE] at 12:35 p.m. The diagnoses included, but were not limited to, dysphagia (difficulty swallowing), dementia, and mild cognitive impairment of uncertain or unknown etiology. The resident was admitted to the facility on [DATE]. A hospital Speech Therapy (ST) evaluation, dated [DATE], indicated the ST recommendations were for a soft and bite sized diet with thin liquids and medications crushed in puree or as tolerated. Per husband, the patient had a history of dysphagia including pocketing and occasional choking of solid foods. During the evaluation, the patient ate at a rapid rate and benefited from verbal and tactile cueing to slow her pace. Recommend soft and bite sized diet with thin liquids and 1:1 assistance for pacing strategies when family was not present. Patient had a history of choking with solids and her husband had completed the Heimlich once due to choking. A physician's order, dated [DATE], indicated the resident was to have a mechanical soft diet with thin liquids. A profile care guide, initiated on [DATE], indicated the interventions included, but were not limited to, mechanical soft diet with thin liquids, eating supervision/assist of (1) one, and the resident pocketed food in her mouth at times. A care plan, initiated on [DATE], indicated the resident was at risk for aspiration due to having a swallowing problem related to dysphagia and pocketing food in her mouth. The goal was the resident would not choke, aspirate, or have adverse effects while consuming food or liquids. The interventions included, but were not limited to, diet as ordered. A care plan, initiated on [DATE], indicated the resident had impaired cognition with associated short term memory impairment and was at risk for confusion, disorientation, altered mood, and impaired or reduced safety awareness related to dementia. The goal was that the resident would remain safe and not injure herself secondary to impaired decision making. Interventions included, but were not limited to, providing cues and supervision for decision making. A care plan, initiated on [DATE], indicated the resident had a potential for alteration in nutritional status. Interventions included, but were not limited to, assisting with meals as needed and providing the diet as ordered. A care plan, initiated on [DATE], indicated the resident had a potential for mouth pain. Interventions included, but were not limited to, to observe and report difficulties chewing and swallowing, and to observe for the need to change diet consistency to increase the ease of eating. A Minimum Data Set (MDS) scheduled 5-day assessment, dated [DATE], indicated the resident was severely impaired cognitively, held food in her mouth/cheeks or had residual food in her mouth after meals. It also indicated the resident had a mechanically altered diet and required supervision or touching assistance for eating. A nursing progress note, dated [DATE] at 6:20 p.m., indicated LPN 6 was alerted by a CNA, the resident was choking. Upon entering the unit, LPN 6 observed another nurse administering the Heimlich Maneuver on the resident. Her face was purple, lips were blue, and her eyes were rolled in her head. Another nurse swept the resident's mouth and there was food removed. LPN 6 attempted the Heimlich Maneuver but was not successful in clearing the airway. The resident was moved to her room, the nurse swept the resident's mouth, and removed food from the oral cavity. A suction machine was retrieved, and suction attempted, however the resident remained purple in color. LPN 6 and another nurse assessed for a pulse, but the resident was found to be without a pulse. Emergency Medical Services arrived and assessed for a pulse, but no pulse was found. In a facility witness statement, dated [DATE], Scribe 4 indicated she was sitting at the nurses' station reviewing paperwork sometime around 5:45 p.m., to 5:55 p.m. She heard LPN 8 say she's choking, she's choking. They both ran to the area where staff were surrounding the resident. Scribe 4 observed the resident to be off colored with a blue hue. She observed LPN 8 begin to provide the Heimlich Maneuver. She overheard Cook 7 call 911. She looked up the resident's code status and informed the nurse the resident was a do not resuscitate. When she returned to the scene, CNA 6 was observed to be holding a piece of silverware and was attempting to clear food from the resident's mouth. LPN 8 had left the scene to obtain the crash cart and suction machine. Upon LPN 8's return she told CNA 6 to stop and move away from the resident. CNA 6 did not stop after being told to stop. Scribe 6 observed food coming from the resident's mouth and described it as chunky but unidentifiable other than bread and something she believed to be fruit. In a facility witness statement, dated [DATE], CNA 6 indicated she observed the resident being taken towards the hallway and heard them ask where the nurse was because someone was choking. CNA 6 approached them, and noted the resident was slightly blue in color. CNA 6 began the Heimlich Maneuver and CNA 3 assisted in getting food out of the resident's mouth. Mostly fruit was coming out, a grape was identified. Other food had been chewed and was not identifiable. LPN 8 came and took over doing the Heimlich and brought a suction machine. In a facility witness statement, dated [DATE], CNA 9 indicated she observed CNA 3 take the resident toward her room. She observed LPN 6 performing the Heimlich Maneuver and CNA 3 performing a sternal rub. The resident was more purple/blue in color than white, and she noticed chunks of food being swept from the resident's mouth. She was not able to identify the food. In a facility witness statement, dated [DATE], Cook 7 indicated she was the cook for the evening shift and did not observe the resident when she arrived in the dining area, as she was preparing meals. Cook 7 took a break, around 5:45 p.m., when she returned to the dining room CNA 3 alerted her to the resident's condition. She noticed the resident's mouth was full of food, she was shaking, and had signs of choking. CNA 3 remained with the resident while the cook ran to the hall and yelled for help. The Heimlich Maneuver was started on the resident. A nurse called out to call 911 and Cook 7 did. Cook 7 indicated meal service began at 4:30 p.m., Resident B had a hamburger with cheese and French fries. The cheeseburger had been quartered for smaller bites. A hamburger patty had been used for the meal. Cook 7 indicated a red meal ticket indicated a special/altered diet. She put the food on the resident's plate. The resident's meal did not include green beans and the meal was prepared per the meal ticket. There were no toppings with the cheeseburger because they were not mechanically soft. In a witness statement, dated [DATE], LPN 6 indicated she was on break when a CNA came to her and said, they need you, one of your resident's is choking. LPN 6 indicated she came back into the facility and found LPN 8 doing the Heimlich on the resident. LPN 8 then went to sweep food out of the resident's mouth and LPN 6 took over the Heimlich. LPN 6 indicated when clearing the airway, a large, chewed chunk of bread and meat, pineapple chunks and other melons were noted. The bread and burger were chewed up and hard to distinguish, but the fruit was unchewed and identifiable. In a witness statement, dated [DATE], CNA 3 indicated she went into the dining room to see which residents needed assistance leaving the dining room after the meal service. She noticed Resident B was attempting to get fruit out of her fruit cup, so she stayed in the dining room with the resident. She noticed the resident's C-collar was dirty and assisted to clean the resident up. CNA 3 indicated it seemed food was falling out of the resident' mouth so she cleared the food away. CNA 3 went to the drink station to fill up a cup and when she turned back around, Resident B was attempting to fork fruit and put it in her mouth and CNA 3 felt her motions seemed off. CNA 3 noted cantaloupe fruit in the resident's mouth and attempted to remove it. CNA 3 noticed the resident had a blue-ish hue to her and was shaking. CNA 3 took the resident in her wheelchair quickly towards the hall where she resided. CNA 3 indicated she helped clear fruit from the resident's mouth while the nurse was doing the Heimlich. She was not able to quantify how much food was cleared from the resident's airway, but it seemed like a decent amount and the majority was fruit. She saw the resident's plate in the dining room and the resident had a cheeseburger cut into quarters on her plate. The resident had consumed 2 quarters of the cut-up cheeseburger. In a witness statement, dated [DATE], LPN 8 indicated when she arrived at the resident, she was blue in color. CNA 3 had what looked like a piece of silverware and was sweeping the resident's airway of visible food. LPN 8 told CNA 3 to stop, and LPN 8 began the Heimlich. Food immediately started to come out. LPN 8 pulled what looked like unchewed chunks of bun out of the resident's mouth. A coroner's report, dated [DATE] and received on [DATE] at 2:34 p.m., indicated the cause of death was from choking due to food bolus at the vocal cord level obstructing the airway. The bolus was described firmly impacted ground red meat and bread material. During an interview, on [DATE] at 3:09 a.m., the Corporate Support Nurse indicated the physician's ordered diet had not been followed for Resident B. During an interview, on [DATE] at 3:29 p.m., CNA 5 indicated at about dinner time, a CNA and a dietary employee came to the unit with a resident. The resident was looking blueish. CNA 5 ran to the resident and began the Heimlich Maneuver. Some of the stuff came out of her mouth like fruit, a grape, and some food which was soft and mashed up. During that time, another nurse from the other unit took over and suctioned the resident and CNA 5 left the room. During an interview, on [DATE] at 3:56 p.m., Cook 7 indicated at the time of the incident she had completed meal service, returned from her break, and was delivering employee meals. CNA 3 said What's wrong with her. Resident B was shaking and had food in her mouth. It looked like she was choking, so Cook 7 went to get a nurse. She returned to the dining room and CNA 3 was taking Resident B to the other nursing station. Cook 7 called 911. She indicated Resident B had been served a hamburger with French fries for the meal. Cook 7 indicated the hamburger was cut into smaller pieces and to her knowledge that was mechanical soft. She indicated she knew now mechanical soft meant to grind up the meat and a mechanical soft diet also required the use of canned fruit, not fresh. During a telephone interview, on [DATE] at 4:23 p.m., CNA 3 indicated she was in the dining room to return residents to their units. There were only two residents left, one of which was Resident B. Cook 7 said she would assist the other resident. When CNA 3 turned around and observed Resident B jabbing her fork into a fruit cup. It was grapes, pineapple, and cantaloupe. Cook 7 indicated the resident's mouth was blue. They both ran to the resident. She had a piece of cantaloupe stuck in her mouth. CNA 3 hit her back and the cantaloupe flew out. She then grabbed the resident and took her to a nurse who began the Heimlich Maneuver. CNA 3 indicated she grabbed a spoon to scoop food out the resident's mouth because the finger sweep was not getting the food. The resident had a lot of food in her throat. A whole grape, pineapple, a whole French fry, and hamburger which was chunky came out. It was like she did not even chew the food and just swallowed it. During an interview, on [DATE] at 9:16 a.m., the Director of Food Service indicated the only canned fruit the facility used were pears and peaches. The facility dd not have mixed canned fruit with pineapple, grapes, and melon. During an interview, on [DATE] at 10:02 a.m., the Speech and Language Pathologist (SLP) indicated she had worked with Resident B for swallowing and cognition. She had seen the resident for meals; sometimes breakfast, sometimes lunch, but she was not in the facility for dinner. She described the resident as impulsive. She would take large bites when she should have been taking small ones and was very fast with eating, even with maximum cueing. It was difficult for Resident B to follow directions due to her severe dementia. Cueing included telling the resident to take smaller bites, alternate her liquids with food, to slow down, and to make sure no residual food was in her mouth. Typically, she had a lot of residual food in her mouth. The SLP indicated the recommendation from the hospital was a mechanical soft diet. She described a mechanical soft diet as soft texture food which would exclude anything that needed to be really chewed like nuts, hard vegetables, fried bread, toast, and meat. Meat needed to be ground up. They could have fruit, but no grapes due to the skin. Pineapple and melon would have to be small pieces. It was recommended, typically, for residents on a mechanically altered diet to have supervision, preferably sitting with the resident if they were impulsive like Resident B. The recommendation for supervision with dining would be verbally relayed to the Director of Nursing, Assistant Director of Nursing or the CNAs as the facility did not want speech therapy to add the order. The order would be added by the nursing staff. A facility meal ticket, titled Wednesday-Dinner Daily Special, received from the Director of Nursing on [DATE] at 12:50 p.m., indicated Resident B was to receive a mechanical soft diet consisting of a burger and fries. The meal ticket was red. A facility document, titled Inservice Topic: Altered Diets and Resident Meal Service, dated [DATE] and received from the Director of Nursing on [DATE] at 12:50 p.m., indicated .Colored meal tickets mean there was an altered diet, liquid, major allergy, etc A facility document, titled Trilogy Health Service Mechanical Soft Cheat Sheet, dated as reviewed and approved on ,d+[DATE] and received from the Director of Nursing on [DATE] at 12:50 p.m., indicated .Meats .All meats are ground .All ground meats should have gravy/sauce .No fresh fruit (may have bananas, canned fruit) .No Coated/battered French Fries (May have Soft or Crinkle cut-no hard, burnt or crispy ends) A facility document, titled Guidelines for Meal Service, dated as last reviewed on [DATE] and received from the Executive Director on [DATE] at 3:46 p.m., indicated .Staff will be available to assist with .eating A facility document, titled Comprehensive Care Plan Guideline, dated as last reviewed on [DATE] and received from the Executive Director on [DATE] at 3:45 p.m., indicated .PURPOSE .To ensure appropriateness of services and communication that will meet the resident's needs, severity/stability of conditions, impairment, disability or disease in accordance with state and federal guidelines A facility document, titled Meal Service, dated as last revised ,d+[DATE] and received from the Director of Nursing on [DATE] at 12:50 p.m., indicated .Staff will assist the individual as needed A facility document, titled Abuse and Neglect Procedural Guidelines, last reviewed on [DATE] and received from the Executive Director on [DATE] at 9:36 a.m., indicated .DEPRAVATION OF GOODS AND SERVICES BY STAFF: staff has the knowledge and ability to provide care and services, but choose not to do it .which result in care deficits to a resident(s) .ADVERSE EVENT-An adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof .UNUSUAL DEATH-means the death of a resident that is unusual and/or the result of an accident .NEGLECT-is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm The Past Noncompliance Immediate Jeopardy began on [DATE] The Immediate Jeopardy was removed and corrected by [DATE], after the facility implemented a systemic plan which included the following actions: a full investigation of the incident to include witness statements, staff in-service education on altered diets and meal service, placement of suction machines in the dining room(s), all residents with mechanically altered diets were audited with the tray cards (meal tickets) for accuracy and the residents had assessments both of oral and respiratory systems to include vital signs and oxygen saturation readings, audits to ensure altered diets were being followed appropriately, and education to the Dietary Supervisor related to having the spreadsheets and recipe book accessible at all times on the cook's line. 3XXX,d+[DATE](a) 3XXX,d+[DATE](h) 3XXX,d+[DATE](i)(4)

Based on interview and record review, the facility failed to protect a resident from misappropriation of property, specifically medications, when the facility discovered the resident was missing 12 oxycodone (a narcotic) from the narcotic box for 1 of 3 residents reviewed for misappropriation of property. (Resident C) The deficient practice was corrected by 2/15/24 prior to the start of survey and was therefore past noncompliance. Finding includes: An Indiana Department of Health (IDOH) incident report, dated 2/10/24, indicated a resident was noted to have 12 missing oxycodone 10/325 milligrams (mg). The resident had an order for the administration of the medication one tablet, twice a day. The clinical record for Resident C was reviewed on 2/21/24 at 12:08 p.m. The diagnoses included, but were not limited to, spinal stenosis cervical region (the neck area of the spine), other cervical disc degeneration, and weakness. A physician's order, initiated on 10/03/23, indicated to give oxycodone/acetaminophen 10/325 mg one tablet twice a day for pain. A facility witness statement, dated 2/10/24, indicated QMA 5 counted the narcotics and received the medication cart from the day shift nurse. The count was correct. She administered the resident's pain medication and signed it out on the narcotic count sheet. She removed one card and documented on the back of the narcotic sheet the card had been removed. She could not recall if she counted the narcotics with the staff member coming on for the next shift. There was a handwritten addendum, dated 2/15/24, which indicated .On shift-to-shift count sheet, I wrote -1. The -2 written over it was not written by me The statement was dated 2/15/24 and signed by QMA 5. A facility witness statement, dated 2/10/24, indicated RN 11 came in at 10:00 p.m., and took over both medication carts on the unit. She did not count the carts. The QMA told her the count was okay and gave her the keys. She did not administer any medications to the resident during the night. The resident's spouse usually asked for a pain pill about 1:00 a.m. She documented on the narcotic sheet she had removed one card and one sheet because she thought she would be administering the medication from the card which contained one tablet. The resident's spouse did not request the pain medication, and RN 11 forgot to correct the numbers on the narcotic count sheet. She did count the cart with the day shift on-coming nurse and the count was correct based on the number of cards and sheets. During an interview, on 2/23/24 at 3:19 p.m., the Director of Nursing indicated the facility did not know what happened to the narcotics. During an interview, on 2/23/24 at 3:19 p.m., the Corporate Support Nurse indicated the narcotics and the narcotic sign-off sheet had not turned up. During an interview, on 2/23/24 at 3:30 p.m., QMA 5 was unable to say why she did not count the narcotics with RN 11 for the shift change to hand off the medication cart. During a telephone interview, on 2/23/24 at 5:12 p.m., RN 11 indicated there were usually two nurses/QMAs on the unit and the nurse left after counting with the QMA. The nurse gave her keys, to the QMA. RN 11 indicated QMA 5 told her the cart was good and without counting the cart she accepted the keys and the carts. RN 11 indicated it was totally her fault and she had learned to count the cart. It would never happen again. A facility policy, titled IIA7: CONTROLLED SUBSTANCES, dated as last revised 11/18 and received from the Executive Director on 2/21/24 at 12:24 p.m., indicated .Accurate accountability of the inventory of all controlled drugs is maintained at all times. When a controlled substance is administered, the licensed staff member administering the medication immediately enters the following information on the accountability record and the medication administration record .Date and time of the administration .Amount administered .Remaining quantity .Initials of the staff member administering the dose, completed after them medication is actually administered A facility policy, titled Guidelines for Narcotic Count, dated as last reviewed 12/31/23 and received from the Executive Director on 2/21/24 at 12:24 p.m., indicated .At the time one nurse or other staff qualified to pass medications relinquishes the keys to the medication cart to another staff member the narcotic shall be reconciled by comparing the medication in the cart to the count sheets This deficient practice was corrected by 2/15/24, prior to the start of the survey and was therefore past non-compliance. The facility investigated the missing narcotics, suspended QMA 5, RN 11 and LPN 12 pending the investigation and drug testing. Staff received in-service on narcotics on 2/12/24 and an audit of all PRN (as needed) pain medications documented in the Medication Administration Record began on 2/10/24. All drug test results were completed on 2/15/24. This citation relates to complaint IN00428611. 3.1-28(a)

Based on record review and interview, the facility failed to ensure a resident was free from verbal abuse when a staff member was heard speaking to a resident loudly and using profanity for 1 of 3 residents reviewed for abuse. (Resident 2) This deficient practice was corrected on 12/26/23, prior to the start of the survey, and was therefore past noncompliance. Finding includes: An incident report to the Indiana Department of Health, dated 12/25/23, indicated a nurse heard a verbal altercation between an employee and a resident. The record for Resident 2 was reviewed on 1/2/24 at 11:51 a.m. Diagnoses included, but were not limited to, dementia, anxiety, and weakness. Resident 2 admitted to the facility on [DATE] and discharged to another facility on 12/29/23. Resident 2 had a Brief Interview for Mental Status completed on 12/19/23 and scored a 12 indicating he was moderately impaired mentally. A facility document, titled .Statement of Witness Form for Resident 2, dated 12/25/23, indicated the male aid was pushy. He was not very nice, and he was harsh with him (Resident 2) while in the shower. A facility document, titled .Statement of Witness Form for Dietary Aide 2, dated 12/25/23, indicated Dietary Aide 2 heard CNA 2 using profanity while talking to a resident. Another staff member tried to calm the CNA down. Dietary Aide 5 heard CNA 2 say .I'm tired of this s**t He also heard the CNA say to Resident 2 .F**k that. I already got him together in the shower As CNA 2 was walking away Dietary Aide 5 told him to calm down, he should not talk to residents that way and he could lose his license/certification. The CNA responded he did not .give a f**k A facility document, titled .Statement of Witness Form for CNA 8, dated 12/25/23, indicated CNA 8 was sitting at the desk charting and heard the nurse asked CNA 2 to get residents' weights. CNA 2 stated .Y'll are getting on my d**n nerves with this Resident 2 wheeled around the corner and CNA 2 said .Hell, I guess I'll get him CNA 2 grabbed Resident 2's wheelchair, Resident 2 yelled out .Hey, what's going on? CNA 2 responded .you don't ask what I am doing The nurse told CNA 2 not to talk to residents like that and the facility was the home of the residents. The CNA responded .Yeah, he learned his lesson in the shower today, didn't you? The nurse removed Resident 2 from the CNA for resident's safety and another nurse sent CNA 2 home. A facility document, titled .Statement of Witness Form for LPN 9, dated 12/25/23, indicated LPN 9 heard CNA 2 speaking loudly. He was getting residents' weights and was transferring Resident 2 from the wheelchair to the weight chair but was not telling the resident what he was doing. CNA 2 raised his voice and said to the resident .just get your a*s over here in this chair. You tried your luck with me this morning in the shower. Didn't you learn from that? LPN 9 and another nurse told CNA 2 to stop, then removed Resident 2 from the CNA. CNA 2 was told to clock out and leave the facility. CNA 2 went to the nurse's desk to chart. LPN 9 then called the Director of Nursing. There were no other residents near CNA 2 while he was at the desk. A facility document, titled .Statement of Witness Form for LPN 10, dated 12/25/23, indicated LPN 10 observed CNA 2 getting residents' weights. She heard CNA 2 tell Resident 2 to get his a*s in the chair. She told the CNA not to curse at the resident, she would take over care of the resident and told the CNA to clock out and go home. The CNA went to the desk and began to chart, Nurse 10 told him it would be best for him to clock out and go home. CNA 2 apologized for his behavior and then left the facility. She notified the Director of Nursing. A facility document, titled .Statement of Witness Form for CNA 2, dated 12/26/23, indicated he was giving Resident 2 a shower and the resident grabbed the shower head and sprayed him. Resident 2 continued to make the shower difficult. He told the resident to .stand here and be still and take this shower The resident began yelling and screaming at the CNA and he was getting bowel movement/feces everywhere. A document, titled Timeline of Events, dated 12/25/23, indicated at 11:30 a.m., the nurse asked CNA 2 to get residents' weights. Without telling Resident 2 what he was doing, CNA 2 told the resident to get his a*s in the chair and then stated, you tried your luck with me this morning in the shower, didn't you learn anything from that? Safety was provided to Resident 2 and CNA 2 was asked to leave. The CNA went to the nursing station. At 11:45 a.m., the Director of Nursing was notified and informed CNA 2 would not leave. All residents were accounted for and safe. At 11:50 a.m., the Director of Nursing contacted CNA 2 and asked him to leave the facility, he exited the campus at 11:55 a.m. At 12:05 p.m., staff statements were initiated. A head-to-toe assessment was completed on Resident 2 at 12:10 p.m. The resident was interviewed at 2:30 p.m., and another head-to-toe assessment was completed. Other residents were interviewed and assessed at that time. The responsible party and physician were notified at 5:00 p.m. At 6:00 p.m., all staff in-service on abuse and resident rights was initiated. On 12/26/23 all statements and assessments had been completed. Social Services had completed mental anguish assessments, CNA 2 was terminated from employment at 3:00 p.m., the police had been notified at 3:15 p.m., and the facility received a case number. CNA 2 was terminated from employment, on 12/26/23, for verbal abuse and gross misconduct. During an interview, on 1/2/24 at 1:38 p.m., LPN 3 indicated abuse could be verbal, physical, sexual, emotional, and financial. All abuse needed to be reported immediately. She indicated she was recently re-educated on abuse and abuse reporting. During an interview, on 1/2/24 at 1:43 p.m., QMA 6 indicated staff was re-educated on abuse about a week ago. Abuse could be verbal, physical, sexual, emotional, or as misappropriation of the residents' belongings. During an interview, on 1/2/24 at 1:48 p.m., Physical Therapist (PT) 7 indicated he was contracted staff and he needed to follow the facility policies. He was educated on abuse and indicated abuse was physical, verbal, misappropriation of resident belongings or financials or emotional. Abuse needed to be reported immediately. During an interview, on 1/2/24 at 2:09 p.m., Dietary Aide 5 indicated he was on the Keystone Unit stocking snacks by the refrigerator. He heard CNA 2 say, to Resident 2, he was tired of this s**t and he did not give a F**k. He attempted to talk to CNA 2 and told him to calm down; he could lose his license/certification. CNA 2 told him he did not care. Dietary Aide 5 then returned to the kitchen and reported the incident to his immediate supervisor. A facility policy, titled Abuse and Neglect Procedural Guidelines, dated as last updated 6/2023 and received from the Corporate Support Nurse on 1/2/24 at 10:16 a.m., indicated .Verbal Abuse .includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability A facility policy, titled Resident Rights Guidelines, dated as last reviewed on 12/31/22 and received from the Corporate Support Nurse on 1/2/24 at 3:37 p.m., indicated .Our residents have the right to be .treated with respect and dignity .Be free of .verbal .abuse This deficient practice was corrected on 12/26/23, after the facility implemented a systemic plan which included the following actions: they completed interviews of staff who were witness to the incident, conducted assessments and interviews of residents residing on the unit, provided abuse and resident right training to employees, Social Services conducted mental anguish assessments, CNA 2 was terminated, and a police report was filed. 3.1-27(b)

Based on observation, interview and record review, the facility failed to provide toileting assistance when a resident had asked for assistance to use the toilet for 1 of 1 resident reviewed for Activities of Daily Living (ADL) care. (Resident 3) Finding includes: During an observation, on 1/2/24 at 2:39 p.m., Resident 3 was in an activity, painting a wooden Christmas tree. She was sitting in a wheelchair, clean and dry. She had an apron over her clothing and was actively engaged in the activity. During an observation, on 1/2/24 at 3:39 p.m., Resident 4 was in an activity, painting a wooden Christmas tree. She was sitting in a wheelchair, next to Resident 3. She was clean and dry and was actively engaged in the activity. During an interview, on 1/2/24 at 2:13 p.m., CNA 4 indicated on 12/24/23, Resident 3 reported to her she had requested assistance to use the toilet and CNA 2 told her to use her brief. CNA 4 indicated she reported the conversation to the Director of Nursing, also wrote a statement, and put it under the Director of Nursing's door. During an interview, on 1/2/24 at 2:42 p.m., Resident 4 indicated she was blind. She heard her roommate, Resident 3, ask CNA 2 if she could get up and go to the restroom. CNA 2 responded for her to go in her pants, and he would change her later. She then indicated it sounded as if he walked quickly, the pace was quick, then she heard the door shut and she did not hear his voice in the room anymore. During an interview, on 1/2/24 at 2:50 p.m., Resident 3 indicated CNA 2 told her No when she asked to use the toilet and told her to use her brief. She indicated it made her feel like dirt. The record for Resident 3 was reviewed on 1/2/24 at 340 p.m. Diagnoses included, but were not limited to, Alzheimer's dementia, aphasia (difficulty speaking), and traumatic brain dysfunction. A Brief Interview for Mental Status (BIMS) was completed, on 12/12/23, and the resident scored a 15 (resident was alert and oriented). The OBRA assessment, completed on 12/12/23, indicated the resident required moderate assistance to use the toilet with a helper/assistant and did most of the work. The record for Resident 4 was reviewed on 1/2/24 at 3:37 p.m. Diagnoses included, but were not limited to, anxiety, depression, and end stage renal disease. The resident had a BIMS score of 15 on 12/5/23. A handwritten document, dated 12/24/23, indicated the staff member was called to Resident 3's room as a witness to the resident's statement. The resident told two (2) staff members she had activated her call light to go to the bathroom and CNA 2 came in. CNA 2 told the resident to go in her brief. The resident's roommate, Resident 4, told CNA 4 she did hear the conversation between Resident 3 and CNA 2. The document was signed by CNA 4. During an interview, on 1/2/24 at 2:59 p.m., the Director of Nursing indicated she was notified of the incident where CNA 2 had told Resident 3 to use her brief to relieve herself. She did receive a statement from a staff member. A facility document, titled Certified Resident Care Associate (CNA/STNA/SRNA/CENA) Expectations of Excellence, dated 4/29/10 and received from the Corporate Support Nurse on 1/2/24 at 10:51 a.m., indicated .If a resident .needs assistance, help then get the assistance they need A facility policy, titled Resident Rights Guidelines, dated as reviewed on 12/31/23 and received from the Corporate Support Nurse on 1/2/24 indicated .Residents shall not leave their .basic human rights behind when they move to a health campus .Our residents have a right to .Be treated with dignity and respect .Be treated fairly, courteously and with respect by staff A facility policy, titled Abuse and Neglect Procedural Guidelines, dated as reviewed on 8/29/19 and received from the Corporate Support Nurse on 1/2/24 at 10:51 a.m., indicated .Neglect .the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid .mental anguish or emotional distress 3.1-38(a)(2)(C)

Based on record review and interview, the facility failed to ensure the discharge MDS (Minimum Data Set) assessment was coded correctly for 1 of 1 resident reviewed for hospital discharge. (Resident 54) Findings include: The record for Resident 54 was reviewed on 11/16/23 at 12:41 p.m. Diagnoses included, but were not limited to, acute respiratory failure with hypoxia, pleural effusion (fluid in the lining of the lungs), morbid obesity, cardiomegaly (enlarged heart), paroxysmal atrial-fibrillation (irregular heart beat), pulmonary hypertension (condition which affects the vessels in the lungs), fibromyalgia, COPD (Chronic Obstructive Pulmonary Disease), chronic diastolic heart failure, and CKD (Chronic Kidney Disease) stage 3. A progress note, dated 10/26/2023 at 1:42 p.m., indicated the resident was discharged to another skilled nursing facility. An MDS assessment, dated 10/26/23, indicated the MDS was coded to reflect a discharge to a short-term general hospital. During an interview, on 11/20/23 at 10:28 a.m., the MDS Coordinator indicated the discharge MDS assessment was incorrectly coded, and the facility followed the RAI (Resident Assessment Instrument) manual. A current, RAI Manual, Version 1.17.1, October 2019, indicated .entry and discharge reporting MDS assessments and tracking records that include a select number of items from the MDS used to track residents and gather important quality data at transition points, such as when they leave a nursing home or when a resident's Medicare Part A stay ends, but the resident remains in the facility .entry/discharge reporting includes entry tracking record, OBRA (omnibus reconciliation act) discharge assessments, Part A PPS (prospective payment system) discharge assessment, and death in facility tracking record 3.1-31(b)

Based on record review and interview, the facility failed to ensure a PASARR (Preadmission Screening and Resident Review) Level I had accurate information and a Level I was completed when residents had an added mental health diagnosis and psychotropic medications prescribed for 2 of 2 residents reviewed for PASARR. (Resident 38 and 20) Finding includes: 1. The record for Resident 38 was reviewed on 11/14/23 at 4:09 p.m. Diagnoses included, but were not limited to, bipolar disorder, dementia, and anxiety disorder. The transfer paperwork from a previous long term care facility indicated the resident had been prescribed Risperdal (an antipsychotic medication) 1 mg (milligram) once a day starting on 11/10/22. A care plan, dated 12/6/22, indicated the resident presented with diagnoses of bipolar, anxiety, and depression which was treated with an antipsychotic medication. A PASARR Level I, dated 12/21/22, indicated the resident had no known or suspected mental health diagnoses, no diagnosis of dementia or neurocognitive disorder, no mental health symptoms, and no mental health medications were prescribed. The resident had been prescribed the Risperdal since 11/10/22 and this was not added to the PASARR Level I. A pharmacy recommendation, dated 1/22/3, indicated the resident had been receiving Risperdal since admission and needed an assessment for abnormal involuntary movement. A psychiatry note, dated 1/20/23, indicated the resident had a mood disorder and anxiety. The resident's bipolar disorder was improving but the anxiety and depression remained a problem. The medications included, but were not limited to, Risperdal 1 mg at bedtime. A physician's order, dated 9/24/23, indicated to give Risperdal at bedtime for bipolar disorder. During an interview, on 11/16/23 at 12:13 p.m., the Social Services Director (SSD) indicated it was a group effort with social services, admissions, and the Minimum Data Set (MDS) staff to make sure the PASARR process was completed for the residents. 46961 2. The record for Resident 20 was reviewed on 11/14/23 at 4:14 p.m. Diagnoses included, but were not limited to, dementia, schizoaffective disorder (a mental health disorder) bipolar type, and psychotic disorder (a mental health disorder) with delusions due to known physiological condition. A PASRR level 1, dated 11/20/2020, indicated no level II was required due to no significant mental illness, intellectual disability, or related condition. The listed diagnoses were dementia with psychotic disorder with delusions due to known physiological condition and major depressive disorder. The behaviors or symptoms listed were delusions or hallucinations. The outcome rationale indicated the level 1 screen did not identify a PASRR disability, because there was no evidence of a PASRR condition of intellectual/developmental disability or a serious behavioral health condition. If changes occur or new information refutes these findings, a new screen must be submitted. Although the diagnosis of major depression was reported further screening was not indicated at that time. A care plan, dated 10/16/22, indicated the resident presents with a diagnosis of schizoaffective disorder, bipolar type which was treated with anti-psychotic medication. The diagnosis list indicated schizoaffective disorder bipolar type, dated 6/1/23. A physician's order, dated 9/24/23, indicated Risperdal (an antipsychotic medication) 0.5 mg twice daily for schizoaffective disorder, bipolar type. During an interview, on 11/15/23 at 4:31 p.m., the Clinical Support Nurse indicated a new screen was not submitted for the changes of schizoaffective diagnosis and the antipsychotic medication. During an interview, on 11/17/23 at 11:35 a.m., the Clinical Support Nurse indicated the facility did not have a PASARR policy and utilized the state guidelines for PASARR. 3.1-16(d)(1)(B)

Based on interview and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice for 1 of 2 residents reviewed for catheter care. (Resident 44) Resident 44 was not provided care to address concerns which developed after a urinary catheter was placed which led to a hospitalization with intravenous antibiotic intervention for the development of urosepsis. Finding includes: The record for Resident 44 was reviewed on 10/21/22 at 1:39 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care area assessment (CAA), dated 9/28/22, indicated the resident had triggered for an indwelling catheter related to [CONDITION(S)], hematuria, urinary retention and CKD. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A Vitals Report, dated 9/24/22 to 10/24/22, indicated Resident 44 had the following recorded: On 9/29/22 at 4:32 p.m., a large amount of urine output was recorded. On 9/30/22 at 12:26 a.m., a large amount of urine output was recorded. On 10/1/22 at 5:50 a.m., 250 ml (milliliters) of urine output was recorded. On 10/1/22 at 1:47 p.m., 400 ml of urine output was recorded. On 10/1/22 at 9:17 p.m., 100 ml of urine output was recorded. On 10/2/22 at 5:05 a.m., 1000 ml of urine output was recorded. On 10/2/22 at 3:27 p.m., 800 ml of urine output was recorded. The documentation indicated the resident had a large output once on each day, of the 9/29 and 9/30, but lacked indication the resident had urine output the rest of the day. A nurse progress note, dated 9/22/22 at 5:34 p.m., indicated Resident 44 was admitted to the facility with a 16 French Foley catheter and had yellow urine. A physician's progress note, dated 9/23/22 at 10:51 p.m., indicated Resident 44 was admitted with a Foley catheter, to attempt a voiding trial and follow up with urology. A review of the nurse progress notes, from 9/29/22 at 8:15 p.m., until 10/1/22 at 4:55 p.m., indicated Resident 44 had no bladder scan completed, no assessment and no call to the provider to notify of concerns of decreased urine output. The staff did not document the voiding trial or when the catheter was removed or reinserted. A nurse progress note, dated 10/1/22 at 4:55 p.m., indicated Resident 44 had a distended abdomen, fever of 99.6 and was given Tylenol. Resident 44 had an in and out catheterization completed and resulted with 2200 ml of urine. The first 1000 ml of urine had been reported as gross hematuria (blood in the urine) and 1200 cc was reported as dark amber with a foul odor. A urine sample was obtained and on call provider notified. A nurse progress note, dated 10/1/22 at 6:22 p.m., indicated orders were received by the on call provider to re-anchor the Foley catheter. Resident 44 had a Foley 14 Fr 30 cc catheter anchored and had drained dark colored urine. A nurse progress note, dated 10/2/22 at 6:47 p.m., indicated Resident 44's temperature was 102.4 degrees Fahrenheit, was very lethargic, had poor appetite and a blood pressure of 102/58. He had a small amount of urine output in his Foley catheter bag and the family requested the resident be transferred to the hospital for evaluation and treatment. A Lab Report, dated 10/3/22, indicated on 10/1/22, a urine sample was collected. The results indicated his urine was positive for blood, protein, leukocytes and bacteria. His culture was positive for greater than 100,000 enterococcus faecalis bacteria. A hospital discharge summary, dated 10/8/22, indicated Resident 44 was hospitalized for the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse progress note, dated 9/29/22 at 8:15 p.m., entered as a late entry on 10/21/22 at 12:07 p.m., indicated Resident 44 had a Foley catheter removed without difficulty with no signs or symptoms of bleeding, pain or discomfort. During an interview, on 10/20/22 at 9:45 a.m., the Licensed Practical Nurse (LPN) 6 indicated if a resident did not urinate at least once in eight hours after the catheter was removed, the staff should notify the physician. The family had requested Resident 44 be transferred to the hospital for evaluation and treatment. During an interview, on 10/21/22 at 1:20 p.m., the Infection Preventionist (IP) indicated Resident 44 had a catheter in place and re-anchored. He developed Urosepsis and was admitted to the hospital. During an interview, on 10/21/22 at 2:00 p.m., the Clinical Nurse Support (CNS) indicated the staff should obtain specific instructions from the physician when an order to remove a catheter was received. Complications to urinary retention included, [CONDITION(S)], tearing of the bladder, pain and kidney failure. A current policy, titled Notification of Change in Condition, indicated the staff must inform the resident, physician, and resident representative when a change in the resident's physical, mental, or psychosocial status. 3.1-41(a)(2)

Based on observation, interview and record review the facility failed to implement measures to prevent an unstageable pressure injury from developing for a resident at know risk of pressure ulcer development, who developed a pressure ulcer that was not identified until it was an unstageable pressure ulcer for 1 of 6 residents reviewed for pressure ulcers. (Resident 14) Findings include: During an observation on 08/13/19 at 10:04 a.m., the pressure ulcer on the right heel had a small dark center with brownish discoloration at 6 o'clock, beneath the wound. The wound was approximately 0.5 centimeters by 1 centimeter. The record for Resident 14 was reviewed on 08/08/19 at 2:15 p.m. [DIAGNOSES REDACTED]. Admission documentation indicated Resident 14 readmitted to the facility on [DATE] after a surgical repair for a broken hip. A Braden Risk assessment (an assessment used for pressure ulcer predictability) was completed on 05/24/19 and Resident 14 had received a score of 14 which indicated she was at a moderate risk of incurring a pressure ulcer due to a slightly limited ability to respond, skin that is often moist, her ability to walk was severely limited and/or nonexistent, she was unable to make frequent or significant changes in per body positioning and she had a potential problem to acquire skin injury from friction and/or sheer. (injury from rubbing or pressure) There were no orders or notes to indicate preventative measures were utilized prior to the discovery of a right heel pressure ulcer on 07/20/19. Daily shower sheets, performed by the certified nursing assistants (CNAs), for the month of (MONTH) 2019, indicated no wounds were found on Resident 14's skin. The weekly skin assessments, preformed by licensed staffing, from (MONTH) 24th, 2019 to (MONTH) 20,2019, indicated no new areas were found on Resident 14's skin. An Admission Observation and Data Collection report provided by the Corporate Nurse Consultant, on 08/09/19, indicated the resident admitted with a skin impairment on 05/24/19. A Nursing Note, completed by the Assistant Director of Nursing (ADON) on 05/24/19 clarified the skin impairment to be a surgical incision to the right hip and lower extremity that was approximated (closed) with 12 staples. There were no other skin issues noted in the ADON's assessment. A Nurse's note dated 07/20/19, indicated an unstageable blackened area was found on the resident's right heel. At this time a treatment was provided and the heels were floated off of the bed with a pillow. In an interview with the ADON, on 08/14/19 at 8:32 a.m., she indicated a Braden score of 14 and indicated the resident was a risk for impaired skin integrity and warranted preventative measures having been put into place. Resident 14 was working with therapy so they did have interventions in place when she returned from the hospital. Also the CNAs filled out shower sheets and would have alerted the nurse's for any changes in the resident's skin and Nurses performed weekly skin assessments to ensure there were no signs of skin breakdown. The ADON indicated she understood preventative measures such as skin prep and prevalon boots were not put into place until after the pressure ulcer had already developed and the first time it was brought to her attention was on (MONTH) 20th, 2019. At that time the wound measured 1.4 centimeters long by 2.5 centimeters in width with 100 percent of the wound covered by eschar (dead tissue). In an interview with the Therapy Department Manager, on 08/14/19 at 8:54 a.m., she indicated off loading (keeping pressure off of an area of the body) was a nursing measure and therapy would not document or order it and there was no documentation of offloading heels while resident was in bed found in the therapy notes. In an interview with the Director of Nursing, on 08/14/19 at 10:39 a.m., she indicated the policy and/or procedure for an at risk Braden score should have been off load/float heels and to keep clean and dry. She indicated she would see if they had that information in a policy. A facility policy provided by the Corporate Nurse Consultant on 08/14/19, titled Guidelines for General Wound and Skin Care indicated, .Use pillows or wedges for positioning .Evaluate the need for .heel floats 3.1-40(a)