Every finding on record at Wellbrooke of Kokomo

Based on observation, interview and record review, the facility failed to ensure staff wore personal protective equipment correctly, isolation signage was posted, orders were followed and medication was destroyed after being dropped for 3 of 4 residents reviewed for infection control. (Resident 3, 74 and 32).Findings include:1. During an observation, on 2/19/26 at 11:47 a.m., Certified Nursing Assistant (CNA) 5 and the Assistant Director of Nursing (ADON) prepared to provide catheter care to Resident 3. The Assistant Director of Nursing and CNA 5 put on a gown and gloves, tied the top of the gown and did not fasten the tie around the waist. During the catheter care, CNA 5's gown opened and her clothes touched the resident's bed and blankets. During an interview, on 2/19/26 at 11:57 a.m., the ADON indicated her and CNA 5 did not tie the waste of their gowns and should have. CNA 5's gown was not covering her clothes during the resident's catheter care and CNA 5's pants touched the resident's bed. During an interview, on 2/19/26 at 11:58 a.m., CNA 5 indicated both ties on the gown needed to be tied to fully cover her clothes. During an interview, on 2/19/26 at 12:09 p.m., the Director of Nursing (DON) indicated a gown and gloves needed to be worn in the isolation rooms. The gowns should be tied in the back. A facility document, titled Guidelines for Donning and Doffing Personal Protective Equipment (PPE), indicated donning a gown you would select the appropriate type and size. With the opening in the back, secure the gown at the neck and waist. If the gown was too small for full coverage, use two; the first with the opening in the front and the second placed over with the opening in the back. 2. During an observation, on 2/16/26 at 10:36 a.m., Licensed Practical Nurse (LPN) 3 was preparing medication for Resident 74 and dropped a pill on the top of the medication cart. LPN 3 placed the pill in the resident's medication cup, walked to the room, and entered the resident's room. The observation was stopped; LPN 3 then returned to the medication cart and destroyed the pill. During an interview, on 2/16/26 at 10:39 p.m., LPN 3 indicated she was not thinking when she dropped the pill and placed it in the medication cup. During an interview, on 12/16/26 at 11:07 a.m., the Director of Nursing (DON) indicated the staff should destroy any pills dropped on the cart or anywhere. 3. The clinical record for Resident 32 was reviewed on 2/16/26 at 9:48 a.m. The diagnoses included, but were not limited to, urinary tract infection (UTI), Vancomycin-Resistant Enterococci (VRE), and metabolic encephalopathy. A physician's order, dated 12/16/26, indicated to flush the peripherally inserted central catheter (PICC) line with 10 cubic centimeter (cc) normal saline before and after medication twice a day. A physician's order, dated 2/19/26, indicated to administer Linezolid 0.9% Sodium Chloride (an antibiotic medication) 600 milligrams (mg)/300 milliliters (ml) intravenous (IV) every 12 hours for VRE UTI. A physician's order for contact precautions or enhanced barrier precautions was not located in the clinical record. During an observation, on 2/16/26 at 11:53 a.m., an enhanced barrier precautions or contact precautions sign was not found in or around the resident's room and the only personal protective equipment (PPE) found in the resident's room were gloves. During an interview, on 2/16/26 at 11:53 a.m., the Director of Nursing (DON) indicated the resident should have had enhanced barrier precautions in place for her PICC line and should have had contact precautions in place for her diagnosis of VRE. During an interview, on 2/19/26 at 11:33 a.m., QMA 9 indicated if a resident arrived from the hospital with a line (IV, Catheter, etc.) or a transmissible infection, the resident would be placed in enhanced barrier precautions or contact precautions, whichever was appropriate, as soon as they arrived to the facility. A current facility policy, titled Guidelines for Contact Precautions, dated 11/28/16 and received from the Clinical Support Nurse on 2/16/26 at 2:16 p.m., indicated .Contact precautions are indicated to prevent and control HAI (health-care associated infections) transmission of infection with any of the following: a. Vancomycin resistant enterococcus species. (VRE ).Precaution Sign: a. Post a sign at the resident's door that is appropriate according to CDC guidance. A current facility policy, titled Enhanced Barrier Precautions (EBP) Standard Operating Procedure, dated 4/1/24 and received from the Clinical Support Nurse on 2/16/26 at 12:56 p.m., indicated .Enhanced Barrier Precautions (EBP) will be in place during high-contact care activities for residents with the following conditions.All Residents with indwelling medical devices 1. Includes but not limited to: catheters, central lines.Personal Protective Equipment (PPE) should be used.at minimum, staff shall wear gloves and gowns during high-contact care activities. A current policy, titled Enhanced Barrier Precaution, dated 6/24 and provided by the Assistant Director of Nursing (ADON) on 12/6/24 at 3:00 p.m., indicated .Enhanced Barrier Precautions All residents with any of the following: Wounds .feeding tube, regardless of MDRO colonization status .Required PPE .Gloves and gown prior to the high contact care activity 3.1-18(b)(1) 3.1-18(b)(2)

Based on observation, interview and record review, the facility failed to ensure controlled substance medications were destroyed when compromised or no longer in use for 1 of 2 medication carts reviewed for medication storage. (100 hall front cart)Findings include:During an observation, on 2/16/26 at 10:45 a.m., the 100-hall front medication cart had two compromised controlled substance cards.a. A card of oxycodone (a narcotic pain medication) 5 milligram tablets for Resident 2 had clear tape covering the back of the number 4 and 5 slots.Resident 2 had discharged from the facility on 2/7/26 and the controlled substance card continued to be stored in the medication cart. During an interview, on 2/18/26 at 10:09 a.m., Qualified Medication Aide (QMA) 4 indicated when narcotic medications were discontinued the nurse and Director of Nursing (DON) would destroy the medication and not leave the medication in the cart.b. A card of Norco (a narcotic pain medication) 10/325 mg tablets for Resident 43 had a slit on the back of the card in the number 4 slot.During an interview, on 2/16/26 at 10:55 p.m., Registered Nurse (RN) 2 indicated the substance control cards should not be taped or have slits on the back of the cards. During an interview, on 2/16/26 at 11:07 a.m., the Director of Nursing (DON) indicated the staff should not tape the backs of the narcotics cards. The pills needed to be destroyed, it could be considered a drug diversion, and the medication could be a different pill.A current facility policy, titled Guidelines for Disposal of Controlled Drugs, dated as reviewed on 12/10/25 and received from the Executive Director on 2/20/26 at 9:10 a.m., indicated .When disposing of pharmaceutical controlled substances by transferring those substances into a collection receptacle, such disposal shall occur immediately, but no longer than three (3) business days after discontinuation of use by the LTCF resident. Discontinuation of use includes a permanent discontinuation of all as directed by the prescriber, as a result of the resident's transfer from the long-term care facility, or as a result of death.A current facility policy, titled Medication Storage In The Facility, dated as reviewed on 11/2018 and received from the Director of Nursing on 2/16/26 at 12:44 p.m., indicated .Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal 3.1-25(o)

Based on interview and record review, the facility failed to ensure a physician's order was followed according to the prescribed parameters and an Abnormal Involuntary Movement Scale (AIMS) assessment was completed for 3 of 7 residents reviewed for quality of care. (Resident 1, 37 and 4)Findings Include:1. The clinical record for Resident 1 was reviewed on 2/17/26 at 9:46 a.m. The diagnoses included, but were not limited to, sepsis, cardiomyopathies, combined systolic (congestive) and diastolic (congestive) heart failure, and hypertensive heart disease with heart failure.A care plan, dated 1/6/26, indicated Resident 1 had an impairment in functional status related to hypertension and cardiomyopathy. Interventions included, but were not limited to, administer medications as ordered.A physician's order, dated 2/12/26, indicated to administer hydralazine (a blood pressure medication) 100 milligrams (mg) three (3) times a day and to hold the medication if the systolic blood pressure was less than 140.The Medication Administration Record (MAR), dated 2/1/26 through 2/18/26, indicated hydralazine was administered when the systolic blood pressure was less than 140 on the following dates:a. On 2/12/26, the morning dose when the systolic blood pressure was 133.b. On 2/14/26, the morning dose when the systolic blood pressure was 121, the afternoon dose when the systolic blood pressure was 121, and the evening dose when the systolic blood pressure was 128.c. On 2/15/26, the morning dose when the systolic blood pressure was 131.d. On 2/16/26, the morning dose when the systolic blood pressure was 114 and the afternoon dose when the systolic blood pressure was 138.e. On 2/17/26, the evening dose when the systolic blood pressure was 111.f. On 2/18/26, the evening dose when the systolic blood pressure was 118.2. The clinical record for Resident 37 was reviewed on 2/17/26 at 9:55 a.m. The diagnoses included, but were not limited to, paroxysmal atrial fibrillation, chronic obstructive pulmonary disease, chronic diastolic (congestive) heart failure, and hypertensive heart and chronic kidney disease with heart failure.A care plan, dated 2/16/26, indicated Resident 37 had the potential for cardiovascular distress. Interventions included, but were not limited to, administer medications as ordered.A physician's order, dated 2/4/26, indicated to administer metoprolol succinate (a blood pressure medication) 25 mg at bedtime and to hold the medication if the systolic blood pressure was less than 110.The MAR, dated 2/1/26 through 2/19/26, indicated metoprolol was administered when the systolic blood pressure was less than 110 on the following dates:a. On 2/11/26, with a systolic blood pressure of 107.b. On 2/15/26, with a systolic blood pressure of 106.c. On 2/18/26, with a systolic blood pressure of 108.During an interview, on 2/18/26 at 3:14 p.m., the Director of Nursing (DON) indicated medications should not be administered outside of the ordered parameters.During an interview, on 2/19/26 at 11:20 a.m., Qualified Medication Aide (QMA) 9 indicated when a resident's blood pressure was outside of the parameters she would hold the medication. If a medication was held, it would show on the MAR with parenthesis around the initials of whoever held the medication and a reason for why it was held.During an interview, on 2/20/26 at 10:13 a.m., the Clinical Support Nurse indicated the facility did not have a policy specifically about medication parameters.3. The clinical record for Resident 4 was reviewed on 2/17/26 at 1:42 p.m. The diagnoses included, but were not limited to, malignant neoplasm of the breast, malignant neoplasm of the ovary, and metastatic brain cancer. A physician's order, dated 1/23/26, indicated to administer quetiapine (antipsychotic medication) 25 milligrams (mg) once a day for brain metastasis. An Abnormal Involuntary Movement Scale (AIMS) assessment was not located in the clinical record.During an interview, on 2/18/26 at 12:18 p.m., the Clinical Support Nurse indicated an AIMS assessment had not been completed and should have been completed.During an interview, on 2/19/26 at 10:20 a.m., LPN 7 indicated a resident on a psychotic medication should have an AIMS assessment completed upon admission and quarterly. A current facility policy, titled Guidelines for: Abnormal Involuntary Movement Scale, dated as last reviewed on 12/10/25 and received from the Clinical Support Nurse on 2/18/26 at 1:10 p.m., indicated .To assess residents that have prescribed antipsychotic medications to identify symptoms .to be completed if possible, prior to the resident beginning this type of medication, or at the earliest possible time, either after admission; after medications listed above are prescribed; and with dosage changes A current facility policy, titled Preparation and General Guidelines and Medication Administration-General Guidelines, dated January 2018 and provided by the Director of Nursing on 2/16/26 at 12:44 p.m., indicated .The medication administration record (MAR) should contain supplemental information to help assure accurate dosing.if a dose of regularly scheduled medication is withheld.it is documented on MAR or the EHR. An explanatory note is also entered.3.1-37(a)

Based on interview and record review, the facility failed to ensure active diagnoses were included on a Minimum Data Set (MDS) assessment for 1 of 1 resident reviewed for MDS assessments. (Resident 4)Findings include:The clinical record for Resident 4 was reviewed on 2/17/26 at 1:42 p.m. The diagnoses included, but were not limited to, malignant neoplasm of the breast, malignant neoplasm of the ovary, and metastatic brain cancer. The MDS assessment, dated 1/23/26, did not include cancer diagnoses.During an interview, on 2/19/26 at 2:49 p.m., the Clinical Support Nurse indicated the MDS assessment should have included the cancer diagnoses, and a care plan should have been in place. The facility did not have a policy for MDS accuracy. The facility followed the Resident Assessment Instrument (RAI) manual.During an interview, on 2/20/26 at 10:24 a.m., RN 12 indicated the cancer diagnoses were not included on the MDS assessment dated [DATE].3.1-31(c)(1)

Based on interview and record review, the facility failed to ensure comprehensive person-centered care plans were developed and implemented for 1 of 1 resident reviewed for care plans. (Resident 4)Findings include:The clinical record for Resident 4 was reviewed on 2/17/26 at 1:42 p.m. The diagnoses included, but were not limited to, congestive heart failure, type 2 diabetes mellitus, and metastatic brain cancer.A physician's order, dated 1/18/26, indicated to administer furosemide (a diuretic medication) 40 milligrams (mg) twice a day.A physician's order, dated 1/23/26, indicated to administer quetiapine (an antipsychotic medication) 25 mg once a day for brain metastasis.A physician's order, dated 2/7/26, indicated to administer insulin lispro (a diabetic medication) according to the sliding scale before meals and at bedtime. The clinical record did not contain a care plan related to congestive heart failure and the use of diuretic medication, type 2 diabetes mellitus and the use of diabetic medication, or metastatic brain cancer and the use of antipsychotic medication.During an interview, on 2/19/26 at 9:58 a.m., Licensed Practical Nurse 8 indicated the resident should have had care plans in place for congestive heart failure, type 2 diabetes mellitus, and metastatic brain cancer.During an interview, on 2/19/26 at 2:49 p.m., the Clinical Support Nurse indicated the resident should have had care plans in place for congestive heart failure, type 2 diabetes mellitus, and metastatic brain cancer.During an interview, on 2/20/26 at 10:21 a.m., RN 12 indicated the resident should have had care plans in place for congestive heart failure, type 2 diabetes mellitus, and metastatic brain cancer.A current facility policy, titled Comprehensive Care Plan Guidelines, dated 5/22/18 and received from the Clinical Support Nurse on 2/19/26 at 2:40 p.m., indicated .to ensure appropriateness of services and communication that will meet the resident's needs, severity/stability of conditions, impairment, disability, or disease in accordance with state and federal guidelines .A comprehensive care plan will be developed within 7 days of the admission comprehensive assessment.Comprehensive care plans need to remain accurate and current 3.1-35(a)3.1-35(b)(1)

Based on interview and record review, the facility failed to ensure a resident was assessed timely after an unwitnessed fall and to ensure monitoring and measurements of a bruise which resulted from the fall was completed for 1 of 3 residents reviewed for quality of care. (Resident C)Findings include:The clinical record for Resident C was reviewed on 8/27/25 at 10:43 a.m. The diagnoses included, but were not limited to, Parkinson's disease with dyskinesia, squamous cell carcinoma of the skin, cerebral ischemia, difficulty in walking, mental disorder, lack of coordination, and repeated falls.A nursing progress note, dated 6/22/25 at 9:13 a.m., indicated Resident C was moved from room [ROOM NUMBER] to 229 due to his toilet being broken. A nursing progress note, dated 6/22/25 at 10:18 a.m., indicated Resident C was on a fall follow-up. He had a bruise observed to his lower back and right lateral side of his chest. He took an as needed Percocet for pain this morning.A nursing progress note, dated 6/22/25 at 1:41 p.m., indicated the occurrence date and time of the fall was on 6/21/25 at 10:30 p.m. Resident C had self-reported a fall in his bathroom. There were no complaints of pain and no limitations with range of motion when he was assessed the next morning. The new intervention was to remind the resident to keep his nonskid footwear on while transferring. The resident's representative was notified of the fall.A nursing progress note, dated 6/22/25 at 5:21p.m., indicated the resident remained on a fall follow-up. He took Tylenol for complaints of lower back pain, where the bruise was located, from the fall he had on 6/21/25.An Intradisciplinary (IDT) note, dated 6/23/25 at 4:43 p.m., indicated Resident C had an unwitnessed self-reported fall in his bathroom on 6/21/25 at 10:30 p.m. He was cognitively intact and reported he transferred himself into his wheelchair, propelled himself into the bathroom, toileted himself, then lost his balance and fell when attempting to transfer himself onto the toilet from his wheelchair. He had a 22-inch wheelchair, which could be difficult for him to maneuver independently in small spaces. He had bare feet at the time of the fall. Resident C reported he got himself up off the floor into his wheelchair, then propelled himself back to his room and turned on his call light to notify staff water was leaking from his toilet. When the nurse assessed the resident, he had bruising to his lower back. He was educated to call for assistance using his call light and was provided with additional nonslip socks. He was offered the chance to move to a different room closer to the nurse's station or with a different bathroom set up, but he declined both offers. The root cause of the fall was the resident lost his balance when he was transferring from the toilet to his wheelchair. The new intervention initiated was a sign was placed in the bathroom and the resident was educated to ask for assistance and wear nonslip footwear when transferring.The resident's record lacked documentation of a post fall assessment the evening the resident fell. The record also lacked an assessment of the bruise to Resident C's back area including a description of the bruise and measurements.During a phone interview, on 8/27/25 at 3:25 p.m., CNA 2 indicated Resident C had his call light on and was sitting in his wheelchair in the doorway to his room. Resident C told her he fallen in the bathroom and broke his toilet, then got himself back up into his wheelchair. He told her he had gotten his own towels out of the linen closet and put them on the bathroom floor. She immediately went to LPN 1 and informed her Resident C fell. She had made it clear which resident had fallen.During a phone interview, on 8/27/25 at 4:22 p.m., QMA 6 indicated, on 6/21/25 at 10:30 p.m., CNA 2 told her a resident fell. The resident she was told had fallen had the same first name as Resident C. QMA 6 indicated she went to the other resident's room (not Resident C) to check on him and he indicated he did not fall. QMA 6 then informed LPN 1 she a resident fell, she checked on him, and he indicated he did not fall. When QMA 6 went into Resident C's room the next morning (on 6/22/25 at approximately 4:00 a.m.) to administer his medications, he indicated his bathroom had been flooded with water from his toilet. QMA 6 then realized Resident C was the resident who had fallen the night before. QMA 6 then went to LPN 5 and reported Resident C had fallen last night.During a phone interview, on 8/27/25 at 12:05 p.m., LPN 1 indicated she was working Resident C's unit, on 6/21/25 from 10 a.m. to 10 p.m., but she was not taking care of Resident C during the shift.During a phone interview, on 8/27/25 at 3:52 p.m., LPN 5 indicated he was notified by QMA 6, on 6/22/25 at approximately 5:00 a.m., Resident C had fallen on 6/21/25 at 10:30 p.m. LPN 5 went to Resident C's room and seen his toilet was broken. He completed a fall assessment with neurological checks at that time.During an interview, on 8/27/25 at 3:30 p.m., Clinical Support 8 indicated Resident C's bruise to his back which was noticed after his fall was not measured and followed according to the facility policy and procedure.A current facility policy, titled Bruise, Rash, Lesion, Skin Tear, Laceration Assessment Guidelines, dated 5/10/16 and provided by Clinical Support 8 on 8/27/25 at 1:09 p.m., indicated .utilized to describe and monitor bruises, rashes, lesions, skin tears and lacerations.If skin alteration occurs post admission, follow the below steps: a. Complete Bruise incident in EHR (electronic health record) by an RN/LPN along with the template/assessment progress note. IDT should review this timely and wound nurse or designee complete an assessment in wound management or Wound Zoom. This may not include hemosiderin staining, petechiae, and senile purpura. B. Continue to monitor weekly in wound management or Wound Zoom. C. Must review for at least 1 week in wound management or Wound Zoom. Once wound nurse/designee determines that the wound is healing as expected, resolved or becomes a chronic skin condition this wound nurse/designee may heal the wound in wound management or Wound Zoom.This citation related to Intakes 1376644, 1376646 and 13766473.1-37(a)

3. The clinical record for Resident 30 was reviewed on 3/17/25 at 10:02 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, pulmonary embolism, hypertension, congestive heart failure, obesity, cerebrovascular accident, hemiplegia, hemiparesis, transient ischemic attack, and muscle weakness. A nursing progress note, dated 1/18/25 at 12:25 p.m., indicated the resident was sent to the emergency room for evaluation. A nursing progress note, dated 1/19/25 at 4:08 a.m., indicated the resident had been admitted to the hospital for pulmonary embolism and right heart strain. During the clinical record review, there was no documentation found to indicate the resident and resident's representative were given information in writing regarding the facility's bed hold policy, including the facility's charge to hold a bed. Based on interview and record review, the facility failed to ensure residents and resident representatives were given notification in writing of the facility's policy for bed hold and cost at the time of transfer to the hospital for 5 of 5 residents reviewed for hospitalization or discharge. (Resident 36, 28, 30, 18 and 74) Findings include: 1. The clinical record for Resident 36 was reviewed on 3/12/25 at 2:49 p.m. The diagnoses included, but were not limited to, hypertensive chronic kidney disease, chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, acute respiratory failure with hypercapnia, influenza with other respiratory manifestations, pneumonia, and sepsis. A nursing progress note, dated 10/30/24 at 7:23 p.m., indicated the resident was sent to the emergency room for evaluation following a fall. A nursing progress note, dated 10/31/24 at 3:01 p.m., indicated the resident had been admitted to the hospital for a hip fracture. During the clinical record review, there was no documentation found to indicate the resident and resident's representative were given information in writing regarding the facility's bed hold policy, including the facility's charge to hold a bed. 2. The clinical record for Resident 28 was reviewed on 3/12/25 at 2:55 p.m. The diagnoses included, but were not limited to, hypertensive heart disease, acute chronic diastolic (congestive) heart failure, left bundle branch block, arteriosclerotic heart disease without angina pectoris, severe protein calorie malnutrition, polyneuropathy, gout, pleural effusion, edema, and osteoarthritis. A nursing progress note, dated 1/23/25 at 4:30 p.m., indicated the resident was transferred to the hospital for evaluation following a fall. A nursing progress note, dated 1/23/25 at 5:11 a.m., indicated the resident had been admitted to the hospital for a right hip fracture. During the clinical record review, there was no documentation found to indicate the resident and resident's representative were given information in writing regarding the facility's bed hold policy, including the facility's charge to hold a bed.4. The clinical record for Resident 18 was reviewed on 3/12/25 at 12:07 a.m. The diagnoses included, but were not limited to, acute respiratory failure, hypertension, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, and diabetes mellitus. A nursing progress note, dated 1/12/25 at 11:49 a.m., indicated the resident was transferred to the hospital for a decline in condition and increased confusion. During the clinical record review, there was no documentation found to indicate the resident and resident's representative were given information in writing regarding the facility's bed hold policy, including the facility's charge to hold a bed. 5. The clinical record for Resident 74 was reviewed on 3/14/25 at 11:11 a.m. The diagnoses included, but were not limited to, malignant neoplasm of cecum, chronic obstructive pulmonary disease, diabetes mellitus, anxiety disorder, acute pulmonary edema, and depression. A nursing progress note, dated 1/12/25 at 11:49 a.m., indicated the resident was transferred to the hospital. The Nurse Practitioner was notified and gave a verbal order to send Resident 74 to the emergency room for evaluation and treatment. During the clinical record review, there was no documentation found to indicate the resident and resident's representative were given information in writing regarding the facility's bed hold policy, including the facility's charge to hold a bed. During an interview, on 3/14/25 at 9:38 a.m., the Clinical Support Nurse indicated they did not find documentation to indicate the resident or resident representatives were given information in writing regarding the facility's bed hold policy at the time of the resident's hospitalization. During an interview, on 3/14/25 at 11:22 a.m., the Executive Director (ED) indicated she did not have any documentation to indicate the resident or resident representatives were given information in writing regarding the facility's bed hold policy at the time of the resident's hospitalization. A current facility policy, titled Bed Hold Policy, dated as revised on 11/18/16 and received from the ED on 3/17/25 at 2:15 p.m., indicated .The campus will properly inform residents in advance of their option to make bed-hold payments as well as the amount of the facility's charge to hold a bed. For this optional payment, the campus must make clear that the resident/responsible party must affirmatively elect to make them prior to being billed .If the resident leaves the campus for hospitalization, therapeutic leave, or any other reason (other than the resident's death) .The campus will continue to hold the resident's bed until notified by resident of the responsible party/agent that the bed is no longer desired .It is the policy of the Company that every campus will properly inform residents in advance of their option to make a bed-hold and the amount of the facility charge A current facility policy, titled Guidelines for Transfer and Discharge (including AMA), dated as reviewed on 11/18/16 and received from the ED on 3/19/25 at 1:39 p.m., indicated .Notice of Bed-Hold Policy and readmission .Before the facility transfers a resident to a hospital or allows a resident to go on therapeutic leave, Nursing staff or other designated staff member should provide written information to the resident and a family member of legal representative of the bed-hold and admission policies 3.1-12(a)(25)(A) 3.1-12(a)(25)(B)

4. The clinical record for Resident 18 was reviewed on 3/12/25 at 12:07 a.m. The diagnoses included, but were not limited to, acute respiratory failure, hypertension, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, and diabetes mellitus. A nursing progress note, dated 1/12/25 at 11:49 a.m., indicated the resident was transferred to the hospital for a decline in condition and increased confusion. During the clinical record review, there was no documentation found to indicate the resident and resident's representative were given information in writing regarding the reason for the resident's transfer to the hospital. 5. The clinical record for Resident 74 was reviewed on 3/14/25 at 11:11 a.m. The diagnoses included, but were not limited to, malignant neoplasm of cecum, chronic obstructive pulmonary disease, diabetes mellitus, anxiety disorder, acute pulmonary edema, and depression. A nursing progress note, dated 1/12/25 at 11:49 a.m., indicated the resident was transferred to the hospital. The Nurse Practitioner was notified and gave a verbal order to send Resident 74 to the emergency room for evaluation and treatment. During the clinical record review, there was no documentation found to indicate the resident and resident's representative were given information in writing regarding the reason for the resident's transfer to the hospital. During an interview, on 3/14/25 at 9:38 a.m., the Clinical Support Nurse indicated they did not find documentation to indicate the residents or resident's representatives were given information in writing regarding the reason for the resident's hospitalization. During an interview, on 3/14/25 at 11:22 a.m., the Executive Director (ED) indicated she did not have any documentation to indicate the residents or resident's representatives were given information in writing regarding the reason for the resident's hospitalization. A current facility policy, titled Guidelines for Transfer and Discharge (including AMA), dated as reviewed on 11/18/16 and received from the ED on 3/19/25 at 1:39 p.m., indicated .Notify the resident in writing, and if known, a family member or legal representative, 30 days in advance, of the transfer or discharge, the effective date of transfer or discharge, the location to which the resident is transferred or discharged , and the reasons for the transfer of discharge, according to the criteria for transfer or discharge .Record the reasons for, the effective date of transfer or discharge, and the location to which the resident is being transferred or discharged in the medical record and on a discharge form or a letter. Give a copy of the discharge notice to the resident and his/her family legal representative .The physician should document medical reasons for transfer or discharge in the medical record when the reason for transfer and discharge is for any reason other than nonpayment of the stay or the facility ceasing to operate 3.1-12(a)(6)(A)(i) 3.1-12(a)(6)(A)(ii) 3.1-12(a)(6)(A)(iii) Based on interview and record review, the facility failed to ensure residents and resident's representatives were given notification in writing of the reason for the resident's transfer and discharge to the hospital for 5 of 5 residents reviewed for hospitalization or discharge. (Resident 36, 28, 30, 18 and 74) Findings include: 1. The clinical record for Resident 36 was reviewed on 3/12/25 at 2:49 p.m. The diagnoses included, but were not limited to, hypertensive chronic kidney disease, chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, acute respiratory failure with hypercapnia, influenza with other respiratory manifestations, pneumonia, and sepsis. A nursing progress note, dated 10/30/24 at 7:23 p.m., indicated the resident was sent to the emergency room for evaluation following a fall. A nursing progress note, dated 10/31/24 at 3:01 p.m., indicated the resident had been admitted to the hospital for a hip fracture. During the clinical record review, there was no documentation found to indicate the resident and resident's representative were given information in writing regarding the reason for the resident's transfer to the hospital. 2. The clinical record for Resident 28 was reviewed on 3/12/25 at 2:55 p.m. The diagnoses included, but were not limited to, hypertensive heart disease, acute on chronic diastolic (congestive) heart failure, left bundle branch block, arteriosclerotic heart disease without angina pectoris, severe protein calorie malnutrition, polyneuropathy, gout, pleural effusion, edema, and osteoarthritis. A nursing progress note, dated 1/23/25 at 4:30 p.m., indicated the resident was transferred to the hospital for evaluation following a fall. A nursing progress note, dated 1/23/25 at 5:11 a.m., indicated the resident had been admitted to the hospital for a right hip fracture. During the clinical record review, there was no documentation found to indicate the resident and resident's representative were given information in writing regarding the reason for the resident's transfer to the hospital.3. The clinical record for Resident 30 was reviewed on 3/17/25 at 10:02 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, pulmonary embolism, hypertension, congestive heart failure, obesity, cerebrovascular accident, hemiplegia, hemiparesis, transient ischemic attack, and muscle weakness. A nursing progress note, dated 1/18/25 at 12:25 p.m., indicated the resident was sent to the emergency room for evaluation. A nursing progress note, dated 1/19/25 at 4:08 a.m., indicated the resident had been admitted to the hospital for pulmonary embolism and right heart strain. During the clinical record review, there was no documentation found to indicate the resident and resident's representative were given information in writing regarding the reason for the resident's transfer to the hospital.

Based on observation, interview and record review, the facility failed to ensure oxygen was administered at the correct physician ordered flow rate for 2 of 4 residents reviewed for respiratory care. (Resident 34 and 37) Findings include: 1. During an observation, on 3/11/25 at 3:49 p.m., the resident was sitting in his room with oxygen administered at 3 liters per minute (L) via nasal cannula. During an observation, on 3/12/25 at 3:22 p.m., the resident was resting in his bed with oxygen administered at 3 L via nasal cannula. The clinical record for Resident 34 was reviewed on 3/13/25 at 9:17 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease with acute exacerbation, acute respiratory failure with hypoxia, acute respiratory infection, and respiratory syncytial virus. A physician's order, dated 2/1/25, indicated to administer oxygen at 2 L per nasal cannula continuously. During an interview, on 3/13/25 at 8:05 a.m., the Director of Nursing (DON) indicated the staff were supposed to verify how much oxygen the resident was on with the physician's order. 2. During an observation, on 3/11/25 at 12:06 p.m., the resident was lying in bed with 3 L of oxygen administered via nasal cannula. During an observation, on 3/12/25 at 3:33 p.m., the resident was lying in bed with 3 L of oxygen administered via nasal cannula. The clinical record for Resident 37 was reviewed on 3/12/25 at 3:42 p.m. The diagnoses included, but were not limited to, hypertensive heart disease with heart failure, acute on chronic diastolic congestive heart failure, chronic respiratory failure with hypoxia, emphysema, pulmonary fibrosis, and shortness of breath. A physician's order, dated 9/19/24, indicated to administer oxygen at 2 L per nasal cannula continuously. During an interview, on 3/13/25 at 10:28 a.m., LPN 1 indicated oxygen should be administered according to the physician's order. A current facility policy, titled Administration of Oxygen, dated 12/13/24 and received from the Clinical Support Nurse on 3/14/25 at 9:40 a.m., indicated .Verify physician's order .Adjust the oxygen delivery device so that .the proper flow of oxygen is administered 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure significant weight changes were identified and timely interventions were implemented for 2 of 5 residents reviewed for changes in weight (Resident 109 and 19). This deficient practice resulted in Resident 109 experiencing two events of significant weight gain which required hospitalization for fluid overload and Resident 19 experiencing significant weight loss which required hospitalization for altered mental status and dehydration. Finding includes: 1. The clinical record for Resident 109 was reviewed on 2/12/24 at 4:19 p.m. The diagnoses included, but were not limited to, sepsis, acute and chronic respiratory failure, acute on chronic congestive heart failure, acute kidney failure, type 2 diabetes mellitus, and unspecified dementia. A care plan, dated 12/28/23, indicated the resident had a potential for cardiovascular distress related to a diagnosis of hypertension, congestive heart failure, anemia and coronary artery disease. The goal indicated the resident would be free from signs and symptoms of cardiovascular distress. The approaches included, but were not limited to, observe and report signs and symptoms of cardiovascular distress and to obtain vital signs as needed. A care plan, dated 12/28/23, indicated the resident had chronic kidney disease stage 4. The goal was for the resident not to exhibit signs of fluid volume excess. The approaches included but were not limited to, assess for fluid excess including weight gain, edema, shortness of breath; and to monitor the weight as ordered. A physician order, dated 12/28/23 through 1/5/24, indicated to weigh the resident daily between 6:00 a.m. and 2:00 p.m. A physician order, dated 2/2/24, indicated the diet was a consistent carbohydrate (CCHO), no added salt with regular texture and thin liquids. The resident had the following weights documented in the vitals report: a. On 12/27/23 the weight was 228.2 pounds. b. On 12/30/23 the weight was 240.4 pounds which was a 12.2 pound significant weight gain of 5.35% in 3 days. There was only one weight documented in the EHR for 12/30/23. c. On 12/31/23 the weight was 241.8 pounds which was an additional weight gain of 1.4 pounds. This was a significant weight gain of 5.96% in 4 days. d. On 1/1/24 the weight was 242. 8 pounds which was an additional weight gain. This was a significant weight gain of 6.4% in 5 days. e. On 1/2/24 the weight was 244.4 pounds which was a total weight gain of 16.2 pounds in 6 days. This was a significant weight gain of 7.10% in 6 days. f. On 1/4/24 the weight was 245.2 pounds which was a total weight gain of 17 pounds in 7 days. This was a significant weight gain of 7.71% in 8 days. A Registered Dietitian (RD) progress note, dated 12/30/23, indicated the resident had a questionable weight gain since admission. The resident had documented excellent meal and snack intake. Daily weights were ordered. The current regimen would be continued. A progress note, dated 1/4/24 at 3:03 p.m., indicated the resident had an 18 pound weight gain since admission on 12/27/23. The weight upon admission was 228.2 pounds. The physician wrote an order on 1/3/24 to add Lasix (diuretic medication) 20 milligrams (mg) daily. The order indicated the staff should continue to monitor the resident and obtain daily weights. A progress note, dated 1/5/24 at 12:56 p.m., indicated the resident's weight was 255 pounds. The resident's weight yesterday was 245 pounds. The resident complained of slight shortness of breath and edema was noted throughout the body. The Emergency Medical Services (EMS) was called. From the documented weights from 1/4/24 and 1/5/24, the resident had gained an additional 10.4 pounds in one day. From 12/27/23 until 1/5/24, the resident had a significant weight gain of 11.7%. A progress note, dated 1/5/24 at 6:22 p.m., indicated the resident was admitted to a local hospital for a diagnosis of fluid overload. A progress note, dated 1/17/24 at 1:13 p.m., indicated the resident was readmitted to the facility from the hospital. The local hospital discharge report, printed 1/17/24, indicated the resident had a diagnosis of heart failure. The discharge instructions indicated to notify the physician for a weight gain of 3 pounds overnight or 5 pounds in one week. Rapid weight gain was probably a sign of fluid retention and a sign of worsening heart failure. If the resident has swelling in the legs, feet or abdomen the medical doctor should be called. A physician's order, dated 1/18/24 through 1/26/24, indicated staff should weigh Resident 109 daily to monitor signs and symptoms of congestive heart failure. The resident had the following weights on the vitals report: a. On 1/17/24 at 1:33 p.m., the re-admission weight was 217.8 pounds. b. On 1/17/24 at 8:56 p.m., the weight was 219.4 pounds. c. On 1/22/24 the weight was 231.8 pounds which was a 12.4 pound significant weight gain of 5.65% in 5 days. There were no daily weights documented in the Electronic Health Record (EHR) between 1/18/24 and 1/21/23 and no weights documented between 1/23/24 and 1/26/24. There were no interventions for the 12.4 pounds significant weight gain on 1/22/24 until 1/26/24. A late entry NP note dated 1/22/24 and entered into the EHR on 1/25/24 at 1:02 p.m indicated the resident was admitted to the facility on [DATE] following hospitalization for sepsis. She returned to the hospital on 1/5/24 for fluid overload. The resident's weight on 1/22/24, was 231.8 pounds. The assessment and plan included the resident had a history of congestive heart failure a had fluid overload which hospitalization for diuresis. The resident was to continue to have daily weights. The NP late entry note lacked documentation to include the resident's weight of 231.8 was identified as a significant weight gain of 12. 4 pounds in 5 days of 5.65%. A progress note, dated 1/26/24 at 12:39 p.m., indicated the resident had a weight gain with edema which was reported to the Nurse Practitioner (NP) and staff were awaiting orders. A progress note, dated 1/26/24 at 1:10 p.m., indicated the resident's oxygen saturations were between 83% and 88%. Oxygen at 2 Liters(L) per minute by nasal cannula was added and the oxygen saturation improved to 95%. The resident had increased edema and weight gain. Lasix (a diuretic) was given intramuscularly (IM) earlier. The NP was aware. A progress note, dated 1/26/24 at 7:52 p.m., indicated the resident reported chest pain. The oxygen saturations were 86-88% on 3L of oxygen per nasal cannula. The resident had gained 12 pounds in 5 days according to recent weights. EMS was called for transport to the emergency room for evaluation and treatment. A hospital ER exam and disposition note, dated 1/26/24, indicated the resident had a history of congestive heart failure, chronic kidney disease stage 4 and Alzheimer's. The resident was from a nursing care facility and had gained several pounds of weight with leg swelling over the last several days. The resident had been complaining of a cough and feeling more short of breath. When EMS arrived at the facility the resident's oxygen saturation was 89% on room air. The diagnoses included hypoxic respiratory failure and acute on chronic congestive heart failure. The resident would be admitted to the hospital. A progress note, dated 1/27/24 at 2:55 a.m., indicated the resident was admitted to the Intensive Care Unit with a diagnosis of congestive heart failure and acute renal failure. During an interview, on 2/14/24 at 12:16 p.m., the Clinical Support Nurse indicated there were no notifications made to the physician, NP or resident representative between 1/22/24 and 1/26/24 for the significant weight gain. There was a physician order for daily weights and no weights were documented in the EHR after 1/22/24 through 1/26/24. The NP saw the resident on 1/22/24 and did not document there was a significant weight gain. During an interview, on 2/14/24 at 2:33 p.m., the Clinical Support Nurse indicated around 1/22/24 there was a lot of staff out with COVID-19 including the Certified Nursing Assistant (CNA) mentor. The CNA mentor would do the daily weights and document them in the EHR. The daily weights were completed on paper although could not be entered into the EHR since they were more than 14 days past the time. The facility only had 14 days to complete a late entry. The facility did not have a policy or protocol for CHF. It was up to the physician to decide on the orders. During an interview, on 2/15/24 at 1:40 p.m., the NP 9 indicated she was not concerned about the resident's weight since the weight prior to the first hospitalization was 255.6 pounds. She did not document the previous weight on 2/17/24 in her progress notes and should have documented it. The resident was a chronic snacker and it was not always healthy snacks. The resident gained fluid quickly. The weights reviewed were in the EHR and not documented on paper. She did not look at the weights charted on paper. She was not aware the daily weights between 1/23/24 and 1/26/24 were not documented in the EHR. She would not have changed the treatment even though the resident had been in the hospital for fluid overload. If she was quick to treat the resident, it could put the resident in worsening renal failure. 2. The clinical record for Resident 19 was reviewed on 2/13/24 at 4:04 p.m. The diagnoses included, but were not limited to, Alzheimer's disease, type 2 diabetes mellitus, major depressive disorder and anxiety disorder. A physician's order, dated 5/123 through 1/17/24, indicated to weigh the resident monthly on the first Wednesday of the month. A physician's order, dated 1/25/24, indicated the resident was to receive a consistent carbohydrate diet (CCHO) with regular texture and thin liquids. A care plan, dated 10/1/22 and last reviewed on 1/29/24, indicated the resident had a potential for an alteration in nutritional status related to her diagnoses, medications, fluid balance, intake, physical activity and metabolic demands. The goal indicated the resident would maintain her weight at a healthy range without any unwarranted significant weight changes. The approaches included, but were not limited to, assist with meals as needed, obtain weight as ordered or needed, provide the diet, supplements, medications and adaptive equipment as ordered. A care plan, dated 9/28/22 and last updated on 1/29/24, indicated the resident received diuretic medication related to hypertension. The goal was that the resident would not exhibit signs/symptoms of low potassium or dehydration. The approaches included, but were not limited to, encourage fluids throughout the day if not contraindicated, observe for dehydration including dizziness on sitting/standing, change in mental status, decreased urine output, concentrated urine, dry lips, dry mucous membranes and report symptoms of low potassium including confusion, irritability, low heart rate and anorexia. The resident had the following weights: a. On 11/15/23 the weight was 153 pounds. b. On 12/6/23 the weight was 158.3 pounds. c. On 1/3/24 the weight was not taken. d. On 1/17/24 at 8:26 p.m. the weight was 140.2 pounds. This was a loss of 18.1 pounds in 28 days which was a 11.43% significant weight loss. e. On 1/17/24 at 8:37 p.m. the weight was 140.2 pounds. A late entry progress note, dated 1/17/24 at 2:06 p.m. and entered on 1/21/24 at 10:08 a.m., indicated there was a noted rash to the right side of the resident's forehead. The medical doctor (MD) gave an order for acyclovir (an antiviral) 800 milligram (mg) 5 times a day for 7 days with a diagnosis of shingles. The resident was placed in contact isolation. A Registered Dietitian progress note, dated 1/18/24, indicated a re-weight was requested to validate the significant weight change. There was no re-weight completed between 1/18/24 and 1/23/24. The electronic health record did not include the resident's representative was notified of the significant weight loss. A progress note, dated 1/20/24 at 2:12 p.m., indicated the resident's treatment for shingles continued and the resident remained in isolation. The rash continued to the right side of the forehead and into the eye. Resident 19 had increased weakness and poor appetite. The significant weight loss of 11.43% occurred on 1/17/24 and the acyclovir was prescribed on 1/17/24. A Nurse Practitioner (NP) progress note, dated 1/22/24 at 10:19 a.m., indicated the resident had shingles over the right eye and was being treated with acyclovir. The resident denied any problems although she had significant cognitive impairment. The weight on 1/22/24 was 140.2 pounds. The assessment and plan included to continue the acyclovir until completion. The NP note did not include documentation to show the NP was aware Resident 19 had experienced a significant weight loss of 18.1 pounds which was 11.43% in 28 days. There was no documentation to include interventions to prevent further weight loss were implemented. A progress note, dated 1/23/24 at 9:18 a.m., indicated the resident was not responsive and the EMS was called. A progress note, dated 1/23/24 at 1:47 p.m., indicated the resident was admitted to the hospital with a diagnosis of dehydration and had not been eating the last 2 to 3 days. A hospital history and physical, dated 1/23/24, indicated the resident had a history of dementia. When the resident presented to the emergency room she had a urinary tract infection and acute kidney injury from dehydration and prerenal azotemia (dehydration as result of failure to ingest fluids or fluid loss from diarrhea). The assessment and plan indicated the following: a. metabolic encephalopathy (damage to the brain) and the resident would likely be back to baseline in 1 to 2 days. b. advanced dementia and in hospice condition. c. prerenal azotemia/acute kidney injury with plan to hydrate slowly. d. dehydration/cystitis(inflammation of the bladder usually caused by infection) and treat with Rocephin (an antibiotic). The resident was hospitalized from 1/23/24 through 1/25/24. During an interview, on 2/14/24 at 4:49 p.m., the Clinical Support Nurse indicated the resident's hospital history and physical indicated the resident had encephalopathy (damage to the brain), dehydration and acute kidney injury (sudden episode of kidney damage common in elderly which could be caused by severe dehydration). The resident had significant weight loss on 1/17/24 and the RD asked for a re-weight. The re-weight was not done since the resident was in isolation for shingles and did not feel well. There were no interventions implemented for the significant weight loss. Drug information from Mayo Clinic was provided by the Clinical Support Nurse on acyclovir which showed it caused dehydration. The resident had been consuming adequate intake. There was no documentation to show the resident's representative had been notified of the significant weight loss. A current policy, titled, Guidelines for Weight Tracking, reviewed on 12/31/23 and received from the Clinical Support Nurse on 2/12/24 at 4:53 p.m., indicated, .To ensure resident weight is monitored for weight gain and/or loss to prevent complications arising from compromised nutrition/hydration .Residents will have their weight taken and recorded upon admission to establish a baseline .The facility dietitian or representative will review the resident's nutritional status, usual body weight and current weight to implement a nutritional program when warranted .The weight should be recorded in the individual resident medical record .Residents who have a weight that seem out of normal range shall be re-weighed to determine the accuracy of the original weight .The physician, resident representative and dietitian shall be notified of a weight variance of 5% in 30 days, 7.5% in 90 days, and 10% in 180 days [unless on a planned weight loss or gain program] .Residents with a significant weight change can be added to Clinically At Risk A current policy, titled, Physician-Provider Notification Guidelines, reviewed on 12/31/23 and received from the Clinical Support Nurse on 2/14/24 at 5:24 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 A current policy, titled, Guidelines for Late Entry and Corrections to Medical Record, reviewed on 12/31/23 and received from the Clinical Support Nurse on 2/14/24 at 5:24 p.m., indicated, .To provide guidelines for entering pertinent information to the medical record out of sequence .Each entry to the medical record shall include the date, time and signature of the staff member recording the data .Late entries should be an exception and not the rule .Late entries to the medical record should be completed within 14 days 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure a resident had a self medication administration assessment and an order for the resident to keep the medication at the bedside prior to leaving eye drops in the room for the resident to self administer for 1 of 1 residents observed for medication administration. (Resident 159) Findings include: During an observation, on 2/8/24 3:35 p.m., Resident 159 had four bottles of eye drops without pharmacy labels on the resident's over bed table. The clinical record for Resident 159 reviewed on 2/12/24 at 3:35 p.m. The diagnoses included, but were not limited to, diabetes mellitus, depression, anxiety disorder and urinary retention. During an interview, on 2/8/24 at 3:35 p.m., Resident 159 indicated the eye drops on the table belonged to him. The resident gave his own eye drops. A physician's order, dated 1/17/24, indicated brimonidine(for glaucoma) drops 0.2 % to give 1 drop in both eyes twice a day. A physician's order, dated 1/17/24, indicated lananoprost 0.005% (for glaucoma) to give 1 drop in the left eye at bedtime. There were no physician orders for the dorozamide hcl 2% (for glaucoma) ophthalmic solution and the systane complete PF propylene glycol (to relieve dry, irritated eyes). During an interview, on 2/08/24 at 3:35 p.m., the Qualified Medical Assistant(QMA) 6 indicated residents need an order to give their own medication. Resident 159's bottles of eye drops should not be left in his room on the table. During an interview, on 2/08/24 at 3:45 p.m., the Director of Health Services (DHS) indicated residents need a physician's order to give their on medication. The bottles of eye drop should not be left in the room. The resident does not have an order to keep the medication at the bedside or a self medication administration assessment completed. A current policy, titled, Guidelines for Self-Administration of Medications, dated 12/31/23, received from clinical support, on 2/12/24 at 4:06 p.m., indicated .residents requesting self-medicate or has self-medication as a part of their plan of care shall be assessed using the observation -Self Administration of Medication within the electronic health record. Results of the assessment will be presented to the physician for evaluation and an order for self-medication .The order should include the type of medication(s) the resident is able to self-medicate .all medications including injection, oral, inhalers, drops .The medication will be kept in a locked drawer in the residents' room. The resident will maintain the key, as well as, a key will be maintained by the licensed nurse and or QMA .A Self-Medication plan of care will be initiated and updated as indicated .The assessment will be documented in the EHR 3.1-11(a)

Based on observation, interview, and record review the facility failed to ensure a resident's facial hair was shaved for 1 of 2 residents reviewed for activities of daily living (Resident 11) and failed to provide denture care for 1 of 2 residents reviewed for activities of daily living (Resident 108). Findings include: 1. During an observation on 2/9/24 at 11:11 a.m., Resident 11 was sitting in her chair in her room. She had facial hair, approximately 1/2 inch long, on her chin. The clinical record for Resident 11 was reviewed on 02/12/24 at 09:45 a.m. The diagnoses included, but were not limited to, hypertensive congestive heart failure, supraventricular tachycardia (rapid heart rate), paroxysmal a fib (irregular heartbeat), pulmonary fibrosis, spondylolistheses cervical region (displacement of vertebra), disc degeneration lumbar, delirium due to known physiological condition, repeated falls, and chronic pain syndrome. A Minimum Data Set (MDS) assessment, dated 12/22/23, indicated the resident required partial and/or moderate assistance with upper body performance. A care plan, dated 12/21/23, indicated the resident had a potential for decline in functional status related to decrease mobility, weakness, and falls. The goal was to be free of complications of functional decline. The interventions include, but were not limited to, offering facial shaving on shower days, as needed (PRN) or as requested and notify nursing of refusals. A review of shower sheets (forms that indicated what type of shower/bath and skin assessment on scheduled shower days), dated 12/22/23 to 2/13/24, did not include shaving had occurred or refused. There was no documentation by the nurse or certified resident care aide of refusals to be shaved. A care profile located on the electronic health record did not include shaving the resident. There were no progress notes the resident had refused to be shaved. 36454 2. During an observation on 2/8/24 at 2:49 p.m., Resident 108 was leaning back in a recliner in the common area close to the nurse's station, his mouth was wide open, and it appeared he was missing some teeth on the top and the bottom of his mouth. The clinical record for Resident 108 was reviewed on 2/12/24 at 9:30 a.m. The diagnoses included, but were not limited to, multiple fractures of the ribs on the left side, laceration of the spleen, fall, cerebral ischemia, depression, and type 2 diabetes mellitus. A care plan, dated 1/23/24, indicated the resident required staff assistance to complete self-care and mobility tasks completed and safely. The approaches included, but were not limited to, offer facial shaving on shower days and provide nail care on shower days. The care plan did not include any type of mouth care or denture care. A Profile Guide, dated 1/23/24, indicated for the category of glasses, dentures, and hearing aids that the resident had glasses. The Profile Guide did not include the documentation of the resident having upper and lower partial dentures. During an interview and observation, on 2/12/24 at 2:57 p.m., Certified Nursing Assistant (CNA) 8 indicated Resident 108 did not have dentures. If the resident had dentures it would be listed in the care plan. CNA 8 went to the resident's room and observed Resident 108 had a partial denture on the top and the bottom. The resident did not have a denture cup in the room. CNA 8 indicated the resident must not take the partial dentures out of his mouth. During an interview, on 2/12/24 at 3:07 p.m., the Director of Health Services (DHS) indicated the CNAs would ask their nurse or look at the assignment sheet to know if a resident had dentures. The resident's assignment sheet did not include if the resident had dentures. The resident's profile guide also did not include if the resident had dentures. The profile guide should have included the dentures and who would be taking care of the dentures. During an interview, on 2/13/24 at 11:15 a.m., the Clinical Support Nurse indicated the resident's upper and lower partial dentures were not listed on the resident's profile guide. This was where the information should be located so the staff would know if they needed to care for the dentures or if the resident would care for the dentures on their own. A Caregiver New Hire Checklist, dated 3/22/23, and received from the Clinical Support Nurse on 2/13/24 at 3:45 p.m., indicated, The Caregiver New Hire Checklist should be completed within the first .days of employment with the guidance of a Caregiver Preceptor. Upon completion, the CRCA[Certified Resident Care Aide] and DHS [Director of Health Services] will sign acknowledging these items were covered and the CRCA is prepared to serve the residents in the campus .AM CARE .Dentures .Oral care .Facial Hair[male and female] .PM CARE .Dentures .Oral Care 3.1-38(a)(3)(C) 3.1-38(a)(3)(D)

Based on interview and record review, the facility failed to ensure there was a physician's order for the use of oxygen and the physician's order was followed for 1 of 1 residents reviewed for oxygen use (Resident 30). Finding includes: The clinical record for Resident 30 was reviewed on 2/14/24 at 2:00 p.m. The diagnoses included, but were not limited to, congestive heart failure(CHF), chronic kidney disease, and edema. A physician's order, dated, 12/29/23, indicated to give continuous oxygen at 3 liters(L). A Vital Signs Record, dated 12/21/23 through 1/3/24, indicated the following: a. On 12/22/23 at 6:16 p.m., the resident was on 2 liters of oxygen. b. On 12/23/23 at 4:21 p.m., the resident was on 2 liters of oxygen. c. On 12/24/23 at 3:51 a.m., the resident was on 3 liters of oxygen. d. On 12/24/23 at 11:03 a.m., the resident was on 2 liters of oxygen. e. On 12/31/23 at 9:01a.m and 4:39 p.m., the resident was on room air. f. On 1/1/24 at 1:21 a.m., 4:06 p.m., and 4:27 p.m., the resident was on room air. g. On 1/2/24 at 9:08 a.m., the resident was on room air. h. On 1/2/24 at 10:02 a.m., the resident was on 2 liters of oxygen. i. On 1/3/24 at 5:38 a.m., 5:39 p.m., and 8:29 p.m., the resident was on room air. A care plan, dated 12/22/23, indicated the resident had a potential for complications related to CHF. Interventions included, but were not limited to, giving oxygen per the physician orders. A care plan, dated 12/22/23, indicated the resident had a potential for shortness of breath while lying down. Interventions included, but were not limited to, administering oxygen per physician orders and as needed. During an interview, on 2/14/24 at 3:45 p.m., the Clinical Support Nurse verified the physician orders for oxygen administration were missing on 12/22/23 and were for 3L continuous on 12/29/23. A current policy titled, Administration of Oxygen, revised 5/2018, received from clinical support, on 2/14/24 at 5:10 p.m., indicated .Verify physician's order for the procedure. In cases of emergency oxygen may be administered as a nursing intervention until a physician order may be obtained 3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure as needed (PRN) anxiety medications were prescribed only for 14 days and reviewed for the need to continue use for 1 of 5 resident reviewed for unnecessary medications (Resident 15). Finding includes: The clinical record for Resident 15 was reviewed on 2/9/24 at 12:16 p.m. The clinical diagnoses included, but were not limited to, depression, anxiety disorder, fracture of left pubis (either of a pair of bones forming the two sides of the pelvis) and hypertension. A physician's order, dated 1/23/24 and open ended, indicated to give 1 tablet lorazepam (an anti-anxiety medication) 0.5 milligrams (mg) three times a day when needed. During an interview, on 2/12/24 at 1:46 p.m., the Director of Nursing (DON) was not aware the PRN lorazepam was not renewed after 14 days. The PRN Ativan should have a 14 day stop date. A current policy titled, Psychotropic Medication Usage and Gradual Dose Reduction, dated 10/9/17, received from Clinical Support, on 2/12/24 at 4:06 p.m., indicated .To ensure every effort is made for residents receiving psychoactive medications to obtain the maximum benefit with minimal unwanted side effects through appropriate use, evaluation and monitoring by the interdisciplinary team .Orders for PRN medications will have designated purpose for use .Administration of PRN medications will be documented in the eMAR and indicate prior interventions to include; non-pharmacological interventions .PRN order for psychotropic drugs are limited to 14 days .PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication 3.1-48(b)(2)

Based on record review and interview, the facility failed to ensure the Electronic Health Record (EHR) contained accurate information about a resident's advanced directives for 1 of 1 resident reviewed for advanced directives (Resident 55). Finding includes: The clinical record for Resident 55 was reviewed on 2/13/24 at 12:14 p.m. Diagnoses included, but were not limited to, a fracture of the neck of the left femur, dementia without behavioral disturbance, depression, insomnia, and dependence on supplemental oxygen. The resident's face sheet indicated the resident's code status was do not resuscitate (DNR). A physician's order, dated 11/21/23, the resident was a full code status. An Out of Hospital Do Not Resuscitate Declaration and Order, was dated 11/21/23 and signed by the resident's representative and two witnesses on 11/21/23. The physician signed the form on 11/21/23. During an interview, on 2/13/24 at 3:32 p.m., the Clinical Support Nurse indicated she did not know the reason the physician order on 11/21/23 indicated the resident was a full code status. A current policy, titled, Guidelines for Advanced Directives, revised on 12/14/23 and received from the Clinical Support Nurse on 2/14/24 at 5:24 p.m., indicated, .To ensure facility staff obtains and follows resident's advanced directives regarding end-of-life care .Advanced Directives will be reviewed with resident and /or resident representative by the Customer Service representative or designee at time of admission, with the quarterly comprehensive assessment and PRN .The resident or representative will advise the CSR[customer services representative]/designee regarding wishes for end of life directives and code status. The 'DNR' form will be completed documenting these desires and scanned into the medical record .The nursing staff will obtain an order from the attending physician for the desired code status .Designation of code status and obtainment of physician order will be part of the medical record 3.1-50(a)(2)

Based on interview and record review, the facility failed to ensure there was a physician's order for the use of oxygen and failed to ensure the physician's order was followed for 1 of 1 residents reviewed for oxygen use (Resident 30). Finding includes: The clinical record for Resident 30 was reviewed on 2/14/24 at 2:00 p.m. The diagnoses included, but were not limited to, congestive heart failure(CHF), chronic kidney disease, and edema. A physician's order, dated, 12/29/23, indicated to give continuous oxygen at 3 liters(L). A Vital Signs Record, dated 12/21/23 through 1/3/24, indicated the following: a. On 12/22/23 at 6:16 p.m., the resident was on 2 liters of oxygen. b. On 12/23/23 at 4:21 p.m., the resident was on 2 liters of oxygen. c. On 12/24/23 at 3:51 a.m., the resident was on 3 liters of oxygen. d. On 12/24/23 at 11:03 a.m., the resident was on 2 liters of oxygen. e. On 12/31/23 at 9:01a.m and 4:39 p.m., the resident was on room air. f. On 1/1/24 at 1:21 a.m., 4:06 p.m., and 4:27 p.m., the resident was on room air. g. On 1/2/24 at 9:08 a.m., the resident was on room air. h. On 1/2/24 at 10:02 a.m., the resident was on 2 liters of oxygen. i. On 1/3/24 at 5:38 a.m., 5:39 p.m., and 8:29 p.m., the resident was on room air. A care plan, dated 12/22/23, indicated the resident had a potential for complications related to CHF. Interventions included, but were not limited to, giving oxygen per the physician orders. A care plan, dated 12/22/23, indicated the resident had a potential for shortness of breath while lying down. Interventions included, but were not limited to, administering oxygen per physician orders and as needed. During an interview, on 2/14/24 at 3:45 p.m., the Clinical Support Nurse verified the physician orders for oxygen administration were missing on 12/22/23 and were for 3L continuous on 12/29/23. A current policy titled, Administration of Oxygen, revised 5/2018, received from clinical support, on 2/14/24 at 5:10 p.m., indicated .Verify physician's order for the procedure. In cases of emergency oxygen may be administered as a nursing intervention until a physician order may be obtained 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to observe and evaluate for appropriate and safe use of fall prevention interventions for 1 of 4 residents reviewed for accidents (Resident 48). Finding includes: During an observation, on 2/8/24 at 2:50 p.m., the resident's bed was in the lowest position with mats on both sides of the bed. The resident was noted to walk from the bed to the chair independently. The clinical record for Resident 48 was reviewed on 02/09/24 03:59 p.m. The diagnoses included, but were not limited to, dementia, sequelae of cerebral infarction, depression, and anxiety. A physician's order, dated 1/5/24, indicated the bed was to be in the lowest position. A physician's order, dated 1/5/24, indicated to place a mat at bedside. A care plan, dated 1/8/24, indicated resident wandered without purpose. A care plan, dated 1/8/24, indicated there was a profile care guide to communicate resident care needs. The interventions included, but were not limited to, bed in low position with mat when occupied, wander guard to right ankle, and dycem (a non-slip material) to the wheelchair. A care plan, dated 1/8/24, indicated the resident was a risk for falls related to decreased mobility, dementia with behavioral disturbances, auditory and visual hallucinations, coronary artery disease, cerebral vascular accident, anemia, hypertension, delirium, psychosis, anxiety, depression, seizures, and convulsion. The interventions included, but were not limited to, bed in low position with mat when occupied, and ensure the floor was free of liquids and foreign objects. An alarm and restrictive device evaluation, dated 2/8/24 at 6:10 p.m., indicated the type of alarm or restrictive device evaluation was for a bed in low position. The resident needed an alarm or restrictive device to identify patterns or routines. An alarm or device informed consent, dated 2/8/24 at 6:12 p.m., indicated the consent was for a bed in low position with a mat at bedside. The benefits for implementing alarm and or device was functional ability, including strength and balance. The risks for implementing the device were accidental hazards, barrier to residents from safety getting out of bed and/or chair, physical restraint, other potential physical outcomes, and other potential negative psychosocial outcomes. The alarm and/or device was being used as an enabler. Verbal consent was obtained from the daughter. During an interview, dated 02/12/24 4:34 p.m., clinical support indicated the family had requested the bed with low mat at admission on 1/5/24. The staff performed a device sweep on 2/8/24 and had completed consents and assessments not done prior to the 2/8/24. A current policy titled, Guidelines for Restraint/Enabler Use, received from clinical support, on 2/13/23 at 2:30 p.m., indicated .the purpose of the policy is to ensure completion of observation and evaluation for appropriate and safe use of restraints/enablers for each resident .each resident shall have an individualized nursing observation upon admission, quarterly and prn (as needed) that shall address the need for a safety device, medical symptom for use of the device and identification of whether the device restricts movement or limits the resident from doing something they could previously do .the interdisciplinary team shall evaluate all factors leading to consideration of a device, determine that resident needs are being met and the need to restrain is not the result of an unmet need, investigate alternatives to restraints and determine that all alternative measures have been exhausted and found to be unsuccessful, weigh the risk and benefits of restraint/enabler use, develop measures to minimize the risks and resident decline, make decisions that the device is the most appropriate for the situation .assess the resident to determine functional status .consideration should be taken to determine what the level of function is 3.1-31(a) 3.1-31(d)

Based on interview and record review, the facility failed to ensure there was accurate documentation of narcotic pain medication being signed out for 1 of 3 residents being reviewed for accurate documentation. (Resident B) Finding includes: The record for Resident B was reviewed on 11/30/23 at 3:45 p.m. Diagnoses included, but were not limited to, malignant neoplasm of endocrine pancreas, Parkinson's disease, type 2 diabetes mellitus, osteoarthritis, secondary malignant neoplasm of liver and intrahepatic bile duct, and muscle weakness. A narcotic count sheet for Resident B's Morphine 100 mg (milligrams) per 5 ml (milliliters) (20 mg/1ml) was reviewed and indicated the following doses of Morphine (a narcotic pain medication, which is highly regulated by the federal government) were given on the following dates and times: On 11/1/23 at 3:00 a.m., 0.25 mg were given, and 0 mg were wasted. On 12/1/23 at 1:30 a.m., 0.5 mg were given, and 0 mg were wasted. On 12/1/23 at 2:30 a.m., 0.5 mg were given, and 0 mg were wasted. On 12/1/23 at 4:00 a.m., 0.5 mg were given, and 0 mg were wasted. The Electronic Medication Administration Record (EMAR), dated 11/1/23 to 11/30/23, included, but was not limited to, the following physician's order: 10/22/23 to 11/24/23, Morphine Concentrate (Schedule II) solution 100 mg/5 ml (20 mg/1 ml). Give 0.25 ml by mouth every six hours as needed (PRN) for pain. There was no documentation in the EMAR, on 11/1/23, to indicate the resident had received a PRN dose of Morphine for pain as recorded on the narcotic sheet. The EMAR, dated 12/1/23, included, but was not limited to, the following physician's order: 11/30/23, Morphine Concentrate (Schedule II) solution 100 mg/5 ml (20 mg/1 ml). Give 0.5 ml by mouth as needed every one hour for pain. There was no documentation in the EMAR, on 12/1/23, to indicate the resident had received a PRN dose of Morphine for pain at 1:30 a.m., 2:30 a.m., or 4:00 a.m., as recorded on the narcotic sheet. During an interview, on 12/1/23 at 2:15 p.m., RN 5 indicated after a PRN narcotic dose was given, the dose administered was to be documented on the EMAR. After reviewing the resident's EMAR's for November and December, they had discovered there were four doses of PRN Morphine solution which were signed out on the narcotic count sheet, but not signed out on the EMARs. By not signing out the PRN doses on the EMAR, this was considered a documentation error. A current policy, titled Disposal of Medications and Medication-Related Supplies IEI: Controlled Substance Disposal, dated 01/17 and provided by the Clinical Support Nurse on 12/1/23 at 2:31 p.m., indicated .Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal and state laws and regulations .The Director of Nursing, in collaboration with the Consultant Pharmacist, is responsible for the facility's compliance with federal and state laws and regulations in the handling of controlled medications A current policy, titled Medication Administration Times Procedural Guidelines, dated 12/1/21 and provided by the Director of Nursing Services (DNS) on 11/29/23 at 1:00 p.m., indicated .To ensure medication is administered in resident centered fashion and documented in medical record This citation relates to Complaint IN00421571. 3.1-50(a)(2)

Based on interview and record review, the facility failed to ensure a resident received medications according to the hospital discharge instructions for 1 of 3 residents reviewed for significant medication error. (Resident B) Resident B was readmitted to the hospital. Findings include: The record for Resident B was reviewed on 3/7/2023 at 2:46 p.m. Diagnoses included, but were not limited to, saddle embolus of pulmonary artery with acute cor pulmonale, acute respiratory failure with hypoxia, acute embolism, and thrombosis of unspecified deep veins of lower extremity, bilateral, hypotension, and type 2 diabetes mellitus with hyperglycemia. The discharge instructions from the hospital, dated 12/22/2022, indicated the resident was to call and schedule an appointment with hematology in 2 weeks: a referral to discuss your blood clot and blood thinner. The discharge medication record from the hospital, dated 12/22/2022, indicated the resident was to receive Eliquis (a blood thinning medication used to prevent blood clots) 5 mg (milligrams) tablets, take 2 tablets (10 milligrams) twice daily for 3 days (12/22, 12/23, and 12/24/2022). The discharge medication record from the hospital, dated 12/22/2022, indicated the resident was to receive apixaban (also known as Eliquis) 5 mg tablet twice a day starting on 12/24/2022 for 30 days. The Medication Administration Record (MAR) indicated Resident B received Eliquis 5 mg on 12/22/2022 instead of 20 mg. The MAR indicated Resident B received Eliquis 5 mg on 12/23/2022 instead of 20 mg. The MAR indicated Resident B received Eliquis 10 mg on 12/24/2022 instead of 20 mg. The MAR indicated Resident B received Eliquis 10 mg on 12/25/2022, the correct dose. The MAR indicated Resident B did not receive Eliquis 10 mg on 12/26, 12/27, 12/28, 12/29, 12/30, 12/31/2022, 1/1/2023, 1/2, and 1/3. The MAR indicated the following medications were not given on 12/23/2022: 1. Nexium (to treat heartburn) 40 mg capsule, give one capsule once daily (QD). 2. Rosuvastatin (to treat high cholesterol) 20 mg tablet, give 1/2 tablet QD. 3. Restasis (to treat chronic dry eyes) 0.5%, give 1 drop to the affected eye twice a day (BID). 4. Trulicity pen injector (used once weekly to improve blood sugar) 4.5 mg/0.5 ml, give 0.5 ml subcutaneous QD on Friday (12/23/2022 was a Friday). 5. Vitamin D3 (a supplement) 25 mcg/1000 units tablet, give one tablet QD. 6. Vitamin B6 (a supplement) 1.5 mg tablet, give one tablet QD. 7. Wellbutrin XL (an antidepressant) 300 mg tablet, give one tablet QD. 8. Hydrochlorothiazide (to treat blood pressure and edema) 25 mg tablet, give one tablet BID (additionally this medication was not given on 12/22/2022). 9. Jardiance (used to lower blood sugar) tablet 10 mg, give one tablet QD. 10. Klor-Con (a supplement) M20 tablet, give one tablet QD. 11. Lantus Solostar U-100 Insulin pen, give 10 units subcutaneous QD. 12. Balsalazide (an anti-inflammatory) capsule 750 mg, give 3 capsules BID. 13. Cetirizine (an antihistamine) 10 mg tablet, give one tablet QD. 14. Meloxicam (a nonsteroidal anti-inflammatory) 15 mg tablet, give one tablet QD (additionally this medication was not given on 12/30, 12/31/2022, 1/1/2023, 1/2 and 1/3/2023). A nursing note, dated 12/23/2022 at 2:44 p.m., indicated medications were pulled from the EDK (emergency drug kit), 5 mg of Eliquis was given but not documented. Augmentin (an antibiotic), aspirin, and metoprolol (a blood pressure medication) were given. Resident B was sent to the emergency room (ER) on 1/3/2023 with shortness of breath (SOB) and chest pain. Diagnoses from the ER indicated Acute Pulmonary Embolism (PE)/bilateral DVTs, and failed anticoagulation. The hospital note indicated the resident was admitted to the hospital PCU (progressive care unit) for close monitoring, it was unclear whether the resident had residual thromboembolism verse a new PE (pulmonary embolism). During an interview, on 03/08/2023 at 1:28 p.m., the complainant indicated the resident had not been receiving her Eliquis medication from the facility which had been ordered daily. The resident told her she had not received her pink pill like she was used to getting for her blood clots. The resident also told her she had not received any medication on 12/23/2022. The complainant told the facility she had a concern regarding medication administration and asked the facility to investigate the situation. The facility told her the resident did not get some of her medications on 12/23/2022 because of the snowstorm and the facility pharmacy refused to deliver medications on 12/23/2022. The Eliquis medication had not been given to the resident since 12/25/2022. The Director of Nursing (DON) indicated there had been a transcription error which caused the resident to not get her Eliquis medication. During an interview, on 3/8/2023 at 11:55 p.m., the Executive Director (ED) indicated the facility was not aware until 1/4/2023, the resident had not been receiving her Eliquis medication as per MD admission order. An investigation found the MD admission order had been transcribed incorrectly. The order transcribed discontinued the Eliquis medication on 12/25/2022. The medication error was not reported to the state because it had been a transcription error which caused the medication error. During an interview, on 3/8/2023 at 12:55 p.m., the DON indicated the facility was not aware until 1/4/2023, the resident had not been receiving her Eliquis medication as per MD admission order. An investigation found the MD admission order had been transcribed incorrectly. The order transcribed discontinued the Eliquis medication on 12/25/2022. The medication error was not reported to the state because it had been a transcription error which caused the medication error. The medications were not given on 12/23/2022 because of their unavailability. The facility pharmacy would not deliver during a snowstorm. No other pharmacies were contacted for the medications not given. During a telephone interview, on 3/7/2023 at 2:30 p.m., Staff Member 2 indicated on 1/3/2023, the resident complained of SOB and chest pain. The nurse practitioner evaluated the resident and treated her with medication. The resident was then sent to the ER. The facility investigation, dated 1/4/2023, indicated Staff Member 3 admitted to not putting in the Eliquis orders correctly. A current policy, titled Guidelines for Medication Orders, dated as reviewed 12/31/2022 and received from the ED on 3/8/2023 at 2:30 p.m., indicated .4. Medication orders a. When recording medication orders specify .The type, route, dosage and frequency, strength of the medication and reason for the order This Federal tag relates to Complaint IN00402582. 3.1-48(c)(2)

Based on interview and record review, the facility failed to ensure significant medication errors were reported to the Indiana Department of Health (IDOH) for 1 of 3 residents reviewed for reporting allegations. Finding includes: The record for Resident B was reviewed on 3/7/2023 at 2:46 p.m. Diagnoses included, but were not limited to, saddle embolus of pulmonary artery with acute cor pulmonale, acute respiratory failure with hypoxia, acute embolism, and thrombosis of unspecified deep veins of lower extremity, bilateral, hypotension, and type 2 diabetes mellitus with hyperglycemia. The discharge instructions from the hospital, dated 12/22/2022, indicated the resident was to call and schedule an appointment with hematology in 2 weeks: a referral to discuss your blood clot and blood thinner. The discharge medication record from the hospital, dated 12/22/2022, indicated the resident was to receive Eliquis (a blood thinning medication used to prevent blood clots) 5 mg (milligrams) tablets, take 2 tablets (10 milligrams) twice daily for 3 days (12/22, 12/23, and 12/24/2022). The discharge medication record from the hospital, dated 12/22/2022, indicated the resident was to receive apixaban (also known as Eliquis) 5 mg tablet twice a day starting on 12/24/2022 for 30 days. The Medication Administration Record (MAR) indicated Resident B received Eliquis 5 mg on 12/22/2022 instead of 20 mg. The MAR indicated Resident B received Eliquis 5 mg on 12/23/2022 instead of 20 mg. The MAR indicated Resident B received Eliquis 10 mg on 12/24/2022 instead of 20 mg. The MAR indicated Resident B received Eliquis 10 mg on 12/25/2022, the correct dose. The MAR indicated Resident B did not receive Eliquis 10 mg on 12/26, 12/27, 12/28, 12/29, 12/30, 12/31/2022, 1/1/2023, 1/2, and 1/3. Resident B was sent to the emergency room (ER) on 1/3/2023 with shortness of breath (SOB) and chest pain. Diagnoses from the ER indicated Acute Pulmonary Embolism (PE)/bilateral DVTs, and failed anticoagulation. The hospital note indicated the resident was admitted to the hospital PCU (progressive care unit) for close monitoring, it was unclear whether the resident had residual thromboembolism verse a new PE (pulmonary embolism). During an interview, on 3/8/2023 at 11:55 p.m., the Executive Director (ED) indicated the facility was not aware until 1/4/2023, the resident had not been receiving her Eliquis medication as per MD admission order. An investigation found the MD admission order had been transcribed incorrectly. The order transcribed discontinued the Eliquis medication on 12/25/2022. The medication error was not reported to the state because it had been a transcription error which caused the medication error. During an interview, on 3/8/2023 at 12:55 p.m., the DON indicated the facility was not aware until 1/4/2023, the resident had not been receiving her Eliquis medication as per MD admission order. An investigation found the MD admission order had been transcribed incorrectly. The order transcribed discontinued the Eliquis medication on 12/25/2022. The medication error was not reported to the state because it had been a transcription error which caused the medication error. The medications were not given on 12/23/2022 because of their unavailability. The facility pharmacy would not deliver during a snowstorm. No other pharmacies were contacted for the medications not given. This Federal tag relates to Complaint IN00402582. 3.1-28(c)

Based on interview and record review, the facility failed to follow facility policy for elopement of a resident who eloped and was outside the facility for greater than 20 minutes with whereabouts unknown for 1 of 3 residents reviewed for elopement ( Resident B). The Immediate Jeopardy began on 12/15/2016 when the facility failed to follow their elopement policy to thoroughly check resident whereabouts when a door alarm sounded. The resident exited the building through the front door and was not identified as having eloped for greater than 20 minutes. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 12/20/16 at 3:20 p.m. The Immediate Jeopardy was removed on 12/16/16 and the deficit practice corrected on 12/16/16 prior to the start of the survey and was therefore Past Noncompliance. Findings include: The Clinical record of Resident B was reviewed on 12/20/2016 at 2:15 p.m. [DIAGNOSES REDACTED]. The resident had a BIMS (Brief Interview of Mental Status) of a 10 meaning he had cognitive impairment. The resident care plan dated 9/3/2015 indicated Resident B had altered cognition due to dementia and he had a wanderguard to his ankle. Nursing progress note dated 12/15/2016 at 8:24 a.m., indicated during change of shift the nurses station desk telephone was answered, staff asked if all residents were accounted for, staff stated unknown male was found walking outside of building with a walker by a citizen. The resident was missing and returned to facility walking unassisted with walker down hallway. Wanderguard intact and functioning properly. Head to toe assessment completed, full Range of Motion noted and Vitals signs were within normal ranges. Resident denied any discomfort or pain. A bystander witness statement dated 12/19/2016 at 11:35 a.m., indicated he was traveling on West Boulevard on 12/15/2016 at 5:40 a.m., and saw a man walking eastbound on the side of the road. The witness indicated he asked the resident if he needed a ride and resident got into his car. Resident stated he had walked from the direction of the Wellbrooke facility. Witness then called 911. The police 911 report, dated 12/15/2016 at 5:48 a.m., indicated on Boulevard, southwest side of road an elderly person was walking with a walker and did not appear dressed for weather. Additional note dated 12/15/2016 at 6:07 a.m., indicated subject walked away from Wellbrooke, they did not know he was missing. During an interview on 12/20/2016 at 11:05 a.m., with Resident B, he indicated he told dietary staff he was leaving the building and was going to work at the college. He indicated he walked out the front doors of the facility and down the street until a person stopped him and asked if he needed a ride. The resident indicated he was wearing 2 sweaters, a light jacket, his hat and gloves, shoes and socks and that is was cold but he really did not notice how cold it was outside. He indicated he was starting a new job and had to be there at 6:00 a.m. Facility documentation of the investigation was reviewed on 12/20/2016 at 11:05 a.m. The investigation report dated 12/15/2016 indicated the resident exited the building using facility front doors at 5:39 a.m., a dietary staff member walked to interior front doors wall panel and pushed buttons to quiet the sounding alarm. At 5:50 a.m., 2 unidentified guests entered entryway and asked if the facility had a resident missing. Elopement procedure was then initiated and Resident B was found to be missing. At 6:08 a.m., the resident was returned to the building by the police department. During an interview with the Director of Nursing on 12/20/2016 at 11:30 a.m., she indicated she was aware of elopement search on 12/15/2016 and a resident could not be found and was returned by police. She indicated the resident's wanderguard was in place and working and the alarm had sounded and a dietary staff member had turned the alarm off and did not follow the elopement process. Resident B was returned safely to the facility with no injury and was assessed by staff immediately upon return to facility and by the facility Nurse Practitioner. Resident was placed on watch for 24 hours. The wanderguard was working and alarm company checked alarm on 12/15/2016. The DON Interviewed the dietary staff member #12 on 12/15/16 who had turned off alarm and she indicated the staff was seen on camera silencing the alarm system and not executing elopement procedures. The dietary staff member #12 was suspended on 12/15/2016 and terminated on 12/20/2016. A review of staff education on 12/20/2016 at 2:30 p.m., indicated Dietary staff member #12 had received elopement training during orientation on 1/19/2015. A policy titled Procedure Guidelines: Elopement Risk Reduction dated 5/11/16 was provided by the Administrator on 12/20/16 at 2 p.m., and deemed as current. The policy indicated: .Elopement occurs when a resident leaves the premises or a safe area without .necessary supervision to do so .A resident who leaves a safe area may be at risk of .heat or cold exposure A Coffee Break topic Suspected Elopement Procedures was provided by the Administrator on 12/20/16 at 2 p.m., and deemed as current. This topic sheet indicated .When an alarm goes off it can sometimes be tempting to assume we know who/what set it off. Such assumptions, however, can be dangerous and might put our residents at risk. When a door alarm sounds, please commit to taking the following action: *Act with a sense of Urgency! . *Don't assume others will go to an alarming door *If an outside door is alarming and you see no one in the vicinity, solicit the help of a 2nd team member .One person should begin circling around the building in one direction while the other team member circles in the opposite direction. This way, you won't be potentially missing someone who might be walking in front of you just out of sight! .To ensure that everyone is safe and accounted for, do a head count of your resident population The Past Noncompliance Immediate Jeopardy began on 12/15/16. The Immediate Jeopardy was removed on 12/16/16 and the deficient practice was corrected on 12/16/16 when the facility completed the following: 1. 12/15/16: The resident was assessed by physician and placed on 24 hour 1 to 1 observation. Wanderguard was checked and working appropriately. 2. Dietary staff member # 12 was immediately suspended on 12/15/16 and terminated on 12/20/16. 3. 12/15/16 (Name of Company) arrived and checked all wanderguards and door alarms and they were functioning properly. 4. 12/15-16/2016 All staff inservicing was completed related to elopement policy and procedure prior to reporting for shift. 5. 12/15/2016 thru ongoing daily elopement drills with inservicing through 12/22/2016, then weekly times one month, then monthly times 3 months, then every 6 months ( to be conducted on all random shifts). 6. 12/16/16 Elopement risk re-assessments completed for all residents. Through record review and interview, nursing, dietary, activity, therapy, laundry and housekeeping staff were able to identify the steps to take, in the event of sounding door alarms, missing resident and indicated they had participated in inservicing and facility elopement drills. On 12/21/2016 at 11:03 a.m. an observation of an elopement drill indicated all staff participating were following facility elopement procedures. This Federal tag related to complaint IN 470. 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to assess and provide interventions to prevent weight loss for 1 of 3 residents reviewed for weight loss and nutrition (Resident #178). Resident #178 had a weight loss of 13.5% in 39 days without assessment or intervention Findings include: The clinical record for Resident #178 was reviewed on 06/17/2015 at 11:00 a.m. [DIAGNOSES REDACTED]. A record review of Resident #178 weights indicated a 13.5% weight loss in 39 days. The resident's weight record indicated on 5/8/2015, Resident #178's weight was 148 pounds and on 06/17/2015, Resident #178's weight was 128 pounds. An admission care plan for resident #178 indicated, .maintain weight at healthy range without unwarranted significant weight change and remain at 90% of usual weight. and .please review my overall weight trends at least once monthly for any undesired weight change and make any necessary recommendations to my physician. The most current nutrition assessment was dated 5/17/2015. No other dietary manager or registered dietician (RD) consultant assessment was found in Resident #178's clinical record for the weight loss. A nursing note dated 5/27/2015 indicated the resident had a 6.8 pound weight loss since 5/25/15. The resident's Physician was notified of weight loss but no new orders were indicated. The nursing note indicated .provide resident with ensure after meals today and encourage her to continue to drink supplement while appetite is suppressed. No care plan for potential weight loss, was found for Resident #178 and Resident #178 continued to lose weight . Resident #178's weights record indicated, 5/26/2015 weight 140 pounds 6/1/2015 weight 130 pounds 6/10/2015 weight 131 pounds 6/15/2015 weight 129 pounds 6/17/2015 weight 128 pounds. During an interview on 6/17/2015 at 4:00 p.m., Resident # 178 indicated she was aware of her weight loss, that her family had brought in ensure for her to drink, and she would have liked to talk to the RD about ways to increase her appetite and stop losing weight. During an interview on 06/17/2015 at 4:45 p.m., RN #1 indicated there was no care plan for weight loss for Resident # 178. During an interview on 06/17/2015 at 5:18 p.m., RN #2 indicated she had spoken to the RD. The RD indicated she was not aware of the resident's weight loss and the RD was present in the facility on 6/12/2015. During an interview on 06/17/2015 at 5:25 p.m., RN #2 indicated Resident #178 should have had a care plan for weight loss and an assessment by the RD, to address the resident's current weight loss. The policy and procedure titled Guidelines For Weight Tracking, dated 11/07, updated 5/2014, received on 6/17/2015 at 4:45 p.m., from Registered Nurse (RN) #1 indicated, .3. The facility dietician or representative will review the resident's nutritional status, usual body weight and current weight to implement a nutritional program when warranted.8. The physician, responsible party and dietician shall be notified of a weight variance of > (greater than) 5% (unless on a planned weight loss program). 3.1-46(a)(1)