Every finding on record at Wellbrooke of Westfield

Based on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed for 1 of 4 residents reviewed for PASARR. (Resident 13)Findings include:The clinical record for Resident 13 was reviewed on 3/12/26 at 11:25 a.m. The diagnoses included, but were not limited to, Parkinsonism, major depressive disorder, and dementia.A physician's order, dated 10/3/25, indicated to administer escitalopram (an antidepressant medication) 5 milligrams (mg) for depression.A physician's order, dated 10/3/25, indicated to administer quetiapine (an antipsychotic medication) 50 mg for depression.There was no PASARR screening located in Resident 13's clinical record.During an interview, on 3/12/26 at 10:35 a.m., Clinical Support Nurse 1 indicated the facility did not have a PASARR for Resident 13 and it was missed.A current facility policy, titled Indiana PASRR, undated and received from the Executive Director on 3/12/26, indicated .admission from Hospital. CSR insures hospital completes required appropriate screenings.admission from Home.CSR/back-up ensures paperwork is submitted to gain approval as part of admission process.410 IAC (Indiana Administrative Code) 16.2-3.1-16(d)(1)410 IAC (Indiana Administrative Code) 16.2-3.1-16(d)(2)

Based on interview and record review, the facility failed to ensure a medication was held according to the physician's order for 2 of 2 residents reviewed for quality of care. (Resident 3 and 58) The deficient practice was corrected on 3/6/26, prior to the start of the survey, and was therefore past noncompliance.Findings include:1. The clinical record for Resident 3 was reviewed on 3/12/26 at 10:14 a.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus, dementia, and chronic diastolic congestive heart failure. A care plan, dated as last reviewed on 12/19/25, indicated the resident received hypoglycemic medication and to administer the medication as ordered. A physician's order, discontinued on 2/26/26, indicated to administer seven (7) units of Novolog FlexPen U-100 Insulin (insulin aspart u-100) with breakfast and lunch and to hold for a blood sugar less than 150. The Medication Administration Record (MAR), dated January 2026, indicated Resident 3 received seven (7) units of insulin with breakfast and/or lunch with a blood sugar less than 150 on the following dates:On 1/3/26, at breakfast with a blood sugar of 122. On 1/4/26, at breakfast with a blood sugar of 116. On 1/6/26, at breakfast with a blood sugar of 117, and at lunch with a blood sugar of 136. On 1/7/26, at breakfast with a blood sugar of 95, and at lunch with a blood sugar of 129. On 1/13/26, at breakfast with a blood sugar of 118.On 1/15/26, at breakfast with a blood sugar of 102.On 1/17/26, at breakfast with a blood sugar of 105, and at lunch with a blood sugar of 118. On 1/18/26, at breakfast with a blood sugar of 118.On 1/24/26, at breakfast with a blood sugar of 118. On 1/31/26, at breakfast with a blood sugar of 123, and at lunch with a blood sugar of 138. The MAR (Medication Administration Record), dated February 2026, indicated Resident 3 received seven (7) units of insulin with breakfast and/or lunch with a blood sugar less than 150 on the following dates:On 2/6/26, at lunch with a blood sugar of 135. On 2/7/26, at breakfast with a blood sugar of 108.On 2/8/26, at breakfast with a blood sugar of 115. On 2/14/26, at breakfast with a blood sugar of 111, and at lunch with a blood sugar of 149. On 2/16/26, at breakfast with a blood sugar of 113, and at lunch with a blood sugar of 112. On 2/19/26, at breakfast with a blood sugar of 118, and at lunch with a blood sugar of 139. On 2/21/26, at lunch with a blood sugar of 142. On 2/22/26, at breakfast with a blood sugar of 119.On 2/25/26, at breakfast with a blood sugar of 117.On 2/26/26, at breakfast with a blood sugar of 110. A physician's order, discontinued on 2/26/26, indicated to administer five (5) units of Novolog FlexPen U-100 Insulin (insulin aspart u-100) at dinner and to hold for a blood sugar less than 150. The MAR, dated January 2026, indicated Resident 3 received five (5) units of insulin at dinner with a blood sugar less than 150 on the following dates: On 1/1/26, with a blood sugar of 124. On 1/3/26, with a blood sugar of 99. On 1/9/26 with a blood sugar of 133. On 1/18/26, with a blood sugar of 98. On 1/22/26, with a blood sugar of 129. On 1/23/26, with a blood sugar of 108. On 1/24/26, with a blood sugar of 96. On 1/31/26, with a blood sugar of 109. The MAR, dated February 2026, indicated Resident 3 received five (5) units of insulin at dinner with a blood sugar less than 150 on the following dates: On 2/5/26, with a blood sugar of 136. On 2/7/26, with a blood sugar of 98. On 2/8/26, with a blood sugar of 117. On 2/12/26, with a blood sugar of 100. On 2/14/26, with a blood sugar of 127. On 2/15/26, with a blood sugar of 122. On 2/19/26, with a blood sugar of 93. On 2/22/26, with a blood sugar of 99. On 2/23/26, with a blood sugar of 107. During an interview, on 3/13/26 at 2:54 p.m., the Clinical Support Nurse 2 indicated the DON (Director of Nursing) had noted medication was administered against the physician's order prior to the start of the survey. During an interview, on 3/13/26 at 2:59 p.m., the DON indicated all medication parameters were to be followed, and the medication should not have been administered. She had educated all staff on following the physician's orders, including the hold parameters. 2. The clinical record for Resident 58 was reviewed on 3/13/26 at 10:30 a.m. The diagnoses included, but were not limited to, hypertensive emergency, primary hypertension, and myocardial infarction (heart attack). A care plan, dated 12/5/25, indicated Resident 58 had the potential for cardiovascular distress related to, but not limited to, hypertension and to administer medications as ordered. A physician's order, dated 1/27/26 to 1/29/26, indicated to administer isosorbide mononitrate (a medication to treat heart related chest pain and blood pressure) and to hold the medication for a systolic blood pressure greater than 120. The MAR indicated, on 1/28/26, Resident 58's blood pressure before the medication administration was 140/78 and the isosorbide mononitrate was administered outside of the physician's ordered hold parameters. During an interview, on 3/13/26 at 2:55 p.m., Clinical Support Nurse 2 indicated the facility had conducted an audit on medication administration and had found medications were being administered outside of physician's ordered hold parameters. During an interview, on 3/13/26 at 2:59 p.m., the DON indicated the medication hold parameters were to be followed and the medication should not have been administered. A current facility policy, titled Medication Administration-General Guidelines, dated 11/2018 and provided by the Administrator on 3/16/26 at 9:08 a.m., indicated .Medications are administered in accordance with written orders of the prescriber This deficient practice was corrected by 3/6/26 after the facility implemented a systemic plan that included the following actions: education to all nursing staff on physician ordered medication parameters, medication audits were completed, and ongoing auditing/monitoring tools were in place. 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on interview and record review, the facility failed to ensure staff did not take and share unauthorized photos of a resident for 2 of 3 residents reviewed for privacy. (Resident B) The deficient practice was corrected on 5/8/25, prior to the start of the survey, and was therefore past noncompliance. Findings include: A Facility Reported Incident (FRI) indicated on 5/7/25, terminated employee Qualified Medication Assistant (QMA) 3 had sent Certified Nursing Assistant (CNA) 2 an unauthorized photo of Resident B and C which had been taken on 4/30/25. 1 The clinical record for Resident B was reviewed on 6/5/25 at 10:15 a.m. The diagnoses included, but were not limited to, anxiety disorder and stage 3 chronic kidney disease. A Brief Interview for Mental Status (BIMS) assessment, dated 4/28/25, indicated Resident B had severe cognitive impairment. 2. The clinical record for Resident C was reviewed on 6/5/25 at 10:20 a.m. The diagnoses included, but were not limited to general anxiety disorder, insomnia, and depression. An assessment, dated 4/11/25, indicated Resident C had severe cognitive impairment. During an interview, on 6/5/25 at 10:15 a.m., the Executive Director (ED) and Clinical Support 5 indicated a former employee took a picture of 2 residents when they were out in the hallway. Resident B was nude, and you could the side of Resident C's face. There were 2 residents in the photo. During an interview, on 6/5/25 at 10:50 a.m., the Assistant Director of Nursing (ADON) indicated staff were not allowed to take pictures of residents. During an interview, 6/5/25 at 10:53 a.m., Registered Nurse (RN) 10 indicated staff were not supposed to be using their phones on the floor and they were not allowed to take pictures of a resident. During an interview, on 6/5/25 at 10:59 a.m., Clinical Support 5 indicated staff were not supposed to be taking pictures of residents with their phones. During an interview, on 6/5/25 at 11:06 a.m., the Executive Director (ED) indicated QMA 3 was not a designated employee to take photos. During an interview, on 6/5/25 at 11:45 a.m., CNA 2 indicated she had woken up in the morning and was sent a text from QMA 3. QMA 3 had sent her Google reviews and a nude picture of Resident B. She then reported the incident to the management. To her knowledge, QMA 3 did not send it to anyone else. Attempts were made to contact QMA 3 but were unsuccessful. A current facility policy, titled Cell Phone, Cameras and Electronic Devices FAQ, dated 3/19/19 and received from Clinical Support 1 on 6/5/25 at 11:00 a.m., indicated .Employees can carry/possess a cell phone during work hours, but the cell phone cannot be used in work areas. Cell phones should also be either turned off or on silent or vibrate mode during working hours .Designated employees may take photos as part of their job duties for business purposes only. The authorized employees are designated by the Executive Director and are usually defined as Department leaders, Life Enrichment Associates, designated social media team members and those with a yellow Photographer name badge .An unauthorized photo of a resident is a violation of the resident's right to privacy and confidentiality The deficient practice was corrected by 5/8/25 after the facility completed education to all staff members and implemented a systemic plan which included staff reeducation on cell phone use and regular audits to ensure compliance. 3.1-3(o) 3.1-3(p)(4) 3.1-3(t)

Based on observation, interview and record review, the facility failed to ensure a resident's oxygen concentrator was turned on to deliver oxygen therapy according to the physician's order and failed to obtain a physician's order for the use of oxygen for 2 of 4 residents reviewed for respiratory care. (Resident 15 and 201) Findings include: 1. During an observation, on 4/21/25 at 1:40 p.m., a staff member walked out of Resident 15's room. Upon entering the room, Resident 15 was observed to be wearing a nasal cannula, but the oxygen concentrator was not turned on. During an observation and interview, on 4/21/25 at 1:47 p.m., Resident 15's oxygen concentrator was turned off. Licensed Practical Nurse (LPN) 6 indicated the oxygen was turned off and it should be turned on. The clinical record for Resident 15 was reviewed on 4/22/25 at 2:01 p.m. The diagnoses included, but were not limited to, a history of Covid 19, chronic respiratory failure with hypoxia, and asthma. A care plan, dated 11/11/23, indicated the resident had a potential for shortness of breath while lying flat related to asthma. Interventions included, but were not limited to, administer oxygen per the physician's orders. A physician's order, dated 4/10/25, indicated Resident 15 was to receive oxygen at 3 liters per minute. 2. During an observation, on 4/21/25 at 10:17 a.m., Resident 201 was sitting in her wheelchair in her room. An oxygen concentrator was in the corner of the room and the oxygen tubing was in a bag. During an observation and interview, on 4/22/25 at 8:49 a.m., Resident 201 was sitting in her wheelchair in her room. Her oxygen tube and cannula were lying on her bed, and the oxygen concentrator was on and running. An imprint from the oxygen tubing and nasal cannula was observed on Resident 201's face. Resident 201 indicated she wore oxygen at night while in bed. The clinical record for Resident 201 was reviewed on 4/22/25 at 12:43 p.m. The diagnoses included, but were not limited to, malignant neoplasm of right main bronchus, chronic obstructive pulmonary disease, and pan lobular emphysema. A care plan, dated 4/9/25, indicated Resident 201 had the potential for complications and a functional and cognitive status decline related to her respiratory disease and to administer oxygen per the physician's orders. A physician's order for oxygen was not found in the electronic health record. The resident's hospice binder indicated the hospice RN visited the resident on 4/8/25 and documented the need for oxygen at 2 liters per minute. A physician's order for oxygen was not found in the hospice binder. During an interview, on 4/22/25 at 12:57 p.m., LPN 5 indicated a physician's order for the use of oxygen was not found in the electronic health record. During an interview, on 4/22/25 at 1:04 p.m., the Assistant Director of Nursing (ADON) indicated she was not able to find a physician's order in the electronic health record for the use of oxygen. She observed the oxygen concentrator in Resident 201's room and indicated the concentrator was delivered by the hospice company. She reviewed the hospice binder and was unable to find a written order for the use of oxygen. A current facility policy, titled Guidelines for Medication Orders, dated 12/17/24 and received from the Clinical Support 3 on 4/22/25 at 1:38 p.m., indicated .The purpose of this policy is to: To establish uniform guidelines in the receiving and recording of medication orders .A current list of orders will be maintained in the electronic clinical record of each resident .Oxygen orders .When recording oxygen orders specify .The rate of flow, route and rationale A current facility policy, titled Administration of Oxygen, dated 12/13/24 and received from the Clinical Support 3 on 4/22/25 at 1:38 p.m., indicated .Guidelines to properly Administering Oxygen and any Respiratory procedure .Verify physician's order for the procedure .Turn on the oxygen 3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure the pre-admission screening and resident review (PASARR) was completed accurately for 2 of 5 residents reviewed for PASARR. (Resident 18 and 33) Findings include: 1. The clinical record for Resident 18 was reviewed on 4/23/25 at 8:33 a.m. The diagnoses included, but were not limited to, visual hallucinations, psychosis, and major depressive disorder. The PASARR for Resident 18, dated 3/28/25, did not include all his mental health diagnoses or mental health medications. A physician's order, dated 3/31/25, indicated Resident 18 was to take aripiprazole (an antipsychotic medication). Aripiprazole was not listed on Resident 18's PASARR and the PASARR did not include a mental health diagnosis to adequately justify the need for antipsychotic medication. A physician's order, dated 3/31/25, indicated Resident 18 was to take clonazepam (an anti-anxiety medication). Clonazepam was not listed on Resident 18's PASARR and the PASARR did not include a mental health diagnosis to adequately justify the need for anti-anxiety medication. During an interview, on 4/24/25 at 10:04 a.m., the Director of Nursing (DON) indicated Resident 18's neurologist followed up on all his psychotropic medications which included, but were not limited to, aripiprazole and clonazepam. During an interview, on 4/23/25 at 2:42 p.m., the Social Service Director (SSD) indicated Resident 18's PASARR did not contain all Resident 18's mental health diagnoses or mental health medications and the PASARR needed to be updated. 2. The clinical record for Resident 33 was reviewed on 4/23/25 at 8:38 a.m. The diagnoses included, but were not limited to, insomnia and pain. The PASARR for Resident 33, dated 2/7/25, indicated Resident 33 did not have any mental health diagnoses and did not take any mental health medications. A physician's order, dated 3/18/25, indicated Resident 33 was to take zolpidem (a sedative-hypnotic medication). During an interview, on 4/24/25 at 12:58 p.m., the SSD indicated Resident 33's PASARR did not include any mental health diagnoses or mental health medications. During an interview, on 4/23/25 at 3:10 p.m., the SSD indicated the facility followed the CMS guidelines and did not have a policy related to PASARR. 3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

Based on interview and record review, the facility failed to ensure a resident's medical record was complete and accurately documented related to meal intakes for 1 of 1 resident reviewed for documentation. (Resident 2) Findings include: During an interview, on 4/22/25 at 10:12 a.m., Resident 2 indicated she did not get her lunch meal delivered to her sometimes. The clinical record for Resident 2 was reviewed on 4/23/25 at 10:01 a.m. The diagnoses included, but were not limited to, vitamin deficiency, repeated falls, and muscle weakness. The meal intakes for Resident 2 were reviewed and indicated: On 3/27/25, no lunch intake was documented. On 4/3/25, no lunch intake was documented. On 4/9/25, no lunch intake was documented. On 4/20/25, no lunch intake was documented. On 4/23/25, no lunch intake was documented. During an interview, on 4/24/25 at 11:18 a.m., Licensed Practical Nurse (LPN) 5 indicated meal intakes were charted in the care assist and would pop up in the vitals tab. Meal intakes should be charted before the end of the staff member's shift. If a resident refused a meal, it would be charted as refused. During an interview, on 4/24/25 at 10:32 a.m., the Clinical Support nurse indicated meals were documented in the record under the meal intake tab. She did not see the lunch intakes documented in the record. A current facility policy, titled Guidelines for Meal Service, dated 5/22/20 and received from the Clinical Support on 4/24/25 at 11:35 a.m., indicated .Meal intakes should be recorded in the electronic health record 3.1-50(a)(1) 3.1-50(a)(2)

Based on interview and record review, the facility failed to ensure there was sufficient documentation to show a behavior care plan was prepared by an interdisciplinary team, which included the participation of the resident and the resident's representative prior to initiation and to ensure care plan meetings were conducted and documented for 3 of 8 residents reviewed for care plans. (Resident 2, 23 and 42) Findings include: 1. The clinical record for Resident 2 was reviewed on 4/23/25 at 10:01 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, depression, and dementia. A quarterly Minimum Data Set (MDS) assessment, dated 2/20/25, indicated the resident was cognitively intact and had no mood or behavior concerns. A care plan, dated 4/18/25, indicated Resident 2 had impaired cognition with a short-term memory impairment and was at risk for confusion, disorientation, an altered mood, and an impaired or reduced safety awareness related to Alzheimer's disease and dementia. A care plan, dated 4/22/25, indicated Resident 2 demonstrated inappropriate behaviors which included making false accusations towards staff and family. The clinical record for Resident 2 did not contain documentation to indicate she made false accusations towards staff or family. During an interview, on 4/23/25 at 11:49 a.m., Licensed Practical Nurse (LPN) 6 indicated Resident 2 did not necessarily make false statements but she did embellish things sometimes. During an interview, on 4/24/25 at 10:32 a.m., Clinical Support 3 indicated care plan revisions were often done during their clinical review or interdisciplinary team (IDT) meetings. During an interview, on 4/25/25 at 10:12 a.m., Clinical Support 3 indicated she would look for documentation for the IDT meeting which was held prior to initiating the care plan. She did not find documentation in the clinical record where the resident made false statements. The facility should document the IDT meetings in the clinical record. During an interview, on 4/25/25 at 11:19 a.m., the Director of Nursing indicated there was no IDT meeting documented. 38872 2. During an interview, on 4/21/25 at 11:17 a.m., Resident 23 indicated she was not sure when her last care plan meeting was held. The clinical record for Resident 23 was reviewed on 4/25/25 at 9:10 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, dementia without behavioral disturbance, and hypertensive kidney disease. The last documented care plan meeting was 11/7/24. There was no care plan meeting for 2/25 documented in the record. During an interview, on 4/25/25 at 1:09 p.m., the Social Service Director (SSD) indicated there was no documented care plan meeting in February 2025 for Resident 23. 3. During an interview, on 4/21/25 at 10:59 a.m., a family member of Resident 42 indicated they went to a few care planning meetings when Resident 42 had Medicare, but they pay privately now and have not had a meeting recently. The clinical record for Resident 42 was reviewed on 4/24/25 at 2:06 p.m. The diagnoses included, but were not limited to, metabolic encephalopathy (a brain dysfunction caused by underlying metabolic disorders or conditions which disrupt the brain's energy supply or chemical balance), sepsis, and dehydration. The last documented care plan meeting was on 11/4/24. During an interview, on 4/23/25 at 9:53 a.m., the SSD indicated there was no documented care plan meeting in February 2025 for Resident 42. A current facility policy, titled Resident's First Meeting Guidelines, dated as reviewed on 12/17/24 and received from Corporate Support Nurse 3 on 4/25/25 at 2:07 p.m., indicated .Subsequent meetings for non-Medicare residents should be conducted minimally quarterly .Subsequent meetings for Medicare residents should be conducted minimally quarterly A current facility policy, titled Comprehensive Care Plan Guideline, dated as revised on 5/22/18 and received from the MDS Clinical Support on 4/24/25 at 11:35 a.m., indicated .Comprehensive care plans need to remain accurate and current. A. New interventions will be added and updated during or directly following the CCM meeting. B. Newly recognized problems will have a care plan developed and added after CCM meeting 3.1-35(a) 3.1-35(d)(2)(B)

Based on observation, interview and record review, the facility failed to ensure a medication was labeled with a resident's name in 1 of 2 medication carts and staff signed the narcotic count log during shift change in 2 of 2 narcotic books reviewed for medication storage. (boardwalk south and 200 south) Findings include: 1. During an observation and interview, on 4/22/25 at 10:24 a.m., a Lantus (insulin) injectable pen was observed inside the boardwalk south medication cart, and it was not labeled with the name of the resident. LPN 5 indicated there should have been a name on the insulin pen. 2. The boardwalk south medication cart Narcotic Count Sheet for April 2025 indicated there were missing signatures for the oncoming shift: On 4/4/25, for the night shift. On 4/6/25, for the evening shift. On 4/12/25, for the day and evening shift. The sheet was missing signatures for the off going shift: On 4/4/25, for the night shift. On 4/6/25, for the evening shift. On 4/12/25, for the evening and night shift. 3. The 200 south medication cart Narcotic Count Sheet for April 2025, indicated there were missing signatures for the oncoming shift: On 4/1/25, for the evening shift. On 4/4/25, for the night shift. On 4/6/25, for the evening and night shift. The sheet was missing signatures for the off going shift: On 4/1/25, for the night shift. On 4/4/25, for the night shift. On 4/6/25, for the evening and night shift. During an interview, on 4/23/25 at 9:23 a.m., LPN 6 indicated the narcotic count sheet needed to be signed every shift change. A current facility policy, titled Guidelines for Narcotic Count, dated 12/17/24 and received from the Corporate Support Nurse on 4/22/25 at 11:09 a.m., indicated .Each controlled drug shall have a corresponding count sheet to track distribution .The narcotic book shall contain a sheet providing space for the off going and oncoming nursing staff to record their signature indicating the narcotics have been reviewed .Both staff members shall signed that the narcotic count is accurately reconciled A current facility policy, titled MEDICATION ORDERING AND RECEIVING FROM PHARMACY, dated November 2018 and received from the Clinical Support Nurse on 4/23/25 at 12:03 p.m., indicated .Each prescription medication label include .Resident's name 3.1-25(e)(3) 3.1-25(k)(1)

Based on interview and record review, the facility failed to notify the Office of the State Long-Term Care Ombudsman when a resident was hospitalized for 1 of 3 residents reviewed for hospitalization . (Resident J) Finding includes: The clinical record for Resident J was reviewed on 4/4/24 at 11:35 a.m. The diagnoses included, but were not limited to, a urinary tract infection, urine retention, and obstruction and reflux uropathy (obstruction of urinary flow). A progress note, dated 7/18/23, indicated the resident was sent to the hospital to be evaluated and treated. A progress note, dated 7/30/23, indicated the resident was sent to the hospital to be evaluated and treated. The Electronic Health Record did not include notification to the Office of the State Long-Term Care Ombudsman for Resident J's hospital discharges on 7/18/23 and 7/30/23. During an interview, on 4/2/24 at 4:40 p.m., the Clinical Support Nurse indicated the Ombudsman was not notified of Resident J going out to the hospital on 7/18/23 and 7/30/23. The staff did not know they were required to report to the Ombudsman. They had no documentation to support the facility contacted the Ombudsman and they should for any transfer and discharges. A current policy, titled Ombudsman Notification, dated as revised on 1/15/21 and received from the Clinical Support Nurse on 4/2/24 at 4:16 p.m., indicated .CMS Requirements of Participation, this SOP will detail expectations on communication of facility-initiated transfer or discharges to the State Long-Term Care Ombudsman .Federal regulation requires that the facility sends a copy of the notice of transfer or discharge to a representative of the Office of the State Long-Term Care Ombudsman 3.1-12(a)(6)(A)(iv)

Based on observation, interview, and record review, the facility failed to ensure oxygen was administered according to an active physician's order, failed to administer oxygen at the specified flow rate once an order was obtained, and failed to label the oxygen tubing for 1 of 2 residents reviewed for respiratory care. (Resident 307) Finding includes: During an observation, on 3/27/24 at 12:36 p.m., Resident 307 was wearing oxygen at a flow rate of 3 liters and the nasal cannula tubing was not labeled with a date. During an observation, on 3/28/24 at 9:45 a.m., Resident 307 was wearing oxygen at 2.5 liters. During an observation, on 3/29/24 at 10:02 a.m., Resident 307 was wearing oxygen at 2.5 liters. The clinical record for Resident 307 was reviewed on 3/28/24 at 3:45 p.m. The diagnoses included, but were not limited to, acute respiratory failure with hypoxia, pleural effusion, and acute posthemorrhagic anemia. The electronic medical record did not contain orders for oxygen, a flow rate, or nasal cannula and humidity change frequency. A physician's order for 2 liters of oxygen prn (as needed) was started on 3/28/24. A vital signs record, dated 3/25/24 at 6:35 a.m., indicated the oxygen flow rate was at 3 liters. A vital signs record, dated 3/27/24 at 3:16 p.m., indicated the oxygen flow rate was at 3 liters. During an interview, on 3/27/24 at 1:12 p.m., LPN 7 indicated Resident 307 was currently on oxygen. During an interview, on 3/29/24 at 11:23 a.m., the Clinical Support Nurse indicated a physician's order for oxygen administration was required and the tubing was to be labeled with a date. During an interview, on 4/4/24 at 2:09 p.m., RN 3 indicated the nurses were to administer oxygen at the flow rate which was ordered by the physician. A current policy, titled Administration of Oxygen, dated as approved on 5/2018 and received from the Executive Director on 4/2/24 at 3:35 p.m., indicated .Verify physician's order for the procedure .Date the tubing for the date it was initiated .Adjust the oxygen delivery device so that .the proper flow of oxygen is administered 3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure a correct diagnosis was added to an antipsychotic order and to monitor for psychotic symptoms for 1 of 5 residents reviewed for unnecessary medications. (Resident 10) Finding includes: The clinical record for Resident 10 was reviewed on 4/1/24 at 11:48 a.m. The diagnoses included, but were not limited to, mild cognitive impairment, major depressive disorder, anxiety disorder, and mild intellectual disabilities. A physician's order, dated 12/20/22, indicated to give aripiprazole (an antipsychotic) 10 milligram (mg) once a day for the single episode major depressive disorder. A care plan, dated 12/20/22, indicated the resident received an antipsychotic medication for a major depressive disorder. The approaches included, but were not limited to, administer medications as ordered by the physician, attempt a gradual dose reduction (GDR) in two separate quarters during the first year and yearly unless clinically contraindicated and attempt to give the lowest dose possible. A psychiatry progress note, dated 10/11/23, indicated the resident denied any changes to his mood or perceptual disturbance. The diagnoses and plan included continuing the aripiprazole 10 mg daily for the major depressive disorder, recurrent severe with psychotic symptoms. The resident had a history of psychosis with auditory hallucinations. The physician's orders did not include the psychotic symptoms and auditory hallucinations or the severe, recurrent major depressive disorder. The care plans did not include monitoring the resident for psychosis and auditory hallucinations. During an interview, on 4/4/24 at 10:27 a.m., the Clinical Support Nurse indicated the electronic health record (EHR) did not contain any monitoring for auditory hallucinations. During an interview, on 4/4/24 at 11:04 a.m., the Clinical Support Nurse indicated the Social Services Director (SSD) was not aware of the auditory hallucinations and did not have monitoring in place or a care plan for auditory hallucinations. During an interview, on 4/4/24 at 11:21 a.m., the Clinical Support Nurse indicated the resident's past hospital records indicated depression and did not include major depression, recurrent and severe with psychosis and auditory hallucinations. The psychiatric provider notes were given to the Social Services Director (SSD) and the clinical leadership should have looked at the notes and seen the diagnosis of psychoses and auditory hallucinations. These diagnoses should have been reviewed and added to the electronic health record. The facility pharmacy did not note a discrepancy for the aripiprazole being given for a single episode of major depression. A current policy, titled Psychotropic Medication Usage and Gradual Dose Reductions, dated as reviewed on 12/31/23 and received from the Clinical Support Nurse on 4/4/24 at 11:35 a.m., indicated .To ensure every effort is made for residents receiving psychoactive mediations to obtain the maximum benefit with minimal unwanted side effects through appropriate use, evaluation and monitoring by the interdisciplinary team .Residents shall receive psychotropic medications only if designated medically necessary by the prescriber, with appropriate diagnosis or documentation to support its usage. The medical necessity will be documented in the resident's medical record and the care planning process .Regular monthly review of antipsychotics in CAR [clinically at risk] for continued need, appropriate dosage, side effects, risks and/or benefits will be conducted, to ensure the use of psychopharmacologic medications are therapeutic and remain beneficial to the resident . 3.1-48(a)(3)

Based on observation, interview and record review, the facility failed to ensure medications were handled in a sanitary manner for 1 of 7 residents observed for medication administration (Resident D) and failed to ensure staff transported clean linen/gowns in a manner which prevents contamination for 2 of 3 staff observed transporting linen. (Housekeeper 5 and CNA 4) Findings include: 1. During a medication administration observation, on 4/1/24 at 11:41 a.m., RN 3 was observed to take a clonidine (a blood pressure medication) 0.2 milligrams from the packaging and put it into her hand, then put the medication into the medication cup after she handled it with her bare hand. During an observation and interview, on 4/1/24 at 11:41 a.m., RN 3 indicated she did put the medication in her hand and when informed of the concern with infection control, she indicated well I guess we won't do that again. RN 3 was then observed to carry the medication to Resident D's room for administration. The resident was not in the room. RN 3 then returned to her medication cart, put the resident information on the outside of the cup, placed a second medication cup on top of the pill in the cup, taped the cups together and placed it in the top drawer of her cart. She was not observed to destroy the medication she handled with her hands or retrieve a new pill for the resident. During an interview, on 4/1/24 at 12:02 p.m., the Executive Director indicated staff were not to put medications into their hands or touch the medications with their hands. 2. During a random observation, on 4/1/24 at 10:15 a.m., Housekeeper 5 was observed to transport clean bed linen pressed against her upper left side of her body with the linen in contact with her clothing. Housekeeper 5 was not able to describe the proper way to transport clean linen. She was not observed to replace the linen with clean linen and proceeded to take the linen to the room. 3. During a random observation, on 4/1/24 at 10:22 a.m., CNA 4 was observed carrying clean linen/gown with the items pressed against her shirt. She was not able to explain the proper way to transport linens. A facility policy, titled Specific Medication Administration Procedures, dated as revised on 1/17 and received from the Corporate Support Nurse on 4/1/24 at 2:26 p.m., indicated .administer medications in a safe and effective manner A facility policy, titled Guidelines for Handling Linen, dated as last reviewed 12/31/23 and received from the Corporate Support Nurse on 4/2/24 at 11:25 a.m., indicated .PURPOSE: To provide clean, fresh linen to each resident .To prevent contamination of clean linen .Linens should be carried away from the body to prevent contamination from clothing 3.1-18(b) 3.1-19(g)(2)

Based on interview and record review, the facility failed to ensure a staff member had a valid nursing license for 1 of 21 nurses reviewed for current licenses. (Registered Nurse 9) Finding includes: During the staff nurse license review, on 4/3/24 at 10:32 a.m., Registered Nurse (RN) 9 had a RN license for the state of New Mexico. RN 9 did not have a nurse compact license (a license which included multiple states). The RN license for the State of Indiana was pending. RN 9 had worked the following shifts at the facility: a. Night shift in training on 3/10/24. b. Night shift in training on 3/12/24. c. Night shift on 3/15/24. d. Night shift on 3/16/24. e. Night shift on 3/17/24. f. Night shift on 3/18/24. g. Evening shift on 3/20/24. h. Evening shift from 6:00 p.m. until 6:00 a.m., on 3/22/24. i. Evening shift from 6:00 p.m. until 6:00 a.m., on 3/23/24. j. Evening shift from 6:00 p.m. until 6:00 a.m., on 3/24/24. k. Evening shift on 3/26/24. l. Evening shift on 3/27/24. m. Night shift on 3/29/24. n. Night shift on 3/30/24. o. Night shift on 3/31/24. p. Evening shift 4/2/24. During an interview, on 4/3/24 at 10:34 a.m., the Executive Director (ED) indicated she thought RN 9 had a valid Indiana license even though it was not showing on the Indiana Professional Licensing Agency website. During an interview, on 4/3/24 at 3:01 p.m., the Clinical Support Nurse indicated RN 9 had applied for her Indiana RN license in February 2024 and had not received it yet. Someone in the facility's corporate staff had told them RN 9 could work while her Indiana license was pending. A current policy, titled Background Check Screening Policy, dated as last updated June 2023 and received from the Clinical Support Nurse on 4/3/24 at 3:43 p.m., indicated .Professional credential, work history and personal and professional reference checks will be verified prior to an offer being extended 3.1-14(s)

Based on interview and record review, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) options were documented as reviewed with the resident in the Electronic Health Record (EHR) and the resident choose correctly for 2 of 3 residents reviewed for beneficiary notices. (Resident 20 and I) Findings include: 1. The SNF ABN notice for Resident 20 indicated, starting on 2/21/24, the resident may have to pay out of pocket for the care listed which may not meet Medicare requirements. The care included skilled nursing, physical therapy, occupational therapy, speech therapy, labs, X-ray, treatments, and extras as needed. The resident was to make an informed decision about their care. The resident chose Option 3 which indicated the resident did not want the care listed and understood she was not responsible for paying for the care. The resident remained in the facility and continued to receive some of the care listed on the SNF ABN notice. 2. The SNF ABN notice for Resident I indicated, starting on 2/3/24, the resident may have to pay out of pocket for the care listed which may not meet Medicare requirements. The care included skilled nursing, physical therapy, occupational therapy, speech therapy, labs, X-ray, treatments, and extras as needed. The resident was to make an informed decision about their care. The resident chose Option 3 which indicated the resident did not want the care listed and understood he was not responsible for paying for the care. The resident remained in the facility and continued to receive some of the care listed on the SNF ABN notice. During an interview, on 4/1/24 at 3:00 p.m., the Social Services Director (SSD) indicated she thought option 3 was if the resident wanted to continue the care although did not want Medicare to be billed. She indicated she guessed she was advising the residents wrong about which option to choose. She did not document the conversations with the residents/representatives about the SNF ABN notice and the options which were explained in the electronic health record. A current policy, titled NOMNC [notice of Medicare non-coverage] Completion SOP [standard operating procedure], dated as reviewed on 10/24/22 and received from the Clinical Support Nurse on 4/2/24 at 3:00 p.m., indicated .To streamline communication for completion of the Notice of Medicare Non-Coverage [NOMNC] and Skilled Nursing Facility Advanced Beneficiary Notice [SNF ABN], this SOP outlines the expectations for completion .When is a campus required to issue an ABN .Only issue when the resident intends to continue services and the campus believes the services may not be covered under Medicare 3.1-4(f)(3)

Based on interview and record review, the facility failed to ensure a lab was obtained according to the physician's order and prior to giving an antibiotic for 1 of 2 residents reviewed for antibiotics. (Resident I) Findings include: The clinical record for Resident I was reviewed on 4/3/24 at 2:56 p.m. The diagnoses included, but were not limited to, right neck femur (thigh bone) fracture, methicillin-resistant staphylococcus aureus (infection usually associated with invasive procedures or devices, such as surgeries) and anxiety disorder. A care plan, dated as revised on 4/1/24, indicated the resident required Intravenous (IV) medication related to an infection. Interventions included, but were not limited to, assessing for complication from the IV site and administering IV medications as ordered. A physician's order, dated 3/14/24 to 3/25/24, indicated vancomycin (an antibiotic) reconstituted solution infusing 1.5 gram by IV daily. A physician's order, dated 3/18/24, indicated to obtain a vancomycin trough (trough levels should be obtained within 30 minutes before the next scheduled dose) lab draw one time. No results for the lab draw ordered on 3/18/24 were in the resident's medical record. A physician's order, dated 3/24/24, indicated to obtain a vancomycin trough lab draw one time. A physician's order, dated 3/26/24 to 4/3/24, indicated vancomycin 750 milligram (ml) intravenous solution every 12 hours. During an interview, on 4/3/24 at 3:20 p.m., the Assistant Director of Nurse Services (ADNS) indicated the vancomycin lab was ordered on 3/18/24. The pharmacy called on 3/21/24, to ask for the results to adjust the resident's medication. The ADNS had no record of the lab results for 3/18/24. The pharmacy told the ADNS to continue the same dosage until the lab results were available. On 3/24/24, the antibiotic dosage was adjusted. The ADNS indicated the nurse either did not put the blood drawn in the correct tub or the lab lost the specimen. During an interview, on 4/3/24 at 12:23 p.m., the Clinical Support Nurse indicated the facility should have obtained the vancomycin level on the resident and they did not. A current policy, titled Ordering Lab Test, not dated and received from the Clinical Support Nurse on 4/3/24 at 12:21 a.m., indicated .Once the specimen has been collected, call [name of lab] Customer Care Team to arrange for transport of your STAT (immediate) specimen(s) to the STAT partner with which we have contracted to you A current policy, titled Antibiotic Stewardship Guideline, dated 11/10/17 and received from the Executive Director at entrance, indicated .Optimize the treatment of infections by ensuring that residents who require an antibiotic, are prescribed the appropriate antibiotic. Reduce the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use .Obtain and review laboratory reports for campus trends of resistance. Monitor antibiotic resistance patterns (MRSA) .Pharmacy provider will assist in review of all antibiotic usage for appropriateness 3.1-48(a)(3)

Based on interview and record review, the facility failed to ensure a physician's order was transcribed correctly to the Medication Administration Record (MAR), to ensure a physician's order was followed, and to notify the physician when a physician's order was not followed for 1 of 1 resident reviewed for dialysis (Resident 25) and failed to monitor and document bowel movements for 2 of 5 residents reviewed for bowel and bladder function. (Resident F and G) Findings include: 1. The clinical record for Resident 25 was reviewed on 4/3/24 at 4:19 p.m. The diagnoses included, but were not limited to, kidney disease with heart failure and with stage 5 chronic kidney disease or end stage renal disease, type 2 diabetes mellitus with diabetic chronic kidney disease, and dependence on renal dialysis. A care plan, dated 1/11/24, indicated the resident received diuretic medication related to congestive heart failure (CHF). The approaches included, but were not limited to, administering the medications as ordered by the physician and reporting adverse drug reactions as needed. A care plan, dated 1/22/24, indicated the resident had a potential for weight fluctuations due to receiving dialysis treatments. The goal included maintaining appropriate weights. The approaches included, but were not limited to, obtaining weight as ordered and periodically reviewing renal specific weights. A physician's order, dated 12/9/23, indicated to give furosemide (a diuretic) 40 milligram (mg) daily as needed (prn) for a weight gain of 5 pounds in one week for a diagnosis of acute on chronic diastolic congestive heart failure. A physician's order, dated 12/14/23, indicated to weigh the resident once a month. The vital records form indicated the resident had the following weights: a. On 12/13/23, the weight was 193.8 pounds. b. On 12/18/23, the weight was 213.2 pounds which was a 19.4-pound weight gain in 5 days. c. On 12/27/23, the weight was 194 pounds. d. On 1/3/24, the weight was 202.4 pounds which was an 8.4-pound weight gain in 7 days. e. On 2/9/24, the weight was 189.8 pounds. f. On 2/12/24, the weight was 197.5 pounds which was a 7.7-pound weight gain in 3 days. g. On 3/8/24, the weight was 186.8 pounds. h. On 3/15/24, the weight was 194.2 pounds which was a 7.4-pound weight gain in 7 days. The MAR, dated 12/1/23 through 4/4/24, indicated to give furosemide 40 mg once a day as needed for acute on chronic diastolic congestive heart failure. The MAR did not include for a weight gain of 5 pounds in one week and did not include any resident weights. The MAR, dated December 2023 through April 2024, showed no furosemide as needed had been administered at all since the physician's order had been obtained. During an interview, on 4/4/24 at 12:07 p.m., the Clinical Support Nurse indicated the physician's order should have been clarified, and the resident's weights should have been recorded on the MAR to show if there had been the 5-pound weight gain. The Clinical Support Nurse indicated the facility pharmacy had not noted a discrepancy with this order. The physician was not notified the order had not been followed. 2. The clinical record for Resident F was reviewed on 4/1/24 at 9:00 a.m. The diagnoses included, but were not limited to, Parkinsonism, dementia, and hypothyroidism. A quarterly Minimum Data Set assessment, dated 1/29/24, indicated the resident was moderately impaired cognitively and was frequently incontinent of bowel. A care plan, initiated 2/16/24, indicated the resident had a potential for constipation. Interventions included, but were not limited to, documenting the frequency and character of bowel movements, and to administer medications/enemas/suppository as ordered. A physician's order, initiated on 11/2/23, indicated to give Miralax 17 grams once a day as needed. A physician's order, initiated on 11/19/23, indicated if the resident had no bowel movement within 72 hours the following bowel protocol may be implemented; give 2 tablespoons of Natural Laxative as needed once a day, if no results within 24 hours after the Natural Laxative, then give 30 cc (equal to 30 milliliters) of Milk of Magnesia (MOM) as needed once a day. If no results within approximately 12 hours of the MOM administration, give a Dulcolax suppository as needed once a day. If the results are not satisfactory within 2 hours of the suppository administration give a fleet's enema as needed once a day. The clinical record did not have a recorded bowel movement from 1/1/24 to 1/4/24 (4 days), 1/30/24 to 2/3/24 (5 days), and 2/27/24 to 3/2/24 (5 days). There was no documentation of a bowel assessment in the record or staff had spoken to the resident about his bowel movements. There was no ineffective bowel event or abdominal assessment found in the record. 3. The record for Resident G was reviewed on 4/2/24 at 10:14 a.m. The diagnoses included, but were not limited to, constipation, epigastric pain, and difficulty walking. An annual Minimum Data Set assessment, dated 2/2/24, indicated the resident was moderately cognitively impaired. A care plan, initiated 9/6/20, indicated the resident had the potential for constipation. Interventions included, but were not limited to, documenting frequency and character of bowel movements and to administer medications/enemas/suppositories as ordered. A physician's order, dated 12/9/23, indicated may use bowel protocol as needed. A physician's order, dated 12/9/23, indicated docusate sodium capsule (a laxative) 100 milligrams. Give two times a day as needed for constipation. A physician's order, dated 12/9/23, indicated to give Miralax powder 17 grams daily as needed for constipation. There was no recorded bowel movement found in the record for 2/20/24 to 2/25/24 (6 days), 2/28/24 to 3/2/24 (4 days) and 3/4/24 to 3/11/24 (8 days). There was no documentation of a bowel assessment in the record or staff had spoken to the resident about his bowel movements. During an interview, on 4/1/24 at 3:44 p.m., the Corporate Support Nurse indicated the facility did not have nursing notes, a bowel assessment, or observations noted, and the staff should ask the resident if they had a bowel movement. A current policy, titled Guidelines for Medication Orders, dated as reviewed on 12/31/23 and received from the Clinical Support Nurse on 4/3/24 at 2:34 p.m., indicated .To establish uniform guidelines in the receiving and recording of medication orders .PRN Medication orders .When recording PRN orders specify .The type, route, dosage, frequency, strength and the reason for administration A current policy, titled Physician-Provider Notification Guidelines, dated as reviewed on 12/31/23 and received from the Clinical Support Nurse on 4/4/24 at 4:26 p.m., indicated .To ensure the resident's physician or practitioner .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 A current facility policy, titled Bowel Protocol Guidelines, dated as last reviewed on 12/31/24 and received from the Corporate Support Nurse on 4/1/24 at 3:44 p.m., indicated .The Ineffective Bowl Pattern Event should be initiated for any resident not have a BM (bowel movement) with 72 hours .A progress note associated to the Ineffective Bowel Event, should be completed until the resident has a BM .The progress note should include abdominal distention, pain and bowel sounds .Nursing staff shall assess for effectiveness, orders may be written as follows .If no bowel movement within 72 hours, 2 tablespoons (30 cc) of 'Natural Laxative' .if no results within 24 hours, after .give 30 cc of Milk of Magnesia .if no results within approximately 12 hours after MOM administer Dulcolax suppository .If results of suppository are not satisfactory within 2 hours give Fleets enema .Nursing staff will enter bowel movements, in the .system each shift 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure a current nurse staff posting was displayed daily at the beginning of each shift for 1 of 7 days reviewed for nurse staff posting. (3/27/24) Finding includes: During an observation, on 3/27/24 at 11:06 a.m., the daily nurse staff posting displayed at the reception desk was dated for 3/25/24. During an interview, on 3/27/24 at 11:08 a.m., the Executive Director (ED) indicated the scheduler was off and the daily staff posting was not updated. The daily staff posting should be displayed daily. A current policy, titled Guidelines for Staff Posting, dated as revised on 5/11/16 and received from the Clinical Support Nurse on 3/28/24 at 11:51 a.m., indicated .To ensure compliance with federal regulations requiring posting on a daily basis for each shift, the number of nursing personnel responsible for providing direct resident care .At the beginning of the day the number and amount of hours of licensed nurses (RN and LPN) and the number and hours of unlicensed nursing personnel, per shift, who provide direct care to residents will be posted .Staffing sheets should be posted in a common area easily visible upon entry to the campus 3.1-17(a)

Based on interview and record review, the facility failed to maintain a record of disposition/return of unused and discontinued medications to the pharmacy and failed to ensure a licensed physician or nurse practitioner authorized or prescribed medications for 5 of 5 residents reviewed for pharmacy services. (Resident 2, 3, 4, 5, and 6) The deficient practice was corrected on 11/02/23, prior to the start of the survey and was therefore past noncompliance. Findings include: During an interview, on 11/06/23 at 10:10 a.m., the Executive Director indicated RN 2 was an employee with the facility. She had worked with another nurse who was terminated prior. RN 2 and the former employee were working together. RN 2 would take the medications out of the facility and give them to the former employee. The medications were antibiotics and an antifungal which had been discontinued and had not been returned to the pharmacy for credit. The medications were discontinued orders except for the Rifampin (an antibiotic) and the Terbinafine (an antifungal). The Rifampin and Terbinafine were not ordered by the facility Nurse Practitioner or the Physician. RN 2 wrote the scripts and placed the orders early to ensure they made the delivery and then discontinued the medications after she knew they were on the way to the facility. None of the residents involved received any medications they did not have ordered. There were no narcotics involved. 1. The record for Resident 2 was reviewed on 11/09/23 at 12:57 p.m. Diagnoses included, but were not limited to, surgical wound after care, disruption (reopening) of a surgical wound, and bariatric surgery status. A physician's order, dated 6/26/23, indicated to give Bactrim DS (an antibiotic) 800-160 mg (milligram) twice a day. The Medication Administration Record indicated the resident received 18 doses of the medication, refused one dose, and missed two doses because she was in the hospital. During an interview, on 11/09/23 at 12:57 p.m., the Corporate Support Nurse indicated a dose was pulled from the EDK (Emergency Drug Kit) and the resident refused the medication. The resident was off campus in the emergency department on 7/29 to 7/30/23. The wound clinic wrote the order. The medication was filled by the facility pharmacy and the EDK. She was not sure how many pills were taken, and the facility was not completing the medication disposition records at that time. 2. The record for Resident 3 was reviewed on 11/09/23 at 1:02 p.m. Diagnoses included, but were not limited to, malignant neoplasm of the bladder (bladder cancer), sepsis (a severe infection), and bacteremia (bacteria in the blood stream). A physician's order, dated 6/08/23, indicated to give Bactrim DS (an antibiotic) 800-160 milligrams twice a day. The order was discontinued on 6/09/23. A physician's order, dated 6/09/23, indicated to give Bactrim DS 800-160 milligrams twice a day. The order was discontinued on 6/12/23. A physician's order, dated 6/12/23, indicated to give Bactrim DS 800-160 milligrams twice a day. The order was discontinued on 6/15/23. The Medication Administration Record indicated the resident received 13 tablets of the medications. 30 tablets were diverted per the facility's investigation. During an interview, on 11/09/23 at 1:02 p.m., the Corporate Support Nurse indicated the resident's medication was discontinued on 6/12/23. The medications were not returned to the pharmacy for credit. There were three (3) separate orders filled. 3. The record for Resident 4 was reviewed on 11/09/23 at 1:05 p.m. Diagnoses included, but were not limited to, urinary tract infection, chronic kidney disease, and dementia. A physician's order, dated 6/08/23, indicated to give sulfamethoxazole-trimethoprim (an antibiotic) 800-160 mg twice a day. The order was discontinued on 6/13/23 due to the resident discharged from the facility. The Medication Administration Record indicated the resident received 11 doses of the medication. She was prescribed to take it twice a day for five (5) days. During an interview, on 11/09/23 at 1:05 p.m., the Corporate Support Nurse indicated all doses were charted as given on the Medication Administration Record. The resident was reviewed for diversion because the police had provided the prescription number for the medications. She indicated the first dose may have been taken from the Emergency Drug Kit. 4. The record for Resident 5 was reviewed on 11/09/23 at 1:20 p.m. Diagnoses included, but were not limited to, dementia, pleural effusion, and multiple left sided rib fractures. A physician's order, dated 8/13/23, indicated to give terbinafine hydrochloride (an antifungal) 500 mg immediately. This medication was ordered by RN 2 and was not authorized by the resident's physician or nurse practitioner. A physician's order, dated 8/13/23, indicated to give terbinafine hydrochloride 500 mg once a day. Two tablets of terbinafine 250 mg were sent to the facility. The Medication Administration Record indicated no medication was provided to the resident and the medication was discontinued on 8/13/23. During an interview, on 11/09/23 at 1:20 p.m., the Corporate Support Nurse indicated RN 2 ordered the medication in the morning and discontinued the medication late. There was no physician's order for the terbinafine. The pharmacy did send the medication to the facility and the nurse took it before the order was printed on the Medication Administration Record. 5. The record for Resident 6 was reviewed on 11/09/23 at 1:28 p.m. Diagnoses included, but were not limited to, Parkinson's disease, asthma, and cyst of the kidney. A physician's order, dated 7/22/23, indicated to give Rifampin (an antibiotic) 300 mg twice a day. The order was discontinued on 07/22/23. This medication was ordered by RN 2 and was not authorized by the resident's physician or nurse practitioner. A narrative from the Police Department indicated a former staff member, who was terminated from the facility on 6/21/23, was stopped by the police on 8/18/23. He was driving a car registered to RN 2. During the search and seizure of goods from the vehicle, medications identified as belonging to the residents in the facility were found. A facility document, titled Trilogy Health Services, LLC Statement of Witness Form, dated 8/23/23 and received by the Executive Director on 11/06/23 indicated, RN 2 contacted the facility via cell phone and was informed of the arrest of another RN while he was in possession of her car. There were several prescription medications which were traced back to former and current residents in the facility. She was informed as part of the investigation she was suspended from her position. RN 2 initially denied knowledge of how the former employee came into possession of the medications from the facility and indicated she .must have left them in her bag instead of destroying them The order for Rifampin was questioned as the Nurse Practitioner told the facility she did not order the medication. RN 2 then indicated she took the medications, from the campus, with purpose. RN 2 indicated the former staff member needed the medication and had no other way of getting them. He had contacted her in late July and requested she get the medications for him. She indicated she attempted to order the medication online but could not get them due to not having a prescription. Resident 3's Bactrim had been discontinued and not returned to the pharmacy, so she took the medication. Resident 2 also had left over medications, and she took those. Resident 4 had a prescription which had been ordered twice but only delivered to the facility on ce, she removed them from the facility also. Resident 6 did not have an order for Rifampin, she placed/wrote an order for the medication and then stopped/discontinued the order later in the evening. The medication came in and she removed it from the facility. RN 2 stated she took all the medications, from the facility, over one weeks' time. The facility requested RN 2 provide a statement within an hour, but the facility never received a statement from RN 2. RN 2 was terminated from employment on 08/29/23 for gross misconduct. During an interview on 11/08/23 at 9:33 a.m., the Corporate Support Nurse indicated all the residents effected were on the skilled unit. All the residents except for Resident 4 were covered by Medicare Part A insurance. Resident 4 was private pay. The facility paid for all the medication bills including Resident 4, due to the theft by their staff member. She indicated RN 2 ordered or refilled medications early in the morning and when the medications were processed and sent out, she would discontinue the orders. The medications did not show up on the Medication Administration Record (MAR). The residents did not receive any medications they were not ordered to receive. The medications had either been discontinued or the medication course had been completed. The medications, that were left over, were stored in the medication room and the returns had not been sent back to the pharmacy. RN 2 told the facility everything about how she acquired the medications and admitted to the diversion of the drugs. After the incident medication audits were completed, the medication carts were audited, staff was educated on return/disposition of medications, and RN 2 was terminated from employment. During a telephone interview on 11/09/23 at 3:21 p.m., Nurse Practitioner 3 indicated the Rifampin and Terbinafine had not been ordered or authorized to be ordered and nurses are not authorized to order medications without a licensed provider's authorization. A facility job description, titled Registered Nurse (RN), undated and received by the Corporate Support Nurse on 11/09/23 at 1:41 p.m., indicated .Administer and document medication .per the physician's order A current facility policy, titled Guidelines for Medication Orders, dated as last reviewed 12/31/2022 and received from the Executive Director on 11/09/23 at 1:34 p.m., indicated .Each resident shall be under the care of a licensed physician authorized to practice medication in the state where care is provided .Physician orders .must be signed and dated in accordance with state regulations The deficient practice was corrected by 11/02/23 after the facility terminated Registered Nurse 2, implemented drug disposition procedures, performed disposition audits, medication cart audits and educated their staff on abuse and misappropriation of property. 3.1-25(e)(2) 3.1-25(o)

Based on interview and record review, the facility failed to protect residents from misappropriation of property, specifically medications, when a Registered Nurse removed discontinued medications from the facility without consent and ordered medications without the authorization of a licensed medical provider and then removed them from the facility for 5 of 5 residents reviewed for misappropriation of property. (Resident 2, 3, 4, 5, and 6) The deficient practice was corrected on 11/02/23, prior to the start of the survey and was therefore past noncompliance. Findings include: During an interview, on 11/06/23 at 10:10 a.m., the Executive Director indicated RN 2 was an employee with the facility. RN 2 would take medications out of the facility and give them to another party not affiliated with the facility. She indicated the medications were antibiotics and an antifungal. The medications were discontinued except for the Rifampin (an antibiotic) and the Terbinafine (an antifungal). None of the residents involved received any medications they did not have ordered. The Rifampin and Terbinafine were not ordered by the facility Nurse Practitioner or the Physician. RN 2 wrote the scripts and placed the orders early to ensure they made the delivery and then discontinued the medications after she knew they were on the way to the facility. The other antibiotics were discontinued medications which had not been returned to the pharmacy. There were no narcotics involved. 1. The record for Resident 2 was reviewed on 11/09/23 at 12:57 p.m. Diagnoses included, but were not limited to, surgical wound after care, disruption (reopening) of a surgical wound, and bariatric surgery status. A physician's order, dated 6/26/23, indicated to give Bactrim DS (an antibiotic) 800-160 mg (milligram) twice a day. The Medication Administration Record indicated the resident received 18 doses of the medication, refused one dose, and missed two doses because she was in the hospital. During an interview, on 11/09/23 at 12:57 p.m., the Corporate Support Nurse indicated a dose was pulled from the EDK (Emergency Drug Kit) and the resident refused the medication. The resident was off campus in the emergency department on 7/29 to 7/30/23. The wound clinic wrote the order. The medication was filled by the facility pharmacy and the EDK. She was not sure how many pills were taken, and the facility was not completing the medication disposition records at that time. 2. The record for Resident 3 was reviewed on 11/09/23 at 1:02 p.m. Diagnoses included, but were not limited to, malignant neoplasm of the bladder (bladder cancer), sepsis (a severe infection), and bacteremia (bacteria in the blood stream). A physician's order, dated 6/08/23, indicated to give Bactrim DS (an antibiotic) 800-160 milligrams twice a day. The order was discontinued on 6/09/23. A physician's order, dated 6/09/23, indicated to give Bactrim DS 800-160 milligrams twice a day. The order was discontinued on 6/12/23. A physician's order, dated 6/12/23, indicated to give Bactrim DS 800-160 milligrams twice a day. The order was discontinued on 6/15/23. The Medication Administration Record indicated the resident received 13 tablets of the medications. 30 tablets were diverted per the facility's investigation. During an interview, on 11/09/23 at 1:02 p.m., the Corporate Support Nurse indicated the resident's medication was discontinued on 6/12/23. The medications were not returned to the pharmacy for credit. There were three (3) separate orders filled. 3. The record for Resident 4 was reviewed on 11/09/23 at 1:05 p.m. Diagnoses included, but were not limited to, urinary tract infection, chronic kidney disease, and dementia. A physician's order, dated 6/08/23, indicated to give sulfamethoxazole-trimethoprim (an antibiotic) 800-160 mg twice a day. The order was discontinued on 6/13/23 due to the resident discharged from the facility. The Medication Administration Record indicated the resident received 11 doses of the medication. She was prescribed to take it twice a day for five (5) days. During an interview, on 11/09/23 at 1:05 p.m., the Corporate Support Nurse indicated all doses were charted as given on the Medication Administration Record. The resident was reviewed for diversion because the police had provided the prescription number for the medications. She indicated the first dose may have been taken from the Emergency Drug Kit. 4. The record for Resident 5 was reviewed on 11/09/23 at 1:20 p.m. Diagnoses included, but were not limited to, dementia, pleural effusion, and multiple left sided rib fractures. A physician's order, dated 8/13/23, indicated to give terbinafine hydrochloride (an antifungal) 500 mg immediately. This medication was ordered by RN 2 and was not authorized by the resident's physician or nurse practitioner. A physician's order, dated 8/13/23, indicated to give terbinafine hydrochloride 500 mg once a day. Two tablets of terbinafine 250 mg were sent to the facility. The Medication Administration Record indicated no medication was provided to the resident and the medication was discontinued on 8/13/23. During an interview, on 11/09/23 at 1:20 p.m., the Corporate Support Nurse indicated RN 2 ordered the medication in the morning and discontinued the medication late. There was no physician's order for the terbinafine. The pharmacy did send the medication to the facility and the nurse took it before the order was printed on the Medication Administration Record. 5. The record for Resident 6 was reviewed on 11/09/23 at 1:28 p.m. Diagnoses included, but were not limited to, Parkinson's disease, asthma, and cyst of the kidney. A physician's order, dated 7/22/23, indicated to give Rifampin (an antibiotic) 300 mg twice a day. The order was discontinued on 07/22/23. This medication was ordered by RN 2 and was not authorized by the resident's physician or nurse practitioner. A narrative from the Police Department indicated a former staff member, who was terminated from the facility on 6/21/23, was stopped by the police on 8/18/23. He was driving a car registered to RN 2. During the search and seizure of goods from the vehicle, medications identified as belonging to the residents in the facility were found. A facility document, titled Trilogy Health Services, LLC Statement of Witness Form, dated 8/23/23 and received by the Executive Director on 11/06/23 indicated, RN 2 contacted the facility via cell phone and was informed of the arrest of another RN while he was in possession of her car. There were several prescription medications which were traced back to former and current residents in the facility. She was informed as part of the investigation she was suspended from her position. RN 2 initially denied knowledge of how the former employee came into possession of the medications from the facility and indicated she .must have left them in her bag instead of destroying them The order for Rifampin was questioned as the Nurse Practitioner told the facility she did not order the medication. RN 2 then indicated she took the medications, from the campus, with purpose. RN 2 indicated the former staff member needed the medication and had no other way of getting them. He had contacted her in late July and requested she get the medications for him. She indicated she attempted to order the medication online but could not get them due to not having a prescription. Resident 3's Bactrim had been discontinued and not returned to the pharmacy, so she took the medication. Resident 2 also had left over medications, and she took those. Resident 4 had a prescription which had been ordered twice but only delivered to the facility on ce, she removed them from the facility also. Resident 6 did not have an order for Rifampin, she placed/wrote an order for the medication and then stopped/discontinued the order later in the evening. The medication came in and she removed it from the facility. RN 2 stated she took all the medications, from the facility, over one weeks' time. The facility requested RN 2 provide a statement within an hour, but the facility never received a statement from RN 2. RN 2 was terminated from employment, on 8/29/23, for gross misconduct. During an interview, on 11/08/23 at 9:33 a.m., the Corporate Support Nurse indicated all the residents affected, in the diversion of the medications, were on the skilled unit. She indicated RN 2 ordered or refilled medications early in the morning and when the medications were processed and sent out, she would discontinue the orders. The medications did not show up on the Medication Administration Record (MAR). The residents did not receive any medications they were not ordered to receive. The medications had either been discontinued or the medication course had been completed. The medications, which were left over, were stored in the medication room and the returns had not been sent back to the pharmacy. RN 2 told the facility everything about how she acquired the medications and admitted to the diversion of the drugs. After the incident medication audits were completed, the medication carts were audited, staff was educated on return/disposition of medications, and RN 2 was terminated from employment. During a telephone interview, on 11/09/23 at 3:21 p.m., Nurse Practitioner 3 indicated the Rifampin and Terbinafine medications had not been ordered or authorized to be ordered. Nurses were not authorized to order medications without a licensed provider's authorization. A current facility policy, titled Guidelines for Medication Orders, dated as last reviewed 12/31/2022 and received from the Executive Director on 11/09/23 at 1:34 p.m., indicated .Each resident shall be under the care of a licensed physician authorized to practice medication in the state where care is provided .Physician orders .must be signed and dated in accordance with state regulations A current facility policy, titled Long-Term Care/Abuse and Incident Reporting Policy, dated as effective 12/08/22 and received by the Executive Director on 11/06/23 at 1:10 p.m., indicated .Misappropriation of resident property/exploitation .Missing prescription medications .Misappropriation of resident property: Deliberate misplacement .wrongful temporary or permanent use of a resident's property .without the resident's consent. Includes any medication dispensed in the name of the resident A current facility policy, titled Abuse and Neglect Procedural Guidelines, dated as last reviewed 8/29/19 and received from the Executive Director on 11/06/23 at 1:10 p.m., indicated .Misappropriation of Property-means the deliberate misplacement, exploitation or wrongful, temporary, or permanent use of a resident's belongings .without the resident's consent The deficient practice was corrected by 11/02/23 after the facility terminated Registered Nurse 2, implemented drug disposition procedures, performed disposition audits, medication cart audits, and educated their staff on abuse and misappropriation of property. 3.1-28(a)

Based on observation, interview and record review, the facility failed to ensure masks were worn correctly in the kitchen, failed to keep boxes off the floor of the freezer, failed to ensure foods were kept closed in the freezer and failed to ensure foods which had been opened were labeled with open dates. This deficient practice had the potential to affect 51 of 51 residents receiving food from the kitchen. Findings include: 1. a. During an observation of the kitchen with the Dietary Manager, on 01/23/22 beginning at 9:30 a.m., Cook 24 was observed working over a bowel of potatoes, which was prepared for all residents, with his face mask below his nose and chin. At that time, the Dietary Manager indicated the mask was to be worn over the nose and mouth. b. In the cooler, three (3) boxes were found stored on the floor. The Dietary Manager indicated the boxes should not have been stored on the floor, they were just put there. 2. a. During a follow up visit to the kitchen with the Dietary Manager in attendance, on 01/24/23 at 2:26 p.m., a box of hamburger patties was found in the freezer. The box was not sealed, and the patties were left open to air. b. A rectangular plastic container full of onion rings was found exposed to air due to the lid was resting on top of the container and not sealed. The container was over-filled, and the lid was not secured. c. A 40-ounce bag of onion rings approximately 1/8 full was found open and without an open date. d. A one gallon container of milk was found in the cooler. The container was half full and did not have an open date. At that time, the Dietary manager indicated it should have had an open date on the container. e. A box containing 16 large Italian sausages was found open to air in the freezer. At that time, the Dietary Manager indicated it should not have been left open to air. f. A ten (10) pound box of catfish fillets, approximately 1/8 full was found open to air with ice crystals on the fillets. The Dietary Manager indicated the boxes were supposed to be closed after getting food items out of the boxes. g. A bag of mixed vegetables, 1/4 full, was found to be opened and sealed with plastic wrap. There was no date to indicate when the bag had been originally opened. A facility policy, titled POLICY, dated as approved on 01/02/23 and provided by the Corporate Support Nurse on 01/30/23 at 12:42 p.m., indicated .REFRIGERATED STORAGE .Food is covered, dated and stored loosely to permit air circulation .FROZEN STORAGE .All foods in the freezer are wrapped in moisture proof wrapping or placed in suitable containers, to prevent freezer burn .Items are labeled and dated . The policy did not address storing boxes on the floor of the freezer. A facility policy, titled Food labeling and Dating Policy, dated as revised on 04/26/22 and provided by the Corporate Dietary Manager on 01/24/23 at 3:15 p.m., indicated .Foods in production need both a production date AND a use by date .Foods are considered to be in production when they have been taken out of the original container AND the seal has been broken .All foods must be properly covered (not exposed to air) 3.1-21(i)(3)