Every finding on record at Westminster Village - West Lafayette

Based on interview and record review, the facility failed to ensure the physician was notified immediately and on-call services were utilized when a resident had a change of condition for 1 of 3 discharged residents reviewed for notification of change. (Resident 67) Resident 67 was admitted to the hospital with a bowel obstruction, perforated bowel, and necrosis. The resident required surgical intervention and subsequently died.The immediate jeopardy began, on [DATE] around 9:40 p.m., when Resident 67 had a change of condition which included, a complaint of constipation with ongoing diarrhea, increased pain, shortness of breath, loss of bowel sounds, and excessive belching. RN 2 faxed the physician's office at this time. On [DATE] at 1:58 a.m., Resident 67 was yelling out about abdominal pain and excessive belching. RN 3's assessment noted hypoactive bowel sounds. There was no documentation RN 3 contacted a physician. At 3:14 p.m., RN 4's assessment noted shortness of breath, verbal difficulty finishing sentences, nausea with clear phlegm. Resident 67 was sent to the hospital and admitted for surgery. The Administrator and Director of Nursing (DON) were notified of the immediate jeopardy on [DATE] at 4:50 p.m. The immediate jeopardy was removed on [DATE] but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include:The clinical record for Resident 67 was reviewed on [DATE] at 11:55. The diagnoses included, but were not limited to, morbid obesity, constipation, a cardiac pacemaker, right fibular fracture, hypertension with heart failure, atrial fibrillation, repeated falls, and chronic anticoagulation.The hospital notes, dated [DATE] through [DATE], indicated Resident 67 presented to the emergency room from an Independent Living facility, with complaints of multiple falls. He complained about an onset of diarrhea this morning. A scan of the abdomen and pelvis was completed on [DATE], which showed no acute traumatic abnormality and prominent colonic stool burden (a significant buildup of hardened stool in the colon). His abdomen had no distention, was soft, and not tender. Resident 67 was negative for Clostridioides difficile (C-diff) (a bacterium which causes severe, watery diarrhea, fever, nausea, and abdominal pain).A facility admission nursing progress note, dated [DATE] at 6:58 p.m., indicated Resident 67 had arrived at the facility at 5:15 p.m., and had an admission assessment completed. No signs and symptoms of shortness of breath were noted. His abdomen was round, soft and distended. He had bowel sounds in all four quadrants, and his last bowel movement was yesterday. His blood pressure was 152/62, heart rate was 68, respirations were 18 and oxygen saturation was 95%. An admission shortness of breath assessment, dated [DATE], indicated no shortness of breath was exhibited.A nursing progress note, dated [DATE] at 2:38 a.m., indicated the resident did not have shortness of breath, his abdomen was round, soft and distended. He had bowel sounds in all four quadrants. His blood pressure was 149/66, heart rate was 67, respirations were 17 and oxygen saturation was 95%. The bowel movement documentation, dated [DATE] for 7:00 a.m. to 3:00 p.m. shift, indicated the resident had diarrhea. The size was not documented. A nursing progress note, dated [DATE] at 5:20 p.m., indicated the resident did not have shortness of breath, his abdomen was soft, non-tender and distended. He had bowel sounds in all four quadrants. His blood pressure was 165/77, heart rate was 75, respirations were 17 and oxygen saturation was 93%. A nursing progress note, dated [DATE] at 5:47 p.m., indicated the resident did not have shortness of breath, his abdomen was round, soft, and distended. He had bowel sounds in all four quadrants. His blood pressure was 148/62, heart rate was 62, respirations were 18 and oxygen saturation was 93%. The bowel movement documentation, dated [DATE] for 11:00 p.m. to 7:00 a.m. shift, indicated the resident an x-large bowel movement. The type of bowel movement was not documented.A nursing progress note, dated [DATE] at 1:01 a.m., indicated the resident's abdomen was distended and taut. The resident indicated his abdomen was at baseline. He had bowel sounds in all four quadrants. His blood pressure was 155/61, heart rate was 73, respirations were 20 and oxygen saturation was 95%. The bowel movement documentation, dated [DATE] for 7:00 a.m. to 3:00 p.m. shift, indicated the resident had diarrhea. The size was not documented. A nursing progress note, dated [DATE] at 3:06 p.m., indicated the resident did not have shortness of breath, his abdomen was soft, non-tender and distended. He had bowel sounds in all four quadrants. His blood pressure was 165/77, heart rate was 75, respirations were 17 and oxygen saturation was 93%. A nursing progress note, dated [DATE] at 8:44 p.m., indicated the resident did not have shortness of breath, his abdomen was soft, non-tender and distended. His blood pressure was 167/98, heart rate was 69, respirations were 18 and oxygen saturation was 97%. The bowel movement documentation, dated [DATE] for 3:00 p.m. to 11:00 p.m. shift, indicated the resident had diarrhea. The size was not documented. The bowel movement documentation, dated [DATE] for 11:00 p.m. to 7:00 a.m. shift, indicated the resident had diarrhea. The size was not documented. A nursing progress note, dated [DATE] 3:10 a.m., indicated Resident 67's respirations were even and non-labored. His abdomen was soft and non-tender. He had bowel sounds in all four quadrants. His blood pressure was 159/74, heart rate was 77, respirations were 16 and oxygen saturation was 95%. A physician's progress note, dated [DATE] at 12:11 p.m., indicated Resident 67 was seen for an admission visit. He was admitted from the hospital on [DATE]. Resident 67 denied any pain and reported having loose stools. The physical exam was limited to decrease the risk of exposure to covid between the nurse practitioner, patient and staff. Resident 67 had no apparent distress, and respirations were clear and unlabored. His abdomen was soft, non-tender, and not distended. Staff were encouraged to contact the office with any concerns. Imodium (an antidiarrheal medication) 2 milligrams (mg) was ordered every six (6) hours as needed for loose stools. A nursing progress note, dated [DATE] at 12:19 p.m., indicated the Nurse Practitioner was there to see the resident and a new order was received for Imodium 2 milligrams every six hours as needed for loose stools.The bowel movement documentation, dated [DATE] for 7:00 a.m. to 3:00 p.m. shift, indicated the resident had diarrhea. The size was not documented. A nursing progress note, dated [DATE] at 4:01 p.m., indicated shortness of breath was noted during a conversation with the resident. The resident indicated this was normal for him. He was educated to notify the nurse with an increase of shortness of breath.The Medication Administration Record (MAR) indicated Imodium 2 mg was administered on [DATE] at 4:45 p.m.A nursing progress note, dated [DATE] at 7:28 p.m., indicated Resident 67 complained of an upset stomach. A standing physician's order (preapproved, written medical protocols used in healthcare settings) for calcium carbonate (Tums) (an antacid used for heartburn) 500 mg two (2) tablets every 4 hours as needed for an upset stomach or indigestion for 48 hours was ordered and the physician was notified by fax. The physician's office did not respond to the fax until [DATE] at 12:27 p.m., to acknowledge the new order entered by the facility.A nursing progress note, dated [DATE] at 9:40 p.m., indicated Resident 67 complained of abdominal pain in all quadrants, indicated he was constipated, and had not had a regular bowel movement in a couple weeks and was only having diarrhea. His abdomen was hard, round, and distended. His bowel sounds were not active. His pain was an eight out of ten. Excessive belching was noted during the assessment. The resident stated he took two (2) Alka-Seltzer (a popular fizzy tablet which provides relief for heartburn and indigestion) with 2 cups of water around 7:30 p.m. This note was faxed to the physician.There was no documentation the on-call physician was contacted directly.The physician's office did not respond to the fax until [DATE] at 12:52 p.m.A nursing progress note, dated [DATE] at 1:58 a.m., indicated Resident 67 was heard yelling out while in bed. He complained of abdominal pain with a lot of belching. His abdomen was distended with hypoactive (decreased) bowel sounds. Resident 67 indicated his stomach had not been hard like this. He was concerned about going back to the hospital and indicated he did not want to go back. His blood pressure was 140/67, heart rate was 94, respirations were 22 and oxygen saturation was 97%. There was no documentation the physician was notified.A nursing progress note, dated [DATE] at 3:03 a.m., indicated a standing physician's order (preapproved, written medical protocols used in healthcare settings) for Miralax 17 grams in 4-8 ounces of beverage of choice every day as needed and Dulcolax suppository rectally every day as needed were entered.A nursing progress note, dated [DATE] at 6:03 a.m., indicated Resident 67 complained of abdominal pain. Nursing leadership was called and indicated to complete a bladder scan to check for urinary retention. The MAR indicated Miralax 17 grams was administered on [DATE] at 11:34 a.m.,A nursing progress note, dated [DATE] at 3:14 p.m., indicated Resident 67 was visibly short of breath and had difficulty finishing sentences. His abdomen was firm and distended. He was holding a basin and spitting clear phlegm with complaints of nausea. His bowel sounds were hypoactive, and his most recent bowel movement was diarrhea yesterday. Resident 67 indicated an increased shortness of breath compared to yesterday. His oxygen saturations were 96% and his pulse was 106. He agreed to be sent to the emergency room. A nursing progress note, dated [DATE] at 3:56 p.m., indicated Resident 67 was notably tachypneic (abnormal rapid, shallow breathing) with shallow respirations. Resident 67's abdomen was distended at baseline, but the resident reported abdominal pain and nausea. Resident 67 was noted with an emesis basin at bedside and phlegm on his chin. Resident 67 reported his last solid bowel movement was three (3) months ago. The resident was admitted with loose stools from hospital on [DATE]. He received an as needed dose of Imodium on [DATE] due to continued loose stools throughout the weekend. Resident 67's bowels were hypoactive in the right upper and lower and the left upper quadrants. No bowel sounds were noted in the left lower quadrant for a three-minute duration. Upon palpation, the abdomen was firm and tight. Resident 67 voiced tenderness upon palpation in all four quadrants. The resident was actively belching during the assessment and reported chest pain but was reporting pain to the upper quadrants as the chest pain site. Write auscultated LS, clear throughout. Resident 67 voiced dyspnea (difficulty in breathing) and feeling bloated. He requested medical intervention to relieve the discomfort but indicated I'd rather not go to the ER. Mottling (a blotchy, lace-like skin discoloration from poor blood flow) was noted to the right lower extremity which was a new onset since admission on [DATE]. Bilateral lower extremities were cool in temperature. The resident was visibly restless. The nurse practitioner was notified of the assessment and resident complaints. Per the nurse practitioner, the resident's CT (computed tomography scan) at the hospital prior to discharge noted a large colonic burden, he was not short of breath during her assessment on [DATE], and this sounded like a change in condition. The resident was to be sent to the hospital for evaluation and treatment. Emergency Medical Services (EMS) arrived in room. His blood pressure was 202/90, heart rate was 106, respirations were 30 and oxygen saturation was 96%. A nursing progress note, dated [DATE] at 10:56 p.m., indicated the resident was admitted to the hospital for a perforated bowel and was undergoing surgery.A nursing progress note, dated [DATE] at 9:03 a.m., indicated the hospital was called for an update and indicated the nurse was with the resident and was unable to give an update at this time. The hospital's unit receptionist indicated the resident was admitted for a small bowel obstruction, perforation, and necrosis (death of cells in an organ).A baseline care plan, dated [DATE], indicated Resident 67 needed assistance with activities of daily living. Interventions included, but were not limited to, notify the physician of any increased pain or discomfort. There were no baseline care plans related to bowels or a diagnosis of constipation. A hospital document, dated [DATE] at 3:29 p.m., indicated Resident 67 arrived at the emergency room with shortness of breath and abdominal pain. He was tachycardic, tachypneic and complained of nausea, vomiting and diarrhea. His abdomen had moderate distention and was hard on palpation. A scan completed at 6:06 p.m., indicated extensive pneumoperitoneum (the presence of free air within the abdominal cavity typically indicating a serious, often life-threatening condition, such as a perforated abdominal organ) consistent with hollow viscus perforation (a life-threatening, full-thickness rupture of the stomach or intestines allowing leakage into the abdominal cavity), extensive small bowel dilation (signifies a significant obstruction) and gastric distention (abnormal stretching or enlargement of the stomach) consistent with obstruction, and pneumatosis of the stomach, duodenum, and small bowel (presence of gas within the walls of these gastrointestinal organs). The ileum (the final and longest section of the small intestine) had collapsed. The diagnosis indicated an acute perforated bowel. Resident 67 was taken into surgery at 7:27 p.m. During the surgery, the hospital was unable to fully remove the duodenum and felt it was best to transfer the patient to a tertiary care center (a specialized, high-level hospital which provides advanced, complex medical treatment).The resident passed away on [DATE].During an interview, on [DATE] at 5:03 p.m., the DON indicated there was no documentation the nurse called the physician and they should have when the resident's condition worsened. The nurse should have called the physician and not have faxed since it was at night. During an interview, on [DATE] at 3:25 p.m., the Nurse Practitioner indicated she seen the resident, on [DATE], and completed an assessment. At that time, he was not complaining of pain, his abdomen was not distended, and he had bowel sounds. The resident was having diarrhea which he had at the hospital, she noticed the resident came with an order for Imodium, which was not put into the facility system, so she added the order to his medications as needed. She was never called and informed of the resident's change in condition. She did receive a fax the next morning and responded as soon as she was given the fax. Her office hours are from 8:00 a.m. to 5:00 p.m. If a fax came in after the office was closed, she would not get the fax until the next day. The faxes were gathered by the office receptionist and dispersed out; this meant it could be a while before she would see the fax. If a facility faxed the office after hours, then she would not know there was a concern until the next day. She did not get a call and responded to the fax as soon as she received it. When she received the fax, she ordered an abdominal x-ray, but she did not think the x-ray was completed because he was sent out before it was obtained. She believed the unit manager did call which was when she ordered the resident to be sent to the hospital. If the resident had a concern or a change in condition, the facility should notify the physician or on-call doctor and not fax. During an interview, on [DATE] at 10:08 a.m., Unit Manager 6 indicated when the resident was admitted his abdomen was round, firm and distended. During the admission skin assessment, they rolled Resident 67 over and he was incontinent of a small loose stool. When the resident was rolled back, he was incontinent with another loose stool. He did not have any discomfort when he was turned but did show some shortness of breath. Unit Manager 6 indicated she was the nurse on-call the weekend Resident 67 had a change in condition. RN 3 called her and informed her Resident 67 had complaints if shortness of breath and abdomen pain. Unit Manager 6 told RN 3 to elevate the head of bed, complete a bladder scan, and follow the normal guidelines of what a physician would order. RN 3 never called her back to follow up, and Unit Manager 6 did not call to check on the resident or follow up on his status. Unit Manager 6 indicated RN 3 should have called her back with an update. Unit Manager 6 also did not call RN 3 back for an update. When she came in the following morning and was completing rounds, she asked RN 7 how the resident was. RN 7 indicated Resident 67 had hypoactive bowel sounds. Unit Manager 6 then completed an assessment, found the resident had hypoactive bowel sounds, and reached out to the physician. It was agreed the resident should be sent out to the hospital.During a telephone interview, on [DATE] at 2:25 p.m., RN 2 indicated she did take care of Resident 67 on [DATE] on the evening shift. RN 2 indicated she worked at the facility on a as needed basis. RN 2 indicated Resident 67 had come out of the bathroom, sat in his recliner, and said he had pain in his abdomen. RN 2 indicated Resident 67 abdomen was distend and hard with no bowel sounds present. RN 2 indicated she passed this information on in report to the oncoming shift.A current facility policy, titled Change in a Resident's Condition or Status, dated February 2021 and received from the DON on [DATE] at 4:55 p.m., indicated .promptly notifies the resident, his or her attending physician.of changes in the resident's medical/mental condition. The nurse will notify the resident' attending physician or physician on call when there has been a(an).significant change.need to alter treatment.need to transfer the resident to a hospital.A significant change of condition is a major decline.that.will not normally resolve itself.impacts more than one area of the resident's health.The immediate jeopardy, that began on [DATE], was removed on [DATE], when the facility reviewed the policies and procedures regarding physician notification of change, the Senior Regional Director of Clinical Services reviewed the process for internal communication of resident condition change to nursing management and educated nursing management on physician notification, audits of all residents and of physician notification of condition changes were completed, staff received education on the requirements for physician notification of a change in a residents condition.3.1-5(a)(1)3.1-5(a)(2)3.1-5(a)(3)

Based on interview and record review, the facility failed to ensure the resident and/or resident's representative was provided in writing the facility's bed hold policy upon transfer for 3 of 3 residents reviewed for hospitalization. (Resident 64, 67 and 3)Findings include:1. The clinical record for Resident 64 was reviewed on 1/15/26 at 9:57 a.m. The diagnoses included, but were not limited to, myocardial infarction, acute pulmonary edema, supraventricular tachycardia, respiratory failure with hypoxia, combined systolic (congestive) and diastolic (congestive) heart failure, and type 2 diabetes mellitus. A nursing progress note, dated 9/21/25 at 10:45 p.m., indicated the resident was sent to the emergency room for increased shortness of breath. A nursing progress note, dated 9/25/25 at 4:18 p.m., indicated the resident returned to the facility after a hospital stay for shortness of breath and exacerbation of congestive heart failure. There was no documentation in the electronic medical record to indicate the resident or resident's representative was provided with information in writing of the facility's bed hold policy, including reserve bed payment. 2. The clinical record for Resident 67 was reviewed on 1/16/26 at 11:00 a.m. The diagnoses included, but were not limited to, constipation, right fibular fracture, hypertension with heart failure, and chronic anticoagulation. A nursing progress note, dated 10/21/25 at 3:56 p.m., indicated the resident was sent to the emergency room for shortness of breath, dyspnea, pain, and nausea. A nursing progress note, dated 10/21/25 at 10:56 p.m., indicated the resident was admitted to the hospital with a perforated bowel. There was no documentation in the electronic medical record to indicate the resident or resident's representative was provided with information in writing of the facility's bed hold policy, including reserve bed payment. 3. The clinical record for Resident 3 was reviewed on 1/14/26 at 3:49 p.m. The diagnoses included, but were not limited to, Parkinson's disease, dementia, morbid obesity, hypertensive chronic kidney disease, and personal history of Covid-19. A nursing progress note, dated 11/12/25 at 6:06 p.m., indicated the resident was sent to the hospital due to rectal bleeding. A nursing progress note, dated 11/14/25 at 6:28 p.m., indicated the resident was returned to the facility, at 5:50 p.m., and had been treated for hypernatremia and fluid overload, which had been resolved. A nursing progress note, dated 11/21/25 at 7:34 p.m., indicated the resident was sent to the emergency room for an ileus pattern (sign on imaging such as an x-ray and symptoms of a paralytic ileus, where the intestines temporarily stop moving) which was seen on a previous scan. A nursing progress note, dated 11/21/25 at 10:34 p.m., indicated the resident was being admitted to the hospital for a gastrointestinal bleed of unknown origin. There was no documentation in the electronic medical record to indicate the resident or resident's representative was provided with information in writing of the facility's bed hold policy, including reserve bed payment. During an interview, on 1/20/26 at 2:23 p.m., the Executive Director (ED) indicated the bed hold policy and reserve bed cost were not given to the resident's representative in writing. During an interview, on 1/20/26 at 3:09 p.m., Unit Manager 8 indicated the bed hold policy form was to be completed with all transfers. The bed hold policy was copied after it was completed and sent with a resident when transferred. Representatives of the residents were to be contacted to see if they would like to hold the bed or not. A current facility policy, titled Transfer or Discharge, Facility Initiated, dated as last revised 10/2022 and received from the Director of Nursing on 1/20/26 at 4:44 p.m., indicated .The resident and representative are notified in writing of the following information.The Notice of Facility Bed-Hold and policies. 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 a PASARR (Preadmission Screening and Resident Review) was completed when the resident had a new mental health diagnosis and was prescribed an antipsychotic medication for 1 of 3 residents reviewed for PASARR. (Residents 5)Findings include:The clinical record for Resident 5 was reviewed on 1/15/26 at 12:27 p.m. The diagnoses included, but were not limited to, depressive disorder, anxiety disorder, congestive heart failure, dementia, and hypertension.A physician's order, dated 11/05/25, indicated to administer Rexulti (an atypical antipsychotic medication) 0.5 mg (milligram) one tablet in the morning related to anxiety disorder. A physician's order, dated 11/05/25, indicated to administer buspirone (an anxiolytic medication) 0.5 mg (milligram) one tablet two times a day. A care plan, dated as revised 12/18/25, indicated the resident was at risk for anxious mood as evidenced by becoming fidgety, restless, tearful, anxious, and agitated. The interventions included, but were not limited to, administering medication as ordered.A PASARR level I screen related to the diagnosis of anxiety disorder, and the new medication was not completed until 1/16/26.During an interview, on 1/21/26 at 10:49 a.m., the Social Service Director (SSD) 5 indicated when a resident had a new psychotic medication or a new mental health diagnosis added, a new Level I needed to be completed. The resident did not have a new Level I completed until 1/16/26. A current facility policy, titled Psychotropic Medication Use, dated as revised 7/2022 and received by the Administrator on 1/20/25 at 3:20 p.m., indicated .A psychotropic medication is a medication that affects brain activity associated with mental processes and behavior A current facility policy, titled Behavioral Assessment, Intervention and Monitoring, dated as revised on 7/2020 and received by the Administrator on 1/20/25 at 3:20 p.m., indicated .A psychotropic medication is a medication that affects brain activity associated with mental processes and behavior .psychotropic medication.3.1-16(d)(1)(A)3.1-16(d)(1)(B)

Based on interview and record review, the facility failed to ensure daily weights were obtained as ordered by the physician for 1 of 1 resident reviewed for quality of care. (Resident 9)Findings include: The clinical record for Resident 9 was reviewed on 1/15/26 at 11:33 a.m. The diagnoses included, but were not limited to, congestive heart failure (CHF), dementia, diabetes mellitus, atrial fibrillation, and anxiety disorder.A physician's order, dated 6/28/25, indicated to obtain a post void daily weight in the morning, before breakfast, while wearing pajamas, and to notify the physician if the resident had a two (2) pound weight gain in 24 hours or a five (5) pound or more weight gain in one (1) week. a. The Medication Administration Record (MAR), dated 10/1/25 to 10/31/25, indicated the daily weights were not documented on 10/10/25, 10/18/25, 10/22/25, and 10/29/25.On 10/27/25, Resident 9 had a weight gain of 2.8 pounds.b. The MAR, dated 11/1/25 to 11/30/25, indicated the daily weights were not documented on 11/5/25, 11/7/25, 11/12/25, and 11/25/25.On 11/28/25, Resident 9 had a weight gain of 2.5 pounds.On 11/30/25, Resident 9 had a weight gain of 3.5 pounds. c. The MAR, dated 12/1/25 to 12/31/25, indicated the daily weights were not documented on 12/1/25, 12/8/25, 12/9/25, 12/10/25, 12/11/25, 12/13/25, 12/14/25, 12/16/25, 12/19/25, 12/22/25, 12/23/25, 12/25/25, 12/26/25, and 12/28/25.A care plan related to congestive heart failure was not located in the electronic medical record.During an interview, on 1/21/26 at 12:59 a.m., CNA 9 indicated the nurse told the CNAs which resident needed a daily weight. When the weight was obtained, the CNA told the nurse, and the nurse charted the weight. During an interview, on 1/21/26 at 1:01 p.m., LPN 10 indicated if a resident had an order for a daily weight, the nurse added the resident's name to the CNAs assignment clipboard. Once the CNA obtained the weight, the nurse added the weight to the electronic health record. When a resident had a diagnosis of congestive heart failure, it was important to obtain the weight, and if the resident had a greater than two (2) pound gain in a day the physician should be notified. A current facility policy, titled Daily Weight Monitoring for Residents with Physician Orders, dated 3/13/25 and received from the Director of Nursing on 1/21/26 at 4:15 p.m., indicated .To ensure accurate, consistent monitoring of resident weights as ordered by the physician, and to promptly identify and report clinically significant weight changes .Weights will be obtained upon arising .Void prior to weighing (when able), Be weighed before first meal .Be weighed before dressing, or in consistent light clothing per facility practice .The physician (or designated provider) must be notified of any weight variances per physician orders .Nursing staff will follow physician orders for further assessment, monitoring, or interventions .All notifications and new orders will be documented in the medical record .Nursing staff are responsible for obtaining and documenting weights accurately. Charge nurse or designee is responsible for ensuring physician notification when parameters are met .All staff are expected to adhere to this policy 3.1-37(a)

Based on interview and record review, the facility failed to ensure behavior and side effect monitoring for psychotropic medications, wound care treatments, and catheter care were documented for 4 of 4 residents reviewed for documentation. (Resident 18, 33, 20 and 12) Findings include: 1. The clinical record for Resident 18 was reviewed on 2/24/25 at 10:17 a.m. The diagnoses included, but were not limited to, dementia with anxiety, mood disturbance, psychotic disturbance, anxiety disorder, depression, and delusional disorder. A physician's order, dated 2/15/24, indicated to monitor for side effects of antianxiety medication three times a day. a. The Medication Administration Record (MAR), dated 1/2025, indicated antianxiety medication side effect monitoring was not documented each shift on 1/1/25, 1/9/25, 1/12/25, 1/24/25 and 1/29/25. b. The MAR, dated 2/2025, indicated anti-anxiety medication side effect monitoring was not documented each shift on 2/16/25 and 2/18/24. A physician's order, dated 2/15/24, indicated to monitor side effects of antidepressant medication three times a day. a. The MAR, dated 1/2025, indicated anti-depressant medication side effect monitoring was not documented each shift on 1/1/25, 1/9/25, 1/12/25, 1/24/25, and 1/29/25. b. The MAR, dated 2/2025, indicated anti-depressant medication side effect monitoring was not documented each shift on 2/16/25 and 2/18/25. A physician's order, dated 2/15/24, indicated to monitor for side effects of antipsychotic medication three times a day. a. The MAR, dated 1/2025, indicated antipsychotic medication side effect monitoring was not documented each shift on 1/1/25, 1/9/25, 1/12/25, 1/24/25, and 1/29/25. b. The MAR, dated 2/2025, indicated antipsychotic medication side effect monitoring was not documented each shift on 2/16/25 and 2/18/25. During an interview, on 2/24/25 at 2:46 p.m., Registered Nurse (RN) 1 indicated behavior monitoring and medication side effects should be monitored and documented in the medical record. 2. The clinical record for Resident 33 was reviewed on 2/20/25 at 11:15 a.m. The diagnoses included, but were not limited to, Parkinson's disease without dyskinesia, depression, dementia and anxiety disorder. A care plan, dated 12/22/21, indicated the resident was at risk for altered mood and behaviors. Interventions included, but were not limited to, observing signs and symptoms of behaviors, notifying social services of any changes in behaviors or an increase in signs and symptoms of hallucinations. A care plan, dated 2/15/24, indicated the resident was at risk for anxious moods. Interventions included, but were not limited to, notify social services of any changes in behavior and observe for signs and symptoms of anxiety. A physician's order, dated 5/17/22, indicated to monitor for side effects of antidepressant medication three times a day. a. The MAR, dated 1/2025, indicated anti-depressant medication side effect monitoring was not documented each shift on 1/5/25, 1/8/25, 1/10/25, 1/13/25, 1/18/25 and 1/19/25. b. The MAR, dated 2/2025, indicated anti-depressant medication side effect monitoring was not documented each shift on 2/13/25, 2/14/25 and 2/20/25. A physician's order, dated 9/12/23, indicated to monitor for side effects of antianxiety medication three times a day. a. The MAR, dated 1/2025, indicated antianxiety medication side effect monitoring was not documented each shift on 1/5/25, 1/8/25, 1/10/25, 1/13/25, 1/18/25 and 1/19/25. b. The MAR, dated 2/2025, indicated antianxiety medication side effect monitoring was not documented on the dayshift on 2/12/25. 3. The clinical record for Resident 20 was reviewed on 2/24/25 at 11:10 a.m. The diagnoses included, but were not limited to, Parkinson's disease, hypertension, fibromyalgia, rheumatoid arthritis, osteoarthritis, failure to thrive, anxiety, depression, and paroxysmal atrial fibrillation. A care plan, dated 7/30/23, indicated Resident 20 was at risk for pressure ulcers related to impaired mobility. Interventions included, but were not limited to, treatments if ordered. A physician's order, dated 2/4/24 to 2/18/25, indicated wound care was to be completed once a day to the right buttock. The Treatment Administration Record (TAR), dated 2/1/25 to 2/28/25, indicated wound care documentation was missing for 2/10, 2/12, 2/13, 2/14, and 2/17/25. During an interview, on 2/25/25 at 4:30 p.m., the Director of Nursing indicated the information should have been completed on the TAR. 4. The clinical record for Resident 12 was reviewed on 2/21/25 at 3:00 p.m. The diagnoses included, but were not limited to, diabetes mellitus, chronic kidney disease, urine retention, and traumatic brain injury. A care plan, dated 10/1/24, indicated Resident 12 had an indwelling catheter. Interventions included, but were not limited to, Foley catheter care every shift and as needed. A physician's order, dated 10/1/24, indicated catheter care every shift. The TAR, dated 1/1/25 to 1/31/25, indicated the following: a. There was documentation missing for the catheter care on the day shift for 1/2, 1/7, 1/10, 1/16, 1/22, 1/24, 1/26, 1/29, and 1/30/25. b. There was documentation missing for the catheter care on the evening shift for 1/3, 1,5, 1/6, 1/8, 1/10, 1/13, 1/16, 1/18, 1/19, 1/21, 1/23, and 1/28/25. c. There was documentation missing for the catheter care on the night shift for 1/5, 1/6, 1/8, 1/18, 1/19, 1/25, and 1/30/25. The TAR, dated 2/1/25 to 2/28/25, indicated the following: a. There was documentation missing for the catheter care on the day shift for 2/1, 2/4, 2/6, 2/7, 2/8, 2/10, 2/12, 2/13, 2/14, 2/15, 2/17, 2/18, 2/20, and 2/22/25. b. There was documentation missing for the catheter care on the evening shift for 2/6, 2/11, 2/13, 2/15, 2/16, and 2/22/25. c. There was documentation missing for the catheter care on the night shift for 2/2, 2/7, 2/8, 2/9, 2/12, 2/15, 2/16, 2/17, 2/19, 2/20, 2/21, and 2/22/25. During an interview, on 2/25/25 at 4:30 p.m., the Director of Nursing indicated the information should have been completed on the TAR. During an interview, on 2/25/25 at 8:47 a.m., Licensed Practical Nurse (LPN) 4 indicated the documentation should be completed on the treatment administration record and if the record was left blank it meant it was not completed. A current facility policy, titled Charting and Documentation, dated as revised on 6/2017 and received from the Clinical Executive Director on 2/24/25 at 2:06 p.m., indicated .Documentation in the medical record may be electronic, manual or a combination .Medication administered .Treatments or services performed A current facility policy, titled Psychotropic Medication Use, dated as revised on 7/2022 and received from the Director of Nursing (DON) on 2/26/25 at 1:38 p.m., indicated .A psychotropic medication is any medication that affects brain activity associated with mental process and behavior .Drugs in the following categories .Anti-psychotics, Anti-depressants, Anti-anxiety medication and Hypnotics .Consideration of the use of any psychotropic medication is based on comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms in order to identify underlying causes .Residents receiving psychotropic medications are monitored for adverse consequences A current facility policy, titled Charting Errors and/or Omissions, dated as revised on 12/2006 and received from the Clinical Executive Director on 2/24/25 at 2:06 p.m., indicated .Late entries in the medical record shall be dated at the time of entry and notes as a late entry 3.1-50(a)(1) 3.1-50(a)(2)

Based on interview and record review, the facility failed to ensure staff followed the physician's ordered medication parameters were followed for 2 of 5 residents reviewed for quality of care. (Residents 45 and 33) Findings include: 1. The clinical record for Resident 45 was reviewed on 2/24/25 at 11:46 a.m. The diagnoses included, but were not limited to, end stage renal disease, congestive heart failure, pulmonary edema and atrial fibrillation. A care plan, dated 7/17/24, indicated Resident 45 had a diagnosis of congestive heart failure and chronic end stage renal failure. Interventions included, but were not limited to, give medications as ordered. A physician's order, dated 7/22/24, indicated to give metoprolol (a blood pressure medication) 12.5 milligrams (mg) twice daily with instructions to hold the medication for a systolic blood pressure of less than 100 or a heart rate of less than 60. The Medication Administration Record (MAR), dated 11/1/24 through 11/30/24, indicated metoprolol was administered: a. On 11/7/24, in the morning with a heart rate of 56. b. On 11/15/24, in the evening with a systolic blood pressure of 97. The MAR, dated 12/1/24 through 12/31/24, indicated metoprolol was administered: a. On 12/2/24, with a heart rate of 58. b. On 12/5/24, with a heart rate of 54. c. On 12/16/24, with a heart rate of 50 and a systolic blood pressure of 90. The MAR, dated 1/1/25 through 1/31/25, indicated metoprolol was administered: a. On 1/18/25, in the morning with a systolic blood pressure of 91. A MAR, dated 2/1/25 through 2/28/25, indicated metoprolol was administered: a. On 2/14/25, in the evening with a systolic blood pressure of 90. During an interview, on 2/25/25 at 4:20 p.m., the Director of Nursing (DON) indicated Resident 45's metoprolol should not have been given outside of the parameters. She indicated a H in parenthesis meant the medication was held. 52091 2. The clinical record for Resident 33 was reviewed on 2/20/25 at 11:15 a.m. The diagnoses included, but were not limited to, orthostatic hypotension (low blood pressure), Parkinson ' s disease, depression, dementia, and anxiety disorder. A physician's order, dated 2/20/24, indicated to give midodrine (used to treat low blood pressure) 5 mg tablet three times a day if the systolic blood pressure (SBP) was less than 130. The Medication Administration Record (MAR), for 2/1/25 to 2/28/25, indicated the 9:00 a.m. dose was given the following dates: a. On 2/1/25, midodrine was given when the systolic blood pressure was 142. b. On 2/2/25, midodrine was given when the systolic blood pressure was 142. c. On 2/6/25, midodrine was given when the systolic blood pressure was 185. d. On 2/8/25, midodrine was given when the systolic blood pressure was 146. e. On 2/9/25, midodrine was given when the systolic blood pressure was 149. f. On 2/12/25, midodrine was given when the systolic blood pressure was 194. g. On 2/13/25, midodrine was given when the systolic blood pressure was 146. h. On 2/16/25, midodrine was given when the systolic blood pressure was 159. i. On 2/18/25, midodrine was given when the systolic blood pressure was 142. j. On 2/21/25, midodrine was given when the systolic blood pressure was 142. k. On 2/23/25, midodrine was given when the systolic blood pressure was 143. l. On 2/25/25, midodrine was given when the systolic blood pressure was 144. The MAR, for 2/1/25 to 2/28/25, indicated the 1:00 p.m. dose was given the following dates: a. On 2/1/25, midodrine was given when the systolic blood pressure was 153. b. On 2/9/25, midodrine was given when the systolic blood pressure was 143. c. On 2/12/25, midodrine was given when the systolic blood pressure was 153. d. On 2/13/25, midodrine was given when the systolic blood pressure was 144. e. On 2/16/25, midodrine was given when the systolic blood pressure was 147. f. On 2/19/25, midodrine was given when the systolic blood pressure was 151. g. On 2/23/25, midodrine was given when the systolic blood pressure was 159. The MAR, for 2/1/25 to 2/28/25, indicated the 5:00 p.m. dose was given the following dates: a. On 2/8/25, midodrine was given when the systolic blood pressure was 155. b. On 2/12/25, midodrine was given when the systolic blood pressure was 140. c. On 2/18/25, midodrine was given when the systolic blood pressure was 167. d. On 2/23/25, midodrine was given when the systolic blood pressure was 141. During an interview, on 2/25/25 at 8:47 a.m., LPN 4 indicated if the resident ' s blood pressure was 130 or greater the medication should not have been given, and the physician should have been called. During an interview, on 2/25/25 at 4:36 p.m., the DON indicated there were several midodrine tablets given and she was not sure why they were given. A current facility policy, titled Administering Medication, dated as revised on 4/2019 and received from the Clinical Executive Director on 2/25/25 at 11:45 p.m., indicated .Medications are administered in a safe and timely manner, and as prescribed .Medications are administered in accordance with prescriber orders, including any required time frames A current facility policy, titled Charting and Documentation, dated as revised on 6/2017 and received from the Clinical Executive Director on 2/24/25 at 2:06 p.m., indicated .Documentation in the medical record may be electronic, manual or a combination .Medication administered .Treatments or services performed 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure physician's orders were followed and therapy evaluations were completed in a timely manner for 2 of 4 residents review for position and mobility. (Resident 51 and 9) Findings include: During an observation, on 2/19/25 at 12:09 p.m., Resident 51 was in the dining room with her wheelchair pushed away from the table. The resident was leaning forward with her left arm dangling below the wheelchair seat. During an observation, on 2/19/25 at 3:08 p.m., the resident was sitting next to the nurse's station with her eyes closed. The resident was leaning forward and sitting crooked in her wheelchair. During an observation, on 2/20/25 at 10:27 a.m., the resident was sitting next to the nurse's office in her wheelchair. The resident was leaning forward trying to touch her left shoe. The nurse was sitting at the desk in the nurse's office with her back facing the resident and the Certified Nursing Assistant (CNA) was assisting residents out of the dining room. During an observation, on 2/21/25 at 10:49 a.m., the resident was sitting in her wheelchair, leaning to the left and touching her left ankle. During an observation, on 2/21/25 at 12:30 p.m., Resident 51 was observed with several staff members surrounding the resident in the common room. The resident fell out of her wheelchair and was lying on the floor. The resident was on her left side. During an observation, on 2/24/25 at 9:11 a.m., the resident was sitting at a table with a visitor. The resident was leaning to the left side with her head down. The resident had her left wrist wrapped with a brown elastic wrap. During an observation, on 2/24/25 at 11:55 a.m., the resident was in the dining room eating her lunch. The resident had a white pillow propped under her left arm. The pillow was pushed down beside the resident and helping the resident sit up straight. The clinical record for Resident 51 was reviewed on 2/20/25 at 11:29 a.m. The diagnoses included, but were not limited to, left wrist fracture, hypertension, diabetes mellitus, dementia, and anxiety disorder. A care plan, dated 3/25/24, indicated the resident was at risk for injury related to falls. Interventions included, but were not limited to, therapy to screen and treat as needed. A care plan, dated 3/25/24, indicated the resident was at risk for decreased activities of daily living (ADL). Interventions included, but were not limited to, therapy to screen and treat as needed. A physician's order, dated 2/4/25, indicated physical therapy (PT) to evaluate and treat. A physician's order, dated 2/24/25, indicated occupational therapy (OT) to treat three times a week for eight weeks. Treatment may include self-care, therapy, and wheelchair management to increase independence in ADL's and facilitate optimal alignment in the wheelchair. The electronic health record did not have any documentation to indicate why it took the therapy department 17 days to complete a therapy evaluation and treatment. During an interview, on 2/24/25 at 12:15 p.m., CNA 6 indicated the resident leaned to the left and the staff propped the resident up on a pillow to keep her straight. She had noticed the resident leaning to the left multiple times and would assist her with positioning. During an interview, on 2/24/25 at 12:24 p.m., the Therapy Director indicated the resident was receiving therapy. The resident was seen on 2/21/25 after the resident fell out of her wheelchair. She did not know if the resident had a history of leaning in her wheelchair. A wheelchair cushion was ordered to assist her with positioning. The Therapy Director did not know why the resident was not seen on 2/4/24 when a physician's order was written for the resident to be evaluated and treated by physical therapy. Normally, residents were seen within 48 hours after the physician's order, and it should not have taken days before the resident was evaluated. 2. During an interview, on 2/20/25 at 11:11 a.m., the Resident 9's family member indicated he had to ask the staff to reposition the resident while she was sitting in her wheelchair as they did not do it on their own. The resident had wounds on her buttocks in the past, but they are healed. Resident 9 would usually lay down after lunch and would get up at 3:00 p.m. The clinical record for Resident 9 was reviewed on 2/20/25 at 11:29 a.m. The diagnoses included, but were not limited to, atrial fibrillation, age-related osteoporosis, Alzheimer's disease, dementia, hypertension, and anxiety disorder. A care plan, dated 8/12/16, indicated the resident had impaired ADL function. Interventions included, but were not limited to, therapy to screen and treat as needed. A care plan, dated 12/29/23, indicated the resident was at risk for further contractures. Interventions included, but were not limited to, notify the nurse of any decline in contractures or if any new contractures noted. A physician's telephone order, dated 2/4/25, indicated physical therapy (PT) and occupational therapy (OT) for evaluation and treatment with a diagnosis of contractures. The order was signed by the Director of Nursing (DON) and a LPN. The Nurse Practitioner signed the order on 2/9/25. A Physical Therapy (PT) evaluation and plan of treatment form, dated 2/20/25, indicated the resident would have therapy from 2/20/25 to 4/18/25, 3 times a week for 8 weeks. The electronic health record did not have any documentation to indicate why it took the therapy department 16 days to complete a PT evaluation and treatment. During an interview, on 2/24/25 at 4:30 p.m., the DON indicated she did not know why the resident was not evaluated on 2/4/25. During an interview, on 2/25/25 at 9:08 a.m., LPN 4 indicated when a physician gave a telephone order, staff would write it on a form, the white sheet went into the physician's folder and the yellow copy went in the Unit Manager folder. The Unit Manager took the order to the morning meeting. The order was reviewed in the meeting and two nurses signed off on the order. A separate order slip would be given to the therapy department. The therapy department was not supposed to take longer than 72 hours to do their evaluation on the resident. The resident was supposed to be seen for contractures. A current facility policy, titled Therapy Management Plan & Referral, dated as revised 2/2021 and received by the Unit Manager on 2/25/25 at 10:54 a.m., indicated .For each resident .receiving management of ordered prescribed treatments or therapy services, the community will prepare and include in the care plan a physician referral for therapy based on decline with ADLs .Referral Criteria includes residents .should be referred for therapy when one or more of the following criteria are met .Declining Function: Observable decline in physical, cognitive .impacting daily functioning .Safety Concerns: Issues with balance, coordination, or risk of falls .Referral Process .Identification of Need: Any healthcare provider .or IDT Team who identifies a potential need for therapy should promptly assess the patient's situation to determine if therapy is appropriate .Observing changes in function .Consulting with family or caregiver about concerns .A formal referral is initiated once the need for therapy is recognized .The referral with physician orders is submitted to the therapy department .Upon receiving the referral, a licensed therapist .conducts a comprehensive assessment to evaluate their needs A current facility policy, titled Charting and Documentation, dated as revised 7/2019 and received by the Clinical Executive Director on 2/24/25 at 2:06 p.m., indicated .The following information is to be documental in the resident medical record .Medication administered .Treatments or services performed .Changes in the resident's condition .Events, incidents or accidents involving the resident .Documentation of procedures and treatments .whether the resident refused the procedure/treatment .notification of family, physicians or other staff 3.1-42(a)(2)

Based on observation, interview and record review, the facility failed to ensure staff initiated new person-centered dementia care interventions for residents with wandering behaviors and to check wanderguard placement for 2 of 5 residents reviewed for dementia care. (Resident B and C) Findings include: 1. During an observation, on 2/19/25 at 1:35 p.m., Resident B was walking in the common area near the exit doors. During an observation, on 2/20/25 at 12:15 p.m., the resident was ambulating down the hall towards the exit doors. During an observation, on 2/21/25 at 1:54 p.m., the resident was ambulating back from the exit door on her unit. During an observation, on 2/24/25 at 9:06 a.m., the resident was sitting on the couch in the common area in front of the main entrance doors. During an observation, on 2/25/25 at 12:15 p.m., the resident was walking near the front entrance frequently looking at the doors. During an observation, on 2/25/25 at 2:05 p.m., the resident triggered the alarm on an exit door multiple times. The staff were redirecting her away from the door, but she returned to the door within minutes. The clinical record for Resident B was reviewed on 2/21/25 at 1:54 p.m. The diagnoses included, but were not limited to, dementia, history of falling, and insomnia. A care plan, dated 10/9/24, indicated the resident was at risk for leaving the facility by herself due to wandering. Interventions included, but were not limited to, a wanderguard was placed on her left ankle, and to remove her from potentially harmful situations. An Interdisciplinary note, dated 11/19/24 at 5:47 p.m., indicated the resident was wandering throughout the day and was at the exit door in the administration hallway. An Interdisciplinary note, dated 12/26/24 at 3:24 p.m., indicated the resident was restless, pacing, and had pushed on the door to the main building this morning and again around 3:20 p.m. A monthly summary report, dated 1/1/25 at 1:40 p.m., indicated the resident was confused with short and long-term memory problems, had moderately impaired decision making, and was able to walk steadily on her own. The report indicated there were no alarms present and no recorded behaviors. The monthly summary report did not indicate the resident had a wanderguard alarm ordered and had known wandering behaviors. An Interdisciplinary note, dated 1/3/25 at 1:19 a.m., indicated the resident wandered the unit continuously and was exit-seeking when awake. An Interdisciplinary note, dated 1/6/25 at 12:40 a.m., indicated the resident was confused, forgetful, wandered, and was exit-seeking. The resident also became combative with care during the night. An Interdisciplinary note, dated 1/6/25 at 12:31 p.m., indicated the resident had severely impaired decision making and cognitive abilities. The resident had a wanderguard in place due to continuous wandering and exit-seeking. An elopement risk assessment, dated 1/6/25 at 3:53 p.m., indicated the resident was at risk for elopement based on her wandering and pushing on exit doors. An Interdisciplinary note, dated 1/7/25 at 9:29 a.m., indicated Resident B wandered daily and resumed wandering with 5 minutes after redirection. A monthly summary report, dated 2/3/25 at 6:20 p.m., indicated the resident was confused with short and long-term memory problems, had moderately impaired decision making, and was able to walk steadily on her own. The report indicated the resident had a bracelet alarm and no behaviors were recorded. The monthly summary report did not indicate the resident had known wandering behaviors. A signed facility statement, dated 2/24/25, indicated the Social Services Coordinator followed up with Resident 6 and 53 regarding Resident B wandering into their rooms. Resident B had tried to take Resident 6's teddy bear, but staff had intervened quickly. Resident B lived on a different unit. A physician's order, dated 10/9/24, indicated to check the wanderguard placement every shift. a. The Treatment Administration Record (TAR), dated 1/2025, indicated the wanderguard placement was not checked every shift on 1/23/25. b. The TAR, dated 2/2025, indicated the wanderguard placement was not checked every shift on 2/1/25, 2/5/25, 2/6/25, 2/7/25, 2/8/25, 2/16/25, 2/18/25, 2/22/25, and 2/24/25. A physician's order, dated 1/28/25, indicated to monitor for behaviors daily on all shifts. a. The Medication Administration Record (MAR), dated 1/2025, indicated behavior management monitoring for behaviors was blocked out and not charted for all shifts during the entire month. b. The MAR, dated 2/2025, indicated behavior management monitoring for behaviors was blocked out and not charted for all shifts during the entire month. 44598 2. The clinical record for Resident C was reviewed on 2/21/25 at 4:33 p.m. The diagnoses included, but were not limited to, Alzheimer's disease, dementia with psychotic disturbance, delirium due to known physiological condition, history of falling, and anxiety disorder. A care plan, dated 6/10/21, indicated the resident was at risk for leaving the facility unaccompanied due to wandering as evidenced by wandering through the hallways and attempting to exit seek and open doors. Interventions included, but were not limited to, wanderguard in place, assessing the area around wanderguard every shift for circulation, motion, skin integrity, and feeling. A physician's order, dated 6/7/21, indicated to check the wanderguard placement every shift and to complete a wanderguard function test every week. A Treatment Administration Record (TAR), dated 1/1/25 to 1/31/25, indicated: a. Documentation was missing on 1/6, 1/7, 1/11 and 1/26/25, for the wanderguard placement check on the day shift. b. Documentation was missing on 1/5, 1/13, 1/20 and 1/22/25, for the wanderguard placement check on the evening shift. c. Documentation was missing on 1/4, 1/5, 1/8, 1/18, 1/19, 1/24 and 1/25/25, for the wanderguard placement check on the night shift. A TAR, dated 2/1/25 to 2/28/25, indicated: a. Documentation was missing on 2/2, 2/3, 2/20, 2/21 and 2/23/25, for the wanderguard placement check on the night shift. During an interview, on 2/24/25 at 10:48 a.m., Licensed Practical Nurse (LPN) 4 indicated the wanderguard was to be checked every shift and documented. If it was not documented, then it was not checked. During an interview, on 2/24/25 at 12:01 p.m., Certified Nursing Assistant (CNA) 5 indicated Resident C did have a wanderguard. During an interview, on 2/24/25 at 4:45 p.m., the Director of Nursing (DON) indicated if the MAR/TAR was not signed, there was no way to prove the monitoring was done. The MAR/TAR should be signed off and not left blank. During an interview, on 2/24/25 at 4:50 p.m., the Clinical Executive Director indicated the wanderguard was checked by the nurses and they used a handheld device. The maintenance department checked the doors quarterly and logged them in a binder. During an interview, on 2/25/25 at 11:47 a.m., the DON indicated the facility did not have wanderguard consents. The facility discussed the wanderguard during care plan meetings with the resident and the resident's family. A current facility policy, titled Elopement Prevention Policy, dated as revised on 4/8/14 and received by the Clinical Executive Director on 2/25/25 at 1:38 p.m., indicated .The Purpose of this policy is to establish procedures for ensuring elopement prevention devices are used in accordance with identified risk, physician orders and to ensure the security system is inspected to identify malfunctions should they occur .It is the policy of this facility to use elopement alert systems and devices when an assessment has identified the risk of elopement .Battery operated transmitter bracelets The elopement alert exit door device will be inspected for proper working order monthly .recorded on the facility approved log .The anklet or bracelet device will be inspected by nursing personnel once each day A current facility policy, titled Charting and Documentation, dated as revised 7/2019 and received by the Clinical Executive Director on 2/24/25 at 2:06 p.m., indicated .The following information is to be documental in the resident medical record .Medication administered .Treatments or services performed .Changes in the resident's condition .Events, incidents or accidents involving the resident .Documentation of procedures and treatments .whether the resident refused the procedure/treatment .notification of family, physicians or other staff This citation relates to Complaint IN00441342. 3.1-37(a)

Based on interview and record review, the facility failed to ensure the pharmacy provided gradual dose reduction (GDR) requests to reduce or discontinue psychotropic medications for 2 of 5 residents reviewed for unnecessary medications. (Resident 18, and 33) Findings include: 1. The clinical record for Resident 18 was reviewed on 2/24/25 at 10:17 a.m. The diagnoses included, but were not limited to, dementia with anxiety, mood disturbance, psychotic disturbance, generalized anxiety disorder, depression, and delusional disorder. a. A physician's order, with an original start date of 11/15/23, indicated to give buspirone (a medication used to treat anxiety) 10 milligrams (mg) three times per day. The clinical record did not include a GDR consideration for buspirone. The facility was unable to provide a GDR consideration for buspirone. b. A physician's order, with an original start date of 11/15/23, indicated to give duloxetine (a medication used to treat depression) 60 mg each day. A consultant pharmacist physician recommendation form, dated 5/16/24, indicated it was time to consider a GDR for duloxetine. The clinical record did not include the required second GDR consideration between 11/15/23 and 11/15/24. The facility was unable to provide a second GDR for duloxetine. c. A physician's order, with an original start date of 11/15/23, indicated to give Zyprexa (an antipsychotic medication) 5 mg nightly. A consultant pharmacist physician recommendation form, dated 12/18/24 and signed by the physician on 2/18/25, indicated it was time to consider a GDR for Zyprexa. The clinical record did not include the required two GDR considerations in separate quarters between 11/15/23 and 11/15/24. The facility was unable to provide additional GDR information. During an interview, on 2/25/25 at 4:00 p.m., the Director of Nursing (DON) indicated the facility had provided all the GDR documentation. 2. The clinical record for Resident 33 was reviewed on 2/20/25 at 11:15 a.m. The diagnoses included, but were not limited to, Parkinson's disease without dyskinesia, depression, dementia, and anxiety disorder. A physician's order, dated 1/9/24, indicated to give buspirone (a medication used to treat anxiety) 5 mg tablet two times a day. The clinical record did not include a GDR consideration for buspirone. On 2/25/25, a consultant pharmacist physician recommendation form, undated and not signed by the physician, which indicated it was time to consider a GDR for buspirone was provided by the facility. During an interview, on 2/25/25 at 4:38 p.m., the Clinical Executive Director indicated the facility received a GDR for buspirone on 2/25/25. It had been over a year since the last GDR for buspirone was done. A current facility policy, titled Tapering Medication and Gradual Drug Dose Reduction, dated as revised on 7/2022 and received from the DON on 2/26/25 at 1:38 p.m., indicated .Residents who use psychotropic medications shall receive gradual dose reductions and behavioral interventions .The staff and practitioner will consider tapering under certain circumstances .The physician will order appropriate tapering of medication .Within the first year after a resident is admitted on a psychotropic medication or after the resident has been started on a psychotropic medication, the staff and practitioner shall attempt a GDR in two separate quarters (with at least one month between the attempts) unless clinically contraindicated. After the first year, the facility shall attempt a GDR at least annually 3.1-48(b)(2)

Based on interview and record review, the facility failed to ensure influenza and pneumococcal vaccinations were provided for 1 of 5 residents reviewed for immunizations. (Resident B) Findings include: The clinical record for Resident B was reviewed on 2/21/25 at 1:54 p.m. The diagnoses included, but were not limited to, dementia, polyosteoarthritis, pure hyperglyceridemia, prediabetes, history of falling, and insomnia. An Informed Consent for Influenza Immunization, dated and signed on 10/9/24 at 4:43 p.m., indicated Resident B's representative gave permission for the influenza vaccination. An Informed Consent for Pneumococcal Immunization, dated and signed on 10/9/24 at 4:43 p.m., indicated Resident B's representative gave permission for the pneumococcal vaccination. An Immunization Report, dated 2/24/25, indicated the resident's last influenza vaccine was given on 9/27/23 and she had not received a pneumococcal vaccination. During an interview, on 2/25/25 at 4:20 p.m., Infection Preventionist (IP) 3 indicated the resident had received Tamiflu for an influenza exposure at the time of admission so she could not receive the vaccine right away. IP 3 indicated she did not know why the influenza vaccination was not given later or why the pneumococcal vaccination was not given. Resident B should have received both by now. A current facility policy, titled Influenza Vaccine, dated as reviewed on 6/25/24 and provided on admission, indicated .Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents .Only inactivated influenza vaccine will be offered to residents A current policy titled Pneumococcal Vaccine, reviewed on 6/25/24 and provided on admission, indicated . upon admission, residents will be . offered the vaccine series within thirty (30) days of admission . Pneumococcal vaccines will be administered to residents Tamiflu Interactions: Alcohol, Medications, and Others. https://www.healthline.com/health/drugs/tamiflu-interactions. Accessed 2/25/25, indicated .Tamiflu and an inactivated flu vaccine will not interact. You should be able to receive an inactivated flu vaccine at any time before, during, or after Tamiflu treatment 3.1-18(b)(5)

Based on observation, interview and record review, the facility failed to ensure residents with a diagnosis of congestive heart failure (CHF) were weighed as ordered by the physician, a resident had accu-checks completed as ordered by the physician and failed to assess and document a non-pressure skin impairment for 4 of 4 residents reviewed for quality of care. (Resident 2, 33, 30 and 25) Findings include: 1. The clinical record for Resident 2 was reviewed on 1/24/24 at 3:10 p.m. The diagnoses included, but were not limited to, heart failure, atrial fibrillation, cardiomegaly, Alzheimer's, dementia, depression, and anxiety disorder. A care plan, dated 1/3/24, indicated the resident had congestive heart failure. Interventions included, but were not limited to, obtain weights as ordered and to monitor and document edema. A physician's order, dated 7/19/22, indicated the resident had congestive heart failure, to monitor weights every other day, and notify the physician of a greater than 5-pound gain. A resident vital stats report, dated 9/1/23 through 1/25/24, indicated the following weights were missing: a. 9/7, 9/9, 9/21 and 9/23/23 b. 10/23, 10/27 and 10/30/23 c. 11/1, 11/3, 11/5, 11/9 and 11/11/23 d. 1/8, 1/10, 1/12, and 1/14/24 During an interview, on 1/26/24 at 12:20 p.m., Unit Manager (UM) 7 indicated she did not know why the resident was not weighed. During an interview, on 1/26/24 at 12:29 p.m., the Director of Nursing (DON) indicated weights should be followed by the physician's order. She did not know why the weights were missing. During an interview, on 1/26/24 at 12:40 p.m., the DON indicated there were no other weights for the resident. 2. The clinical record for Resident 33 was reviewed on 1/24/24 at 4:08 p.m. The diagnoses included, but were not limited to, aphasia (affects how you communicate), congestive heart failure, anxiety disorder, and depression. A care plan, dated 8/17/20, indicated the resident had a history of congestive heart failure. Interventions included, but were not limited to, evaluate extremities for edema (swelling), update the physician as needed, and administer medications as ordered. A physician's order, dated 11/16/22, indicated to obtain a daily weight first thing in the morning, post-void, in pajamas, and before breakfast. Notify the physician of a weight gain greater than 2 pounds in 24 hours and/or 5 pounds in 1 week. A resident weight tracking system report, dated 1/24/24, indicated the following weights were missing: a. 11/2, 11/3, 11/5, 11/6, 11/8, 11/9, 11/16 and 11/17/23 b. 12/8, 12/9, 12/16, 12/17 and 12/21/23 c. 1/2, 1/13, 1/14 and 1/15/24 During an interview, on 1/24/24 at 3:29 p.m., Resident 33 indicated the staff did weigh her this morning, but they did not always weigh her. During an interview, on 1/25/24 at 10:20 a.m., the DON indicated if a resident had a daily weight order her expectations was for the order to be followed and the resident should be weighed. The weighing of the resident was to be completed in the morning and after they void. The staff was to use the same scale. During an interview, on 1/25/24 at 10:32 a.m., CNA 6 indicated the residents with daily weights were weighed first thing in the morning and used the same scale. During an interview, on 1/25/24 at 10:34 a.m., CNA 4 indicated the daily weights should be done first thing when the resident got up for the day. During an interview, on 1/25/24 at 11:21 a.m., UM 7 indicated a daily weight was to be done in the morning and after the resident voided. The staff were required to use the same scale and approximately the same time every day. If the weight was not recorded, then it was not completed. During an interview, on 1/26/24 at 3:29 p.m., the DON indicated no additional weights could be found. 3. The clinical record for Resident 30 was reviewed on 1/25/24 at 6:32 a.m. The diagnoses included, but were not limited to, diabetes mellitus, Parkinson's disorder, and mild cognitive impairment. A physician's order, dated 9/22/23, indicated to check blood glucose levels twice a day. The Medication Administration Record, dated 12/1/23 through 1/26/24, indicated the following were missing: a. The 6:00 a.m., accu-check on 12/16/23 was missing. b. The 3:00 p.m., accu-checks on 12/9/23, 12/16/23, 12/27/23, 1/6/24, 1/7/24, 1/9/24, 1/15/24 and 1/19/24 were missing. During an interview, on 1/26/24 at 11:47 a.m., the DON indicated she was not aware of the missing accu-checks. The accu-checks should be documented. During an interview, on 1/26/24 at 3:37 p.m., UM 7 indicated the resident was missing accu checks. She did not notice the missing accu-checks and the physician was not notified. 49708 4. During an observation, on 1/23/24 at 12:31 p.m., Resident 25 was observed, in her wheelchair, wearing open toe sandals with a small bandage on her left great toe. During an observation, on 1/26/24 at 11:17 a.m., the resident was sitting up, in her wheelchair, she had sandals on, and a small bandage was noted on her left great toe. The bandage was not dated and had some red drainage present. The clinical record for Resident 25 was reviewed on 1/26/24 at 10:50 a.m. The diagnosis included, but were not limited to, Alzheimer disease, type 1 diabetes mellitus with diabetic neuropathy, bell's palsy, osteoarthritis, and venous insufficiency. A physician's order, dated 1/18/24, indicated the resident may be seen by a wound doctor. A podiatrist note, dated 1/18/24, indicated the resident had non palpable pulses in her bilateral feet and edema was noted. The feet were dry, cool, rubor (red), and her nails were long, moderately thick, and discolored. There was no documentation of bleeding, or a small bandage being applied. A review of Resident 25's nursing progress notes, from 1/20/24 to 1/26/24 had no information about the small bandage on the residents left great toe or the visit with the podiatrist. During an interview, on 1/26/24 at 11:07 a.m., LPN 9 indicated the bandage on the left great toe was from a recent podiatry appointment. The podiatrist would have added the bandage if treatment caused bleeding. During an interview, on 1/26/24 at 1:59 p.m., LPN 10 indicated she would check the progress note from the podiatrist. If nothing was documented about the bandage, she would assess the toe, and then call the physician for a treatment order. A current policy, titled Heart Failure - Clinical Protocol, received from the DON on 1/25/24 at 11:00 a.m., indicated .The physician will review and make recommendations for relevant aspects of the nursing care plan; for example, what symptoms to expect, how often and what (weights, renal function, digoxin level, etc.) to monitor, when to report findings to the physician, etc A current policy, titled Glucose Monitoring, dated 3/20/14 and received from the DON on 1/26/24 at 12:42 p.m., indicated .The management of individuals with diabetes mellitus should follow relevant protocols and guidelines. The physician will order the frequency of glucose monitoring A current policy, titled Physician's Orders, dated 3/26/23 and received from the DON on 1/26/24 at 10:30 a.m., indicated .Physician Orders will be carried out as ordered A current policy, titled Non-Pressure Skin Wounds, dated 5/3/18 and received from Unit Manager on 1/26/24 at 3:30 p.m., indicated .Evaluate and document wound in resident medical records per facility protocol .Obtain a physicians order as needed 3.1-37(a)

Based on interview and record review, the facility failed to ensure a resident received mouth care twice daily for 1 of 2 residents reviewed for activities of daily living (ADL) care. (Resident 37) Finding includes: During an interview, on 1/22/24 at 2:22 p.m., Resident 37's wife indicated the resident had full upper dentures and a partial bottom denture anchored to his remaining natural teeth. The staff would forget to brush his teeth, the toothbrush was dry when she checked it, and she had observed food and debris on natural teeth. The clinical record for Resident 37 was reviewed on 1/24/24 at 10:38 a.m. The diagnoses included, but were not limited to, hemiplegia (paralysis affecting one side of the body) following cerebral infarction, Alzheimer's disease, dysarthria (slurred speech) following cerebral infarction, and dysphagia (difficulty swallowing) following cerebral infarction. A care plan, dated 10/14/21, indicated the resident had a need for dental care related to having some permanent teeth, a lower partial, and full upper denture. The approaches included, but were not limited to, a need for dental care related to having some permanent teeth, a partial lower denture, and full upper denture, as the resident allowed. A physician's order, dated 4/6/23, indicated to assist the resident with brushing his teeth twice daily in the morning and in the evening. A Treatment Administration Record (TAR), dated November 1 through November 30, 2023, indicated mouth care was not documented as being completed on the following dates: a. On 11/22/23, for morning mouth care. b. On 11/3/23 and 11/17/23, for evening mouth care. A TAR, dated December 1, 2023, through December 31, 2023, indicated mouth care was not documented as being completed on the following dates: a. On 12/6/23, 12//7/23, 12/11/23 and 12/21/23, for morning mouth care. b. On 12/8/23, 12/9/23, 12/12/23, 12/15/23, 12/20/23, 12/21/23, 12/23/23, 12/25/23, 12/27/23, and 12/29/23, for evening mouth care. A TAR, dated January 1, 2024, through January 24, 2024, indicated mouth care was not documented as being completed on the following dates: a. On 1/14/24 and 1/22/24, for morning mouth care. b. On 1/4/24, 1/6/24, 1/7/24 and 1/9/24, for evening mouth care. During an interview, on 1/26/24 at 11:41 a.m., CNA 8 indicated the dentures were rinsed, adhesive was applied, and the resident was assisted with putting in his dentures. The resident did not have natural teeth, so they did not brush his teeth. Night shift removed the resident's dentures and put them in a cup with a denture tablet. A current policy, titled Activities of Daily Living [ ADL,s], Support, dated 7/13/20 and received from the Director of Nursing on 1/26/24 at 3:00 p.m, indicated .Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living [ADLs] .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal hygiene .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with consent of the resident and in accordance with the plan of care, including appropriate support and assistance with .Hygiene [bathing, dressing, grooming and oral care] 3.1-38 (a)(3)(C)

Based on observation, interview and record review, the facility failed to ensure all areas of the wireless call system were functioning properly for 2 of 2 residents reviewed for call devices. (Residents 19 and 13) Findings include: 1. During an interview, on 1/22/24 at 1:14 p.m., Resident 19 indicated sometimes call lights were not answered or could take a long time to be answered. He used his call pendant around his neck as his call light. During an observation and interview, on 1/22/24 at 1:45 p.m., Resident 19 pressed his call pendant around his neck. During an observation and interview, on 1/22/24 at 1:56 p.m., RN 2 indicated she did not know the resident's call light was pressed. She did not have a notification to her Vocera (wireless communication system staff members wore to receive call light notifications and talk to other staff). There was no indication the resident's call light was pressed per the call light monitor screen out in the hall. During an interview, on 1/22/24 at 1:58 p.m., RN 2 indicated the resident's call pendant was not working. During an interview, on 1/26/24 at 4:10 p.m., the DON (Director of Nursing) indicated their [NAME] daily system status report (system for showing missing and low batteries) showed low batteries and missing batteries for the residents. Somehow Resident 19's call pendant got missed and they were working on figuring out why. The clinical record for Resident 19 was reviewed on 1/22/24 at 2:50 p.m. The diagnoses included, but were not limited to, unspecified paraplegia, pain in the lower left and right knee, and unspecified osteoarthritis. 44598 2. During an interview, on 1/23/24 at 12:31 p.m., Resident 13 indicated the staff did not always answer the call lights and it took a long time after you press your call light for the staff to answer. During an observation, on 1/23/24 at 12:31 p.m., the resident pressed her pendant and the light on the pendant flashed red. The pendant did not make a sound when it was pressed. During an observation, on 1/23/24 at 12:42 p.m., the resident pressed the pendant again. During an observation, on 1/23/24 at 12:46 p.m., Unit Manager (UM) 7 walked by the room and did not look in the resident's room. The clinical record for Resident 13 was reviewed on 1/25/24 at 9:38 a.m. The diagnoses included, but were not limited to, atrial fibrillation, muscle weakness, pain right knee, cognitive impairment of uncertain or unknown etiology, pacemaker, epilepsy, congestive heart failure, cardiomegaly, depression, and history of (healed) traumatic fracture. A care plan, dated 2/6/23, indicated the resident was at risk for falls related to impaired mobility, history of falls, and history of a fractured left femur. Interventions included, but were not limited to, frequent visual checks, resident was not to be left unattended, and a 2-person maximum assist using a mechanical lift. A physician's order, dated 11/27/23, indicated the resident's activity level was weight bearing as tolerated. During an interview, on 1/23/24 at 12:58 p.m., QMA 3 indicated she knew the resident's call light was going off. During an interview, on 1/23/24 at 12:59 p.m., QMA 5 indicated she had a pager, but the battery was dead, and she probably should get a new one. During an interview, on 1/23/24 at 1:05 p.m., UM 7 indicated a pager would need to be replaced right away if the pager was not working properly. The screens with the call lights are on both ends of the halls and at the nurse's station. The devices the staff carry would beep and flash the room number when a call light was pressed. The staff could look at the screens to see who had their call light on. UM 7 saw Resident 13's call light when she walked by the room. She was too busy to answer the call light. During an interview, on 1/26/24 at 2:17 p.m., the DON indicated when a resident pressed their pendant or room call light the resident's room number would appear on the staff's vocera. The location of the resident would also appear on a wall computer screen. There were computer screens on each hallway and nurse's station. The screen would light up red and would indicate the location of the resident. The staff would have to search for the resident if they moved locations. The call light pendant the staff wore would beep when the devices battery was low and would inform the staff the battery was low. When the batteries were not replaced, the device would turn off. The extra batteries were stored at the nurse's station. When the batteries were dead then you would have to check the screens. A Qualified Medication Aide (QMA) position description indicated the QMA was to answer resident's calls promptly. A Certified Nurse Aide (CNA) position description indicated the CNA was to monitor residents through frequent rounds to ensure their personal care needs were being met and to answer resident's calls promptly. A current policy, titled Nurse Call System, dated as revised 4/29/19 and received from the Admissions Nurse on 1/26/24 at 3:40 p.m., indicated .If the Nurse Call System is temporarily out of service for more than thirty (30) minutes, the Charge Nurse will notify the Administrator and/or Designee 3.1-19(u)

Based on observation, interview and record review, the facility failed to ensure items were not stored on the floor in resident rooms, carpet squares edges were not peeling, and the walls were free of gouges for 4 of 4 rooms reviewed for environment. (Room A10, A9, A3 and C11D.) Findings include: 1a. During an observation, on 1/22/24 at 10:30 a.m., Room A10 had a small pile of magazines, two decorative boxes, and opened mail on the floor. 1b. During an observation, on 1/25/24 at 12:20 p.m., Room A10 had a large cardboard box with papers inside and opened mail stored on the floor. 2. During an observation, on 1/22/24 at 10:36 a.m., Room A9 had a grocery sack with the resident's personal items on the floor next to the window. 3. During an observation, on 1/22/24 at 2:51 p.m., Room A3 had four squares of carpet peeling up in the center of the four squares. 4. During an observation, on 1/22/24 at 3:49 p.m., Room C11D had a large area of gouges in the drywall and missing paint. During an interview, on 1/22/24 at 12:20 p.m., Certified Nurse Aide (CNA) 6 indicated the sack on the floor of A9, the boxes, and the opened mail should not be left on the floor. The items on the floor could make the residents fall or it could cause bugs. During an interview, on 1/22/24 at 3:39 p.m., the resident in Room C11D indicated the facility had made no attempts to repair the wall since the resident moved in on 7/28/23. During an interview, on 1/25/24 at 11:21 a.m., Unit Manager 7 indicated the boxes, mail on the resident's floor, and the carpet tiles peeling up could be a tripping hazard. The cardboard box and papers could be an infection control problem as they could attract bugs. During an interview, on 1/25/24 at 12:20 p.m., the Director of Nursing (DON) indicated the items should not be on the floor. A current policy, titled Homelike Environment, dated as revised 2/2021 and received from the Director of Nursing on 1/24/24 at 4:47 p.m., indicated .Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personnel belongings to the extent possible. Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences .clean, sanitary and orderly environment 3.1-19(f)(5)

Based on observation, interview and record review, the facility failed to ensure posted nurse staffing was up to date and had the correct hours of staff nurses for 2 of 2 posted nurse staffing lists. (1/23/24 and 1/24/24) Finding includes: During an observation, on 1/24/24 at 3:25 p.m., the front door had staffing posted for 1/23/24. During an observation, on 1/24/24 at 3:40 p.m., the posted nurse staffing, dated 1/24/24, on the Terrace Unit indicated 2.5 nurses were scheduled for the 2:30 p.m., through 10:30 p.m., shift. During an interview, on 1/24/24 at 3:45 p.m., the Health Facility Administrator (HFA) indicated the staffing at the front door was not the correct date and the posted nurse staffing on the Terrace Unit did not have 2 and a half nurses working. There were 2 nurses working the entire shift and one nurse working a split shift. A current policy, titled Posting Direct Care Daily Staffing Numbers, dated as revised on August 2022 and received from the Director of Nursing on 1/26/24 at 3:20 p.m., indicated .Our facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents .Within two [2] hours of the beginning of each shift, the number of licensed nurses .and the number of unlicensed nursing personnel .directly responsible for resident care is posted in a prominent location [accessible to residents and visitors] and in a clear and readable format .The information recorded on the form shall include the following .The current date .The actual time worked during that shift for each category and type of nursing staff 3.1-17(a)

Based on observation, interview and record review, the facility failed to ensure a resident was free from abuse when a staff member did not follow the facility's abuse policy or the employee handbook for use of a phone in a work area and a second staff member did not follow the facility's abuse policy and report abuse for 1 of 1 resident reviewed for abuse through the use of phone technology. (Resident B) Findings include: A concern was received by email from former Staff Member 13 indicating a photo of a resident was sent to her from a former co-worker. She was not a current employee, but since she had worked at the facility in the past, she knew who the resident in the photo was and wanted to report the incident to the Indiana Department of Health. The concern indicated the resident in the photo was laying on the floor in a soiled gown, her sheets from her bed were sitting in the trash can and her bed was not made. There was no wheelchair by her bed. The photo was taken of an exposed resident laying on the floor and was sent to people. The photo of the resident was observed. The resident was laying on her left side between her bed and the wall in front of her nightstand, with her back to the camera. The back of her gown was open exposing her back and her brief. Her gown was laying under her left arm and had a brown substance on it. She was barefooted. The record for Resident B was reviewed on 4/27/23 at 11:45 a.m. Diagnoses included, but were not limited to, type 1 diabetes mellitus, osteoarthritis, hyperkalemia, cerebral ischemia, major depressive disorder, Alzheimer's Disease, chronic kidney disease, persistent mood disorder, and anxiety disorder. An Interdisciplinary Note, dated 4/23/23 at 1:04 p.m., indicated Resident B was found on the floor by her bed on her left side. She was assisted up by three staff members with a gait belt. She had originally refused to get up earlier in the morning and staff went to her room to check if she was ready to get up for lunch when they found her laying on the floor. She received a skin tear to her left forearm measuring 2.5 cm (centimeters) by 1.7 cm. A quarterly MDS (Minimum Data Set) assessment, dated 4/18/23, indicated Resident B's BIMS (Brief Interview for Mental Status) was scored at a 10 out of 15, which indicated she was moderately cognitively impaired. She required extensive assist of two person for bed mobility, transfers, dressing, and toilet use. Resident B had a care plan, which addressed the problem she had impaired cognition related to her diagnosis of dementia. Interventions included, but were not limited to, maintain daily schedule which she could depend on for increased comfort and familiarity. Started 8/9/21. Resident B had a care plan, which addressed the problem she was at risk for decreased activities of daily living abilities due to her cognitive impairment. She required assistance with bed mobility, transfers, toileting, eating, and other ADL's secondary to her diagnoses of type 1 diabetes mellitus with diabetic neuropathy, anxiety, Alzheimer's disease with dementia, osteoarthritis, venous insufficiency, pain in lower leg and right radial and ulna fractures. Interventions included, but were not limited to, provide privacy and dignity. Started 8/3/21. During an interview, on 4/26/23 at 11:02 a.m., the DON (Director of Nursing) was shown the photo of the resident laying on the floor, and she indicated she could identify the resident by the lamp sitting on her table. She was unaware the photo had been taken or which employee could have taken it. Resident B had a fall, on April 23, 2023, so she thought the picture was taken on that day. During an interview, on 4/26/23 at 11:57 a.m., RN 3 indicated Resident B refused to get out of bed or eat breakfast the morning of 4/23/23. She was found on the floor on 4/23/23 at 11:15 a.m., when two CNAs went into her room to check if she was ready to get up for the day. During an interview, on 4/26/23 at 12:41 p.m., CNA 6 indicated she and CNA 8 found Resident B on the floor on 4/23/23 at approximately 11:15 a.m., when they went into her room to see if she was ready to get up for the day. When CNA 8 went to get the Hoyer lift, she snapped the picture of Resident B laying on the floor and sent it to CNA 7 privately as a message via Snapchat (a social media communication application). When asked why she took the photo of Resident B, she indicated she was having a bad day. One of her favorite residents passed away, everyone left their work for her to do, and then Resident B fell . She took the picture to send to CNA 7, not as a malice intent, but to vent to her how her day was going. She did not think CNA 7 would share the picture with anyone else. During a phone interview, on 4/26/23 at 2:11 p.m., Former Staff Member 13 indicated CNA 7 sent the photo of Resident B to her. She knew the picture was a form of abuse, so she emailed the office of Indiana State Department of Health and reported it. During a phone interview, on 4/26/23 at 2:21 p.m., CNA 7 indicated CNA 6 sent her a picture of Resident B laying on the floor by the texting feature of Snapchat, after she asked how Resident B was doing. She had been off work on FMLA (Family Medical Leave of Absence) and wondered how some of the residents were doing while she was off work. She sent the picture of Resident B laying on the floor to Former Staff Member 13 who had been asking how Resident B was doing. A current policy, titled Cell Phone Usage, dated as revised 09/2008 and provided by the DON on 4/26/23 at 2:30 p.m., indicated .Procedure .unless properly authorized, employees will refrain from the use of any form of personal electronic communication device during normal work hours. These devices should be turned off during work hours and stored in a secure place such as a locker. Authorization from the supervisor must be obtained before an employee may carry a personal electronic communication device on their person on the work site. These devices may be used during breaks or when employees are at lunch. They must be used in employee break areas and not used in work areas, public hallways or resident common areas. Employees whose electronic communication devices are camera-enabled are restricted from using these devices anywhere in the building or on the company property at anytime. Further, employees who are found to have used these camera-enabled features will be subject to progressive discipline A current policy, titled Federal Resident Rights, dated 11/28/2016 and provided by the DON on 4/26/23 at 2:30 p.m., indicated .A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident .Respect and dignity. The resident has a right to be treated with respect and dignity A current policy, titled Abuse and Neglect, dated with a revision date of February 2021 and provided by the DON on 4/26/23 at 2:30 p.m., indicated Purpose .To ensure that each resident is free of .material exploitation. To ensure employees are monitored for signs or symptoms of stress that could lead to abuse and neglect .Policy .The safety and welfare of the residents entrusted to our care shall be maintained at all times. Definitions: Abuse-is the willfully [sic] infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .MENTAL ABUSE includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation. The procedures for reporting and documenting mental abuse are the same as reporting physical abuse .TRAINING: Employees are monitored for signs or symptoms of stress that could lead to abuse/neglect such as: physical, i.e. headaches, chronic fatigue, nail biting, tense Emotional, i.e. anger, hostility, apathy, crying, irritability, depression, repeatedly speak of working short Intellectual, i.e. indecisive, preoccupied, forgetfulness, poor communication skills Social, i.e. withdrawn from others, criticism of others, dominating, stress in personal life, Spiritual, i.e. low self-esteem, lack of lack of commitment to values. The following strategies are encouraged when employees display signs or symptoms of stress such as: Remove yourself from the situation (if the resident is safe), Ask co-worker for assistance, count to ten and take deep, slow breaths, repeat a favorite saying or song in your mind, Schedule time off, and seek outside assistance. All information regarding employees, residents, and their families is confidential and is not to be discussed either inside or outside of the facility .REPORTING: 1. Any suspicion of abuse/neglect must be reported to the Charge Nurse, Administrator and Director of Nursing Services A current policy, titled Employee Handbook, dated as revised 2021 and provided by the DON on 4/26/23 at 2:30 p.m., indicated .Employee Use of Cell Phones .Employees are encouraged to use cell phones on personal break times or meal periods and encouraged to store phones in employee lockers. The use of cell phones includes but is not limited to: phone calls, texting, Internet, etc. Employees are not permitted to use cell phones while providing any service or care for residents or families, Employees should avoid the use personal or company cell phones in public view including but not limited to lobbies, corridors, dining rooms, etc .Blogging and Electronic Disclosure of Confidential Information .You may not take or post photos of Westminster Village and/or coworker, client, and/or community resident without the express written permission of Westminster Village, the coworker, client and/or community resident. You may not post personal information about the Company, coworkers, clients and/or community, residents, including general addresses or locations any information which would be construed by the coworker, client and/or community resident to be personal or an invasion of their privacy This Federal tag relates to Complaint IN00407001. 3.1-27(a)(1) 3.1-28(c)

Based on observation, interview and record review, the facility failed to ensure [CONDITION(S)] medications were prescribed for approved diagnoses and gradual dose reductions (GDRs) had an appropriate clinical rationale when declined for residents with dementia for 6 of 8 residents reviewed for unnecessary medications. (Resident 34, 44, 47, 4, 12 and 33) Findings include: 1. The record for Resident 34 was reviewed on 10/31/22 at 11:55 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, generalized anxiety disorder, major depressive disorder, dementia with behavioral disturbance and a psychotic disorder with delusions due to known physiological conditions. A physician's order, dated 4/2/22, indicated to give [MEDICATION(S)] (a medication for seizures, [CONDITION(S)] and migraines) 125 mg (milligram) two capsules once daily and one capsule in the evening for dementia with behavioral disturbance. A pharmacy recommendation, dated 10/5/22, indicated it was time to consider a GDR on [MEDICATION(S)] 250 mg every morning and 125 mg in the evening for dementia with behaviors. The prescriber response indicated the resident was on hospice and the medication was providing comfort for the resident. The current dosage and frequency had the achieved desired effects. The pharmacy recommendation did not include the diagnosis of dementia with behaviors was not approved for the use of the [MEDICATION(S)]. The prescriber response did not include what the desired effects included. A care plan, dated 6/19/2020, indicated the resident was at a risk for socially inappropriate behavior related to the diagnosis of dementia and Alzheimer's. The resident had been found attempting to get into bed with her roommates and entering other resident rooms. The approaches included, but were not limited to, medication as ordered. During an interview, on 11/3/22 at 3:30 p.m., the facility pharmacist indicated she had planned to address the diagnosis for the [MEDICATION(S)] prescribed for dementia with behaviors if the prescriber had not approved the GDR. She indicated she did see a lot of facilities use [MEDICATION(S)] for dementia with behaviors. 2. The record for Resident 44 was reviewed on 10/31/22 at 2:48 p.m. Diagnoses included, but were not limited to, dementia without behaviors, a psychotic disorder with delusions due to a known physiological condition, depression and anxiety disorder. A physician's order, dated 3/29/22, indicated [MEDICATION(S)] (an antipsychotic) 25 mg twice daily for dementia with behavioral disturbance and psychotic disorder with delusions due to known physiological condition. A physician's order, dated 10/3/22, indicated [MEDICATION(S)] 25 mg three times daily for psychotic disorder with delusions. The Treatment Administration Record (TAR), dated October 2022, indicated the resident's targeted behaviors were calling out, anxiety and restlessness. The TAR showed the only behaviors documented for October were on 10/6/22, on the evening shift. A care plan, dated 4/8/22, indicated the resident experienced hallucinations and delusions. She often said she was dying or called out for help because she was scared. The care plan did not include any resident specific hallucinations or delusions. 3. The record for Resident 47 was reviewed on 10/31/22 at 3:01 p.m. Diagnoses included, but were not limited to, unspecified dementia with behavioral disturbance, major depressive disorder, anxiety disorder and chronic pain. A physician's order, dated 9/22/22, indicated [MEDICATION(S)] 250 mg at bedtime for dementia with behavioral disturbance. A care plan, dated 9/20/22, indicated the resident had impaired cognition related to the diagnosis of dementia with behaviors and was prescribed medication. A care plan, dated 9/20/22, indicated the resident had an anxious mood and was also at risk for behaviors related to advanced dementia. The resident's behavior was spitting on the floor. During an interview, on 11/2/22 at 3:20 p.m., the Social Services Designee (SSD) indicated the resident's behavior was spitting and it was more of a habit. He would spit on the table and the floor of his room and in the dining room. During an interview, on 11/3/22 at 3:45 p.m., the facility pharmacist indicated she had planned to ask for a clarification for the diagnosis for the [MEDICATION(S)] prescribed for dementia with behaviors and had not yet. 4. The record for Resident 4 was reviewed on 10/28/22 at 4:33 p.m. Diagnoses included, but were not limited to, dementia, [CONDITION(S)] disease (a movement disorder), cognitive communication deficit, psychotic disorder with hallucinations and depression. A Preadmission Screening and Resident Review (PASSAR), dated 7/26/21, indicated the resident was on [MEDICATION(S)] (an antipsychotic) 50 mg for a diagnoses of [CONDITION(S)]. A physician's order, dated 7/29/21, indicated [MEDICATION(S)] 25 mg at bedtime for a diagnoses of hallucinations. A care plan, dated 7/30/21, indicated the resident was at risk for potential drug related complications related to the use of an antipsychotic medication for hallucinations. Interventions included, but were not limited to, complete [CONDITION(S)] medication alternatives and observe for antipsychotic side effects. 5. The record for Resident 12 was reviewed on 10/31/22 at 10:59 a.m. Diagnoses included, but were not limited to, [CONDITION(S)] disease (a disorder affecting movement), hypertension, dementia without behaviors, psychotic disorder with hallucinations, Alzheimer's disease and depressive disorder. A PASSAR level I, dated 3/8/18, indicated the resident did not have a diagnoses of psychotic disorder with hallucinations. A Psychology Progress note, dated 2/21/22, indicated the resident started Nuplazide 34 mg (an atypical antipsychotic) 1 daily on 6/10/22 and stopped on 7/21/20. On 5/2020, the residents hallucinations were reported as non-distressing. The resident was being treated for anxiety and depression. A physician's order, dated 10/1/22, indicated [MEDICATION(S)] 25 mg one tablet twice a day related to a psychotic disorder with hallucinations. A care plan, dated 1/11/19, indicated the resident was at risk for potential altered mood and behaviors having hallucinations (audio, visual and tactile) and delusions with history of thinking she had glue on her hands. Interventions included, but were not limited to, utilize gloves for hands, assist resident with calling her daughter(s) and offer activities. 6. The record for Resident 33 was reviewed on 11/01/22 at 12:23 p.m. Diagnoses included, but were not limited to, Alzheimer's disease, anxiety, adult failure to thrive, depression, dementia, and restlessness and agitation. A physician's order, dated 8/5/22, indicated [MEDICATION(S)] (an antipsychotic) 0.5 mg three times daily for restlessness and agitation. A physician's order, dated 5/26/22, indicated ABH ([MEDICATION(S)] [antianxiety], Benadryl [antihistamine] and [MEDICATION(S)] [antipsychotic]) 1 milligram/25 milligrams/1 milligram per 0.5 milliliter gel twice daily for restlessness and agitation. A physician's order, dated 8/5/22, indicated [MEDICATION(S)] (an anxiety medication) 5 milligram twice daily for dementia with behavioral disturbance. A progress note, dated 12/20/21 at 12:22 p.m., indicated the resident was packing personal items to go to her mothers house, she was not distressed, and her mood was pleasant and cooperative. The staff provided interventions which included, 1:1, assisted with packing and frequent visual checks. The staff was unable to redirect her from packing. A progress note, dated 6/5/22 at 7:10 p.m., indicated the resident was intermittently agitated and requesting to check out of her room, the attempts to redirect were ineffective. She refused her pain medication at 2:00 p.m. and the resident indicated she did not need the medication. A progress note, dated 6/5/22 at 7:24 p.m., a late note for dayshift 6/3/22, indicated the resident was disoriented to situation and place. The routine [MEDICATION(S)] 1 mg bid and ABH gel 0.5 ml continue for dementia with behavioral disturbance. The resident was easily redirected during the shift. A progress note, dated 6/22/22 at 6:06 p.m., indicated the resident was worried about getting to the airport to pick up a friend. The interventions included, but were not limited to, allowed to vent, a snack and was pushed around the unit in her wheel chair, but the interventions were not successful. A consultant pharmacist physician recommendation, dated 5/12/22, indicated it was time for a gradual dose reduction for [MEDICATION(S)] ([MEDICATION(S)]). The physician's rationale was to continue as is and defer to hospice in the future. A notation, per the interdisciplinary team, indicated the dose reduction was not indicated per hospice order. A consultant pharmacist physician recommendation, dated 9/7/22, indicated it was time to consider a gradual dose for [MEDICATION(S)] for dementia with behaviors. A notation indicated to consider updating the diagnosis to anxiety if clinically indicated. The rationale for decline indicated the resident was comfortable and was on hospice. Her dosage and frequency had achieved the desired effects. A care plan, dated 10/3/19, indicated the resident was at risk for anxious mood related to room moves and adjusting to change. She believed people had stolen items when they were in her room. She received an antianxiety and antipsychotic for diagnoses of anxiety, restlessness and agitation. A care plan, dated 3/17/22, indicated the resident was at risk for anxious mood as evidenced by becoming fidgety, restless, irritable, anxious and agitated. At times, it was a result of hallucinations and delusions, such as packing items to leave and asking about her care or refusing care. Antipsychotic and antianxiety medications were used for diagnoses of dementia with behavioral disturbances, anxiety, restless and agitation. A care plan, dated 10/2/19, indicated the resident was at risk for adverse effects related to the use of routine antidepressants secondary to diagnoses of depression and adult failure to thrive. Interventions included, but were not limited to, assess, record and report to MD drug related cognitive or behavioral impairment, or change in ADL functioning, assess need for continued use. A care plan, dated 10/2/19, indicated the resident was at risk for adverse effects related to the use of antipsychotic medications secondary to agitation and restlessness related to Alzheimer's disease. During an interview, on 11/02/22 at 11:40 a.m., the nurse indicated the ABH gel was initiated due to the resident becoming upset and resistive to care. She would become angry and paranoid. She was looking for car keys and trying to leave and was difficult to redirect. During an interview, on 11/02/22 at 3:28 p.m., the Social Service Designee (SSD) indicated the resident became agitated and wanted to go home. She indicated she became distressed and would wheel towards doors and was not easily redirected. A recent publication of PDR.net indicated .[MEDICATION(S)] ([MEDICATION(S)]) was indicated for the treatment of [CONDITION(S)] disorder, including [CONDITION(S)], [CONDITION(S)] depression and major depressive disorder .the black box warning indicated antipsychotic's are not approved for the treatment of dementia-related [CONDITION(S)] in geriatric patients and the use of [MEDICATION(S)] in this population should be avoided if possible due to an increase in morbidity and mortality A recent publication of PDR.net indicated .[MEDICATION(S)] ([MEDICATION(S)]) was indicated for the treatment of [CONDITION(S)] disorder including [CONDITION(S)] .the black box warning indicated antipsychotic's are not approved for the treatment of dementia-related [CONDITION(S)] in geriatric patients and the use of [MEDICATION(S)] in this population should be avoided if possible due to an increase in morbidity and mortality A recent publication of PDR.net indicated .[MEDICATION(S)] ([MEDICATION(S)]) was indicated for the treatment of [CONDITION(S)] .the black box warning indicated antipsychotic's are not approved for the treatment of dementia-related [CONDITION(S)] in geriatric patients and the use of [MEDICATION(S)] in this population should be avoided if possible due to an increase in morbidity and mortality A recent publication of PDR.net indicated .[MEDICATION(S)] ([MEDICATION(S)]) was indicated for the treatment of [CONDITION(S)] .the black box warning indicated antipsychotic's are not approved for the treatment of dementia-related [CONDITION(S)] in geriatric patients and the use of [MEDICATION(S)] in this population should be avoided if possible due to an increase in morbidity and mortality A current policy, titled Antipsychotic Medication Use, dated December 2016 and received from the Director of Nursing on 11/3/22 at 4:37 p.m., indicated .antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective .diagnosis of a specific condition for which antipsychotic medications are necessary to treat will based on a comprehensive assessment of the resident .antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record .conditions included, but were not limited to, [CONDITION(S)], [CONDITION(S)] disorder, schizophreniform disorder, delusional disorder, delusional disorder, mood disorder, [CONDITION(S)] in the absence of dementia A current policy, titled Medication Therapy, dated April 2007 and received from the Director of Nursing on 11/2/22 at 10:00 a.m., indicated .all decisions related to medications shall include appropriate elements of the care process such as principles of prescribing for the elderly .periodically and when circumstances are present that represent a greater risk for medication-related complications, the staff and practitioner will review the medication regimen for continued indication, proper dosage and duration, and possible adverse consequences 3.1-48(b)(1) 3.1-48(b)(2)

Based on observation, interview and record review, the facility failed to ensure a PASARR (Preadmission Screening and Resident Review) was completed when a new mental health diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident 44 and 12) Findings include: 1. The record for Resident 44 was reviewed on 10/31/22 at 2:48 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A PASARR Level I, dated 2/22/22, indicated the resident did not need a level II screen and had no evidence of a PASARR condition. The resident had anxiety and depression diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no known mental health behaviors which affected interpersonal communications. The mental health medication was listed as [MEDICATION(S)] (medication to treat anxiety disorders). If changes occurred or new information refuted these findings, a new Level I screen must be submitted. During an interview, on 10/31/22 at 4:15 p.m., the SSD (Social Services Designee) indicated there was not another PASARR after the resident was prescribed [MEDICATION(S)] and another PASARR level I should have been completed. 2. The record for Resident 12 was reviewed on 10/31/22 at 10:59 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A PASARR level I, dated 3/8/18, indicated the resident had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . If changes occurred or new information refuted these findings, a new Level I screen must be submitted. During an interview, on 10/31/22 at 4:12 p.m., the Social Service Designee (SSD) indicated a new PASARR Level I should have been completed when the resident started an antipsychotic medication. During an interview, on 11/1/22 at 9:56 a.m., the SSD indicated Resident 12 did not have a Level I completed when [MEDICATION(S)] was started and should have had a new Level I completed. A current policy, titled Indiana PASRR Level I & Level of Care Screening Procedures for Long Term Care Services Provider Manual, dated as revised 4/29/20 and received from the Social Service Coordinator on 11/1/22 at 11:14 a.m., indicated .Identifies people who have or might have a serious mental illness (SMI), Intellectual disability (ID), or a condition related to intellectual disability .determine services and supports any person with MI/ID/RC need. The PASRR Level II evaluation identifies the rehabilitative or specialized services that the person needs. Nursing facilities must plan for and deliver or arrange for the delivery of all rehabilitative services that the PASRR Level II identifies .The Level I screen gathers information about people with SMIs. This information includes the person's mental health diagnoses, their symptoms and intensity, and how much the condition and its symptoms have impacted the person's life and well being .If a NF resident's behavioral or mental status significantly changes, the NF must submit a new Level I to report the change through the PASRR process 3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

Based on observation, interview and record review, the facility failed to ensure a resident needing assistance with ADL's (activity of daily living) was provided the scheduled showers for 2 of 2 residents reviewed for activity of daily living. (Resident 4 and 45) Findings include: 1. During an observation, on 10/27/22 at 3:30 p.m., Resident 4's hair appeared greasy and uncombed. The resident indicated she did not always get a shower and it had been days since her hair was washed. During an interview, on 11/1/22 at 11:24 a.m., Resident 4 indicated she did not receive a shower on 10/27/22. The record for Resident 4 was reviewed on 10/28/22 at 4:33 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS (Minimum Data Set) assessment, dated 7/21/22, indicated the resident needed one person extensive assist with showers and bathing. A Shower Schedule, received on 11/1/22 at 3:46 p.m., by the Director of Nursing, indicated Resident 4 had showers scheduled on Wednesday and Saturday. A Shower Alert-Skin Alert indicated the resident missed the following showers: a. 7 showers in August. b. 6 showers in September. c. 9 showers in October. During an interview, on 11/2/22 at 1:56 p.m., CNA 5 indicated she was unaware if the resident refused showers. During an interview, on 11/2/22 at 2:28 p.m., CNA 5 indicated if the shower sheets were missing, the resident did not receive a shower. 2. During an observation, on 10/31/22 at 12:31 p.m., Resident 45 was sitting in her wheelchair, asleep. Her hair was greasy and uncombed. During an observation, on 11/01/22 at 10:30 a.m., the resident was sitting, in her wheelchair, with her eyes closed. Resident 45's hair was greasy. The record for Resident 45 was reviewed on 10/28/22 at 4:29 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment, dated 9/22/22, indicated the resident was a two person total assist with showers and bathing. A Shower Schedule, received on 11/1/22 at 3:46 p.m., by the Director of Nursing, indicated Resident 45 had showers scheduled on Tuesday, Friday and Sunday. A Shower Alert-Skin Alert indicated Resident 45 missed the following showers: a. 7 showers in August. b. 8 showers in September. c. 10 showers in October. A current policy, titled Activities of Daily Living (ADL's), Supporting, dated as revised 3/2018 and received from the Social Services Coordinator on 11/3/22 at 4:37 p.m., indicated .Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and the accordance with the plan of care, including appropriate support and assistance with: Hygiene (bathing, dressing, grooming, and oral care) .If residents with cognitive impairment or dementia resist care, staff will attempt to identify underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate .The resident's response to interventions will be monitored, evaluated and revised as appropriate 3.1-38(a)(3)(B) 3.1-38-(b)(2)

Based on observation, interview and record review, the facility failed to obtain complete physician's orders for the use of oxygen for 2 of 5 residents reviewed for oxygen. (Residents 33 and 214) Findings include: 1. The record for Resident 33 was reviewed on 11/01/22 12:23 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's order, dated 6/7/21, indicated 2 to 4 liters of oxygen per nasal cannula as needed for comfort. The order did not indicate symptoms or parameters to titrate the oxygen from 2 to 4 liters. A care plan, dated 6/8/21, indicated the resident was receiving hospice care for end stage disease and terminal illness of Alzheimer's disease. She was to be supported to promote comfort and dignity through out her terminal illness. Interventions included, but were not limited to, if increased pain was noted notify hospice and comfort medications as ordered and needed. The interventions did not include oxygen for comfort. The electronic health record did not include a respiratory care plan. 2. The record for Resident 214 was reviewed on 11/01/22 at 9:43 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's order, dated 10/28/22, indicated oxygen to maintain saturations between 92-94% for chronic obstructive pulmonary disease, acute and chronic respiratory failure with [CONDITION(S)] and hypercapnia. The physician's order did not contain a liter flow or route of administration. The medication record for October 2022 indicated the resident's oxygen saturations ranged from 90% to 97% and the oxygen liter flow ranged from 2-5 liters. During an interview, Resident 214 indicated he would adjust the oxygen flow rate as he desired. He indicated he was not sure of the staff's capabilities to adjust the oxygen During an interview, on 11/03/22 at 2:12 p.m., Licensed Practical Nurse 2 indicated an order to adjust oxygen to maintain a saturation, should have included an oxygen liter flow and should have been titrated to meet the desired saturation. She would start with a low oxygen liter flow and increase if the oxygen saturation was not in range. If the resident was on hospice and the order read 2 to 4 liters per nasal cannula, she would start with a low oxygen liter flow and increase with symptoms. A current policy, titled Medication Orders, not dated and received from the Director of Nursing on 11/2/22 at 10:00 a.m., indicated .oxygen orders .when recording orders for oxygen, specify the rate of flow or titration goal, route and rationale A current policy, titled Oxygen Administration, dated 7/22/20 and received from the Director of Nursing on 11/2/22 at 10:00 a.m., indicated .check physician's order for liter and flow and method of administration .monitor flow of oxygen and oxygen saturations every shift and as needed 3.1-47(a)(6)