Every finding on record at White River Lodge

Based on interview and record review, the facility failed to ensure an order for an as needed (PRN) psychotropic medication was limited to 14 days for 1 of 5 residents reviewed for unnecessary medications. (Resident 3)Findings include:On 3/25/26 at 2:03 p.m., Resident 3's clinical record was reviewed. The diagnoses included, but were not limited to, insomnia and anxiety. A Physician's Order, dated 11/5/25, indicated the resident was prescribed Ativan (an antianxiety medication) 0.5 milligrams (mg) every 8 hours as needed, with no stop date. During an interview on 3/27/26 at 11:45 a.m., the Corporate Administrator Consultant indicated the facility did not limit the use of as needed psychotropics to 14 days. On 3/27/26 at 11:40 a.m., the Administrator provided a copy of the policy, Psychoactive Medication Protocol, revised on April, 2025, and indicated it was the policy currently being used. A review of the policy indicated, .3. the facility must ensure . d. PRN orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicated the duration for the PRN order . 410 IAC (Indiana Administrative Code) 16.2-3.1-48(a)(2)

Based on observations, interview, and record review, the facility failed to ensure a nasal cannula was not left on the floor for 1 of 1 resident reviewed for respiratory care. (Resident 2)Finding includes:On the following dates and times, the oxygen nasal cannula connected to tubing which was connected to a humidifying oxygen concentrator was observed on the floor in Resident 2's room beside the resident's chair: 3/24/26 at 12:08 p.m.3/25/26 at 10:57 a.m. 3/26/26 at 10:05 a.m.3/26/26 at 2:00 p.m. On the following dates and times, Resident 2 was observed sitting in the chair in her room with the oxygen nasal cannula in her nares: 3/24/26 at 1:30 p.m.3/25/26 at 1:42 p.m.3/26/26 at 11:12 a.m. On 3/25/26 at 9:40 a.m., Resident 2's clinical record was reviewed. The diagnoses included, but were not limited to, atrioventricular block and acute respiratory failure. A current physician's order with a start date of 3/13/26 indicated the resident was receiving continuous oxygen therapy via nasal cannula at 2 liters per minute. During an interview on 3/24/26 at 1:33 p.m., Resident 2 indicated staff put the cannula on for her when she was in her chair, but she did not know if it was cleaned or replaced before being placed in her nares. During an interview on 3/26/26 at 2:04 p.m., the Director of Nursing indicated the resident's nasal cannula should not have been left on the floor. 410 IAC (Indiana Administrative Code)16.2-3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to ensure a resident had a dental consult for assessed dental problems for 1 of 1 residents reviewed for dental care. (Resident 13)Finding includes:During an observation on 3/24/26 at 1:33 p.m., Resident 13 was observed to have broken and missing teeth. At that time, she indicated she had not seen the dentist and would like to have her broken teeth pulled for dentures.On 3/26/26 2:18 p.m., Resident 13's clinical record was reviewed. The diagnoses included, but were not limited to, left-sided hemiplegia (paralysis on one side of the body) and atherosclerotic heart disease.The Brief Oral Health Status Examination Assessment Tool, indicated the following:- On 10/21/25, Resident 13 had 1-3 decayed or broken teeth. The assessment indicated she needed referred to the dentist immediately.- On 1/13/26, Resident 13 had 1-3 decayed or broken teeth. The assessment indicated she needed referred to the dentist immediately.The clinical record lacked documentation of a dentist referral after 10/21/25 and 1/13/26 oral assessments.During an interview on 3/27/26 10:26 a.m., the Director of Nursing (DON) indicated Resident 13 oral assessments were completed quarterly. The clinical record lacked documentation of a dental consult after the 10/21/25 and 1/13/26 assessments.On 3/27/26 at 11:25 a.m., the Administrator provided the facility policy, Dental Services, dated 5/2025 and indicated it was the policy currently being used by the facility. A review of the policy indicated, .6a. Although the cumulative score is helpful, individuals who score on items with an asterisk that are underlined should be referred for a dental evaluation and exam and follow-up immediately.410 IAC (Indiana Administrative Code) 16.2-3.1-24(a)

Based on observation, interview, and record review, the facility failed to label and discard medications for 1 of 1 medication rooms observed. (Resident 24, Resident 12, Resident 13) Findings include: On 6/2/25 at 11:55 a.m., in the refrigerator of the medication room the following was observed. - Two Ozempic injector pens (an injectable medication used to treat type 2 diabetes, which is a condition that occurs when the body doesn't produce enough insulin), for Resident 24 and Resident 12, were not dated with an open date and/or an expiration date. Resident 24's Ozempic pen had a date of 4/25/25 written on the box. The Director of Nursing (DON) verified there was only one date and could not specify if this was an open or expiration date. Resident 12's Ozempic pen had no date written on the box or pen. The DON verified there was no date on the medication. The DON indicated every medication that was open should have an opened date and an expiration date on the vial or the pen. The DON indicated that Ozempic pens should be discarded 56 days after first use. - A bottle of liquid Omeprazole (a medication used to treat frequent heartburn), for Resident 13, was observed with an expiration date of 5/20/25. The DON verified the date written on the bottle and indicated the medication should have been discarded on 5/20/25. The DON indicated this medication had been discontinued on 5/12/25 and was not currently being administered to the resident. On 6/2/25 at 3:00 p.m., the Administrator provided the facility's policy on Storage of Medications and Biologicals, dated 5/21/18, and indicated it was a current policy being used by the facility. A review of the policy indicated .21. Disposal of medications should be completed for medications that are without secure closure, outdated . The policy did not indicate how to label medications when they were opened. The Administrator indicated she could not find a policy regarding labeling of medications when they were opened. 3.1-25(j) 3.1-25(o)

Based on observation, interview, and record review, the facility failed to implement infection control practices for 1 of 2 residents reviewed for urinary catheters. The urinary catheter tubing and drainage bag was touching the floor. (Resident 33) Findings include: On 5/27/25 at 11:03 a.m., Resident 33 was observed to be resting in a low bed with the urinary catheter tubing on the floor and drainage bag on the floor. On 5/28/25 at 10:03 a.m., Resident 33 was observed to be resting in a recliner with the urinary catheter tubing on the floor. On 5/28/25 at 2:05 p.m., Resident 33 was observed to be resting in a low bed with the urinary catheter tubing on the floor. On 5/29/25 at 1:44 p.m., Resident 33 was observed to be resting in a low bed with the urinary catheter tubing on the floor. On 6/2/25 at 12:06 p.m., Resident 33 was observed to be sitting in a recliner with the urinary catheter tubing on the floor. On 5/29/25 at 11:42 a.m., Resident 33's clinical record was reviewed. The diagnoses included, but were not limited to, diabetes mellitus, cerebral infarction (stroke), and neurogenic bladder (condition where the nerves controlling the bladder are damaged). Resident 33's physician order, dated 2/22/25, indicated to change indwelling 14 fr (French) (size of catheter) catheter once a month. The care plan, dated 4/9/25, indicated Resident 33 had urinary retention related to chronic kidney disease. The care plan lacked documentation on placement of the catheter tubing while in the bed or recliner. During an interview on 6/2/25 at 12:35 p.m., CNA 1 indicated at times, Resident 33's urinary catheter tubing was on the floor. The catheter tubing was not to be on the floor. On 6/2/25 at 3:00 p.m., the Administrator provided the facility's policy, Catheter Management, revised date 4/25, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .j. collecting bags should always be kept below the level of the bladder, and not resting on the floor . 3.1-18(b)(1)

Based on interview and record review, the facility failed to ensure the written notification required for facility-initiated transfers was given to the resident or the resident representative for 1 of 1 resident reviewed for hospitalization . (Resident 21) Findings include: A review of Resident 21's progress notes on 4/10/23 at 10:30 a.m., indicated the resident was sent out to the hospital on 2/24/23. There was no documentation that the resident or resident's representative had been notified of the transfer in writing and provided the appeal rights information in writing including the contact information of the Office of the State LTC (Long-Term Care) Ombudsman after the resident was sent out to the hospital. During an interview on 4/10/23 at 11:01 a.m., the Clinical and Quality Support staff member indicated the transfer and discharge forms were sent with the resident during the transfer to the hospital and the representative was notified by phone. On 4/10/23 at 3:00 p.m., the Clinical and Quality Support staff member provided the facility policy . Transfer and Discharge Policy with a revised date of 10/2022, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . 7. Before the facility transfers or discharges a resident, the facility will notify the resident and the resident's representative of the transfer and reasons for the move in writing and in a language the resident understands . 3.1-12(a)(6)(A)(i) 3.1-12(a)(6)(ii)

Based on interview and record review, the facility failed to ensure the notification of the bed hold policy required for residents who transferred to the hospital was provided for 1 of 1 resident reviewed for hospitalization . (Resident 21) Findings include: A review of Resident 21's progress notes on 4/10/23 at 10:30 a.m., indicated the resident was sent to the hospital on 2/24/23. There was no documentation that a written notice that specified the facility's bed-hold policy permitting the resident to return and resume in the facility was provided to the resident or the resident's representative. During an interview on 4/10/23 at 11:01 a.m., the Clinical and Quality Support staff member indicated the bed hold policy forms were sent with the resident during the transfer to the hospital and the representative was notified by phone. On 4/10/23 at 3:00 p.m., the Clinical and Quality Support staff member provided the facility policy, . Bed Hold Policy with a revised date of 10/2017, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . 2. At the time of transfer for a resident for hospitalization or therapeutic leave, the facility will provide to the resident and the resident representative written notice . 3.1-12(a)(25) 3.1-12(a)(26)

Based on observation, interview, and record review, the facility failed to ensure a resident's weight was monitored as ordered by the physician's plan of care for 1 of 3 residents reviewed for nutrition. (Resident 37) Findings include: On 4/4/23 at 2:50 p.m., Resident 37 was observed in her wheelchair in the hallway. She appeared to be thin and lethargic. On 4/5/23 at 11:50 a.m., the resident was observed in the dining area. A staff member was assisting the resident with her meal. On 4/6/23 at 10:20 a.m., Resident 37's clinical record was reviewed. The diagnoses included, but were not limited to, cerebral infarction and flaccid hemiplegia. The resident's care plan indicated she was at risk of malnutrition related to her condition and her weights were to be monitored as ordered by the physician. A current physician's order, with a start date of 2/9/22, indicated, the resident's weight was to be monitored one time a week on Wednesday mornings. The clinical record indicated since that physician's order, the resident's weight was obtained 17 times out of 61 opportunities. During an interview on 4/11/23 at 12:20 p.m., the facility Administrator indicated the resident's weights were not documented as the physician's order directed. 3.1-35(g)(2)

Based on observation, interview, and record review, the facility failed to ensure staff provided adequate supervision and interventions to prevent falls for 1 of 3 residents reviewed for falls. The resident sustained a left wrist fracture following a fall. (Resident 11) Finding includes: On 2/23/22 at 11:22 a.m., Resident 11 was observed ambulating down the hallway towards the dining room with the assistance of 2 staff. The resident was observed to be very unsteady on her feet, grabbing the handrail, and stopped in the hallway. The resident indicated that she had recently broken her wrist because she fell in her room. CNA (Certified Nursing Assistant) 2 indicated the resident doesn't always ask for help when wanting to get up, so the resident had a chair alarm and a bed alarm in place when she was in her room. On 2/25/22 at 1:47 p.m., Resident 11 was observed sitting up on the edge of the recliner seat. The resident was visibly tired with her eyes slightly open. At that time, the resident stated she had a dream she could walk and asked if she should get up and walk. CNA 3 walked by the room and was observed to enter into the resident room and prop up the footrest of the recliner. The resident indicated she was so tired. On 2/21/22 at 2:48 p.m., Resident 11's clinical record was reviewed. The diagnoses included, but were not limited to: [CONDITION(S)] ([CONDITION(S)], or stroke) and [CONDITION(S)] (weakness or inability to move one side of the body.) The Quarterly MDS (Minimum Data Set) assessment, dated 12/15/21, indicated the resident required limited assistance of 2 staff with transfers and locomotion (walking), had functional impairment on one side of their upper and lower extremities, and was moderately cognitively impaired. Resident 11's CNA (certified nurse assistant) assignment sheet indicated the resident was an assist of 2 staff with strong support to the right side due to left side flaccidity (weakness) due to [CONDITION(S)]. The assignment sheet did not mention the use of position change alarms. Resident 11's fall care plan, dated 11/18/202 (sic) with no goal date, indicated the resident was a post [CONDITION(S)] with left [CONDITION(S)], recently had a fall which resulted in an open fracture of the left wrist, and required extensive assistance with ADL's (Activities of Daily Living.) The resident had no peripheral vision to the left side and was receiving therapy services. The MDS Coordinator indicated the resident did not have an active fall prevention care plan between September, 2021 and November, 2021. The Progress Notes included, but were not limited to: -On 9/17/21 at 2:00 p.m., the resident sustained an unwitnessed fall in her bedroom while reaching for a cup water. The immediate intervention implemented was to place the water within reach on the right side. -On 10/12/21 at 11:50 a.m., the resident sustained an unwitnessed fall in her bedroom and was found on the floor, face down, with broken glasses, and a visible compound fracture to the left wrist. The immediate intervention implemented was for the resident to utilize a soft touch call light. ANP (Adult Nurse Practitioner) note, dated 11/2/21, indicated Resident 11 attempted to self ambulate and was sent toER on [DATE] following a fall which resulted in a left arm fracture. An orthopedic procedure was performed to remove fragmented bone. -On 11/1/21 at 5:10 a.m., the resident sustained an unwitnessed fall in her bedroom and was found on the floor. The immediate intervention implemented was for a cushioned floor mat to be placed by the bed. -On 11/8/21 at 11:00 p.m., the resident was in her bedroom and sustained an unwitnessed fall while reaching for her bed controller. The immediate intervention implemented was to put the bed controller within reach of the resident. -On 11/21/21 at 8:20 a.m., the resident was in her bedroom and sustained an unwitnessed fall. The resident had a visible hematoma (a solid swelling of clotted blood within the tissues), complained of dizziness, nausea, vomited, and was sent to the ER after the fall. The intervention implemented was to encouraged the resident not to lean forward in her recliner chair. -On 1/15/22 at 3:00 a.m., the resident was in her bedroom and sustained an unwitnessed fall. The resident had a visible raised bruise above the left eye. The immediate intervention implemented was to place non-skid strips under the floor matt so the matt would not slide. On 1/19/22 at 8:25 p.m., the resident sustained a witnessed fall in her room. The immediate intervention implemented was for the resident to wear slipper socks. During an interview on 2/24/22 at 10:14 a.m., CNA 3 indicated Resident 11 would just get up and go whenever she wanted and she was very unstable on her feet. The CNA indicated the resident had bed, wheelchair, and recliner alarms in place to facilitate fall prevention. During an interview on 2/24/22 at 10:20 a.m., the DON (Director of Nursing) and Administrator indicated Resident 11 would just get up and go without any warning and did not use her call light to ask for help. During an interview on 2/25/22 at 11:30 a.m., Resident 11's RCAs (Root Cause Analysis) were reviewed. The RCAs with the facility staff present indicated the interventions did not meet the needs of the resident and some interventions were already in place. During an interview on 2/25/22 at 2:25 p.m., the DON indicated Resident 11 did not have an order for position change alarms and did not have a completed assessment for alarm usage. The DON indicated position change alarms are for short term use and not to be used for the convenience of the staff. On 2/25/22 at 2:17 p.m., the DON provided the facility policy, Fall Assessment and Prevention Protocol, revised August, 2021, and indicated it was the policy currently being used by the facility. A review of the policy indicated resident care plans were to be updated the next business day with appropriate fall interventions. The policy did not mention staff to increase supervision. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a safe and sanitary environment for 9 of 12 rooms reviewed. Dark brown substances were found around bathroom toilet bases and bedroom walls were scuffed and unfinished. (Room 215, Room 217, Room 210, Room 303, Room 311, Room 315, Room 214, Room 206, Room 313) Findings include: 1. On 2/22/22 at 11:05 A.M., a dark substance was observed around the base of the bathroom toilet in Room 215. The drywall at the head of the resident's bed was observed to have scuff marks and was unfinished. 2. On 2/22/22 at 11:10 A.M., a dark substance around the base of the bathroom toilet in Room 217 was observed. The drywall at the head of the bed in Room 217 was observed to have scuff marks and was unfinished. 3. On 2/22/22 at 11:20 A.M., a dark substance was observed around the base of the bathroom toilet in Room 210. 4. On 2/22/22 at 11:24 A.M., the drywall at the head of bed in Room 303 was observed to have scuff marks and was unfinished. 5. On 2/22/22 at 11:30 A.M., the drywall at the head of both resident beds in Room 311 was observed to have scuff marks and was unfinished. 6. On 2/22/22 at 2:30 P.M., the drywall at the head of both resident beds in Room 315 was observed to have scuff marks and was unfinished. 7. On 2/22/22 at 2:35 P.M., a dark substance was observed around the base of the bathroom toilet in Room 214. 8. On 2/22/22 at 2:40 P.M., a dark substance was observed around the base of the bathroom toilet in Room 206. 9. On 2/22/22 at 2:45 P.M., a dark substance was observed around the base of the bathroom toilet in Room 313. During an interview, on 2/25/22 at 2:10 PM., the maintenance director indicated the scuffed walls and toilet bases were in need of repair and cleaning. On 2/25/22 at 10:35 A.M., the facility Administrator provided the Resident Rights, updated March 15, 2017, and indicated these were the Resident Rights currently used by the facility. A review of the Resident Rights indicated, .you have the right to a .clean, comfortable, and homelike environment . 3.1-19(f)

Based on observation, interview, and record review, the facility failed to provide a restorative program to residents with assessed limited range of motion (amount of movement around a specific joint) for 3 of 3 residents reviewed for mobility. (Resident 2, Resident 11, Resident 21). Findings include: 1. During an observation on 2/21/22 at 3:03 p.m., Resident 2 was observed sitting in her recliner. Her right wrist and hand had limited range of motion. At that time, Resident 2 indicated she had limited range of motion of her right wrist and hand from a stroke. She was not receiving any restorative programs. During an observation on 2/22/22 at 11:30 a.m., Resident 2 was observed to be in the activity lounge playing piano with her left hand and her right hand had limited range of motion. On 2/25/22 at 10:20 a.m., Resident 2's clinical was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment, dated 3/10/21, indicated Resident 2 was cognitively intact, had limited range of the motion of upper and lower extremity on one side, and was not on a active or passive range of motion restorative program. The Quarterly Minimum Data Set (MDS) assessment, dated 11/17/21, indicated Resident 2 was cognitively intact, had limited range of motion of the upper and lower extremity on one side, and was not on a active or passive range of motion restorative program. The Occupational Therapy (OT) Progress & Discharge Summary, dated 4/27/21, indicated Resident 2 was discharged from OT and was placed on restorative nursing program for range of motion to the upper right and left arm to maintain her current strength. The Nursing Caregiver Training tool, dated 6/28/21, indicated Resident 2 required limited assistance of one nursing staff to ambulate 100 feet and required a range of motion restorative program to her hips and knees. The Physical Therapy (PT) Progress & Discharge Summary, dated 7/3/21, indicated Resident 2 was discharged from PT and was placed on a restorative nursing program for ambulation and exercises. The clinical record lacked documentation of Resident 2's restorative notes or restorative care plans. During an interview on 2/22/22 at 10:11 a.m., the MDS nurse indicated Resident 2 was not on any nursing restorative programs. During an interview on 2/23/22 at 2:06 p.m., Licensed Practical Nurse (LPN) 1 indicated Resident 2 was not on any nursing restorative programs. During an interview on 2/24/22 at 1:42 p.m., Certified Nursing Assistant (CNA) 1 indicated Resident 2's right hand and wrist had limited range of motion. Resident 2 was not on a nursing restorative program. During an interview on 2/25/22 at 9:55 a.m., the MDS nurse indicated when a resident was discharged from therapy, the resident would be placed on a restorative program. During an interview on 2/25/22 at 11:14 a.m., the MDS nurse indicated Resident 2 was not on a restorative program. Resident 2's clinical record lacked documentation of restorative program notes or a care plan. During an interview on 2/25/22 at 11:48 a.m., Physical Therapist Assistant (PTA) 1 indicated when a resident was discharged from therapy, the therapist would complete a Nursing Caregiver Training tool for a nursing restorative program. Resident 2 was discharged from therapy with an ambulation and range of motion restorative program. 2. On 2/23/22 at 11:22 a.m., Resident 11 was observed ambulating down the hallway towards the dining room with the assistance of 2 staff. The resident was observed to be very unsteady on her feet. The resident indicated that she had recently broken her wrist because she fell in her room. On 2/21/22 at 2:48 p.m., Resident 11's clinical record was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS (Minimum Data Set) assessment, dated 12/15/21, indicated the resident required limited assistance of 2 staff with transfers and locomotion (walking), had functional impairment on one side of their upper and lower extremity, and was moderately cognitively impaired. A Nursing Caregiver Training Tool, dated 11/26/21, indicated the resident was to have ROM (range of motion) exercises to the hip, knee, and shoulder. A Therapy Discharge Summary, dated 11/27/21, indicated Resident 11 was to receive restorative services. During an interview on 2/22/22 at 11:00 a.m., the MDS (Minimum Data Set) nurse indicated that Resident 11 was not receiving restorative services. During an interview on 2/25/22 at 2:25 p.m., the DON (Director of Nursing) indicated she did not have any restorative services notes for Resident 11. 3. On 2/21/22 at 2:54 p.m., Resident 21 was observed to have a splint on her right hand and a brace on her right leg. On 2/23/22 at 10:02 a.m., Resident 21 was observed with a large bandage on her forehead. CNA 2 indicated the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] On 2/21/22 at 2:48 p.m., Resident 21's clinical record was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS (minimum data set) assessment, dated 1/7/22, indicated the resident required extensive assistance of 2 staff with bed mobility and transfers. The resident had functional impairment on one side of their upper and lower extremities. During an interview on 2/22/22 at 11:00 a.m., the MDS (Minimum Data Set) nurse indicated Resident 21 was not receiving restorative services. During an interview on 2/25/22 at 2:30 p.m., the DON (Director of Nursing) indicated she did not have any restorative services notes for Resident 21. During an interview on 2/25/22 at 9:55 a.m., the MDS nurse indicated the facility needed to work on their restorative program. On 2/25/22 at 2:15 p.m., the Director of Nursing provided the facility policy, Restorative Nursing Program, dated December, 2021, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .The RAI [Resident Assessment Instrument] instructs facilities to begin restorative nursing programs when a resident is discharged from therapy . Restorative nursing focuses on maintaining function in a long-term, ongoing process . 3.1-42(a)(2)

Based on interview and record review, the facility failed to ensure the physician provided a rationale for declining a Gradual Dose Reduction (GDR) for residents who were prescribed [CONDITION(S)] medications for 2 of 5 residents reviewed for unnecessary medications. (Resident 30, Resident 31) Findings include: 1. On 2/22/2022 at 2:57 p.m., Resident 30's clinical record was reviewed. The diagnoses included, but were not limited to, depression, anxiety, and delusions. The Physician orders, dated 2/11/2022, indicated Resident 30's medications included, but were not limited to: -[MEDICATION(S)] (an antidepressant) 60 mg (milligrams) 1 capsule by mouth every day. -[MEDICATION(S)] (an antianxiety) 0.25 mg by mouth three times a day. -[MEDICATION(S)] (an antipsychotic) 50 mg by mouth twice a day. A review on 2/25/2022 at 10:30 a.m., of the documents titled Consultant Pharmacist Recommendation to Physician indicated the following: -On 6/19/2021, the report indicated the pharmacist had reviewed Resident 30's medications and recommended evaluating to see if reducing the [MEDICATION(S)] and [MEDICATION(S)] were appropriate. The report indicated, . If no changes are made, please document a clinical contraindication statement . The physician indicated no changes but did not provide patient specific rationale describing why the recommendations were refused. -On 12/13/2021, the report indicated the pharmacist had reviewed Resident 30's medications and recommended reducing the [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. The report indicated, . If no changes are made, please document a clinical contraindication statement . The physician did not provide patient specific rationale describing why the recommendations were refused. 2. On 2/23/2022 at 1:50 p.m., Resident 31's clinical record was reviewed. The diagnoses included, but were not limited to depression, anxiety, and behavioral disorders associated with dementia. The Physician orders, dated 2/11/2022, indicated Resident 31's medications included, but were not limited to: -[MEDICATION(S)] HR (an antidepressant) 187.5 mg (milligrams) 1 capsule by mouth every day. -[MEDICATION(S)] (an antidepressant) 100 mg by mouth every day. -[MEDICATION(S)] (an antianxiety) 0.5 mg by mouth every day. -[MEDICATION(S)] (an antipsychotic) 50 mg by mouth twice a day. A review on 2/25/2022 at 11:15 a.m., of the documents titled Consultant Pharmacist Recommendation to Physician indicated the following: -On 4/16/2021, the report indicated the pharmacist had reviewed Resident 31's medications and recommended evaluating to see if reducing the [MEDICATION(S)] and [MEDICATION(S)] were appropriate. The report indicated, . If no changes are made, please document a clinical contraindication statement . The physician indicated no changes at this time but did not provide patient specific rationale describing why the recommendations were refused. -On 10/11/2021, the report indicated the pharmacist had reviewed Resident 31's medications and recommended reducing the [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. The report indicated, . If no changes are made, please document a clinical contraindication statement . The physician indicated, disagree but did not provide patient specific rationale describing why the recommendations were refused. During an interview on 2/25/2021 at 10:55 a.m., the MDS (Minimum Data Set) Coordinator indicated the rationale for why the physician refused the pharmacist recommendations on Resident 30 and 31 would be on the document titled, Consultant Pharmacist Recommendation to Physician but there was nothing written on those forms as to why the physician refused. On 2/25/2022 at 2:17 p.m., the Director of Nursing provided the policy Psychoactive Medication Protocol with a revised date of 8/2021, and indicated it was the policy currently being used by the facility. A review of the policy did not address GDR's and the physician providing a rationale for refusing the pharmacist recommendations. 3.1-48(b)(2)

Based on interview and record review, the facility failed to provide showers for residents according to their preferences for 2 of 2 residents reviewed for activities of daily living (Resident 16 and Resident 31). Findings include: 1.) Interview, on 2/11/20 at 11:32 a.m., Resident 16 indicated she was only getting 2 showers a week and she preferred to get 3 showers a week. Sometimes I don't get 2. On 2/12/20 at 3:00 p.m., Resident 16's clinical record was reviewed. [DIAGNOSES REDACTED]. Resident 16's Quarterly Minimum Data Set (MDS) assessment, dated 10/19/19, indicated the resident was cognitively intact and required extensive assistance of one staff member with personal hygiene. The MDS indicated a shower did not occur during the 7 day assessment reference period. Resident 16's Resident Preference form, dated 7/1/19, indicated, . Your Showers/Baths are scheduled on (blank) on the AM (morning) shift. Will this work for you: (blank) . A blank space equated to task not completed. Resident 16's Skin and Body Assessment forms indicated the following: -For the week of December 29-31 through January 1-4, the resident received 1 shower, on 1/1/20. -For the week of January 5-11, the resident received 1 shower, on 1/8/20. -For the week of January 12-18 through February 1, the resident received 1 shower, on 1/15/20. -For the week of January 26-31 through February 1, the resident received 1 shower, on 1/29/20. -For the week of February 2-8, the resident received 1 shower, on 2/8/20. Interview, on 2/12/20 at 3:04 p.m., the MDS coordinator indicated she checked with the staff to see what days would work for their schedule in order to schedule the residents' showers. After she spoke with staff, she would go back to the resident and ask them if the assigned days worked for them. I don't want them (staff) to have 10 showers in one day. After she looked at Resident 16's Resident Preferences she needed to look at the computer to see what days she had assigned for the resident since the form was blank in regard to a shower schedule. Interview, on 2/12/20 at 3:11 p.m., the MDS coordinator indicated Resident 16's showers were scheduled for mornings, on Wednesdays and Saturdays. Interview, on 2/13/20 at 3:30 p.m., the Director of Nursing indicated staff should fill out a Skin and Body Assessment form after they gave a resident a shower. No other documentation was provided in regard to Resident 16's showers by survey exit, on 2/13/20 at 4:00 p.m. On 2/10/20 at 2:00 p.m., the Administrator provided the facility policy, Resident Rights, dated 3/15/17, and indicated it was the policy currently being used. Review of the policy indicated, . Self-determination. You have the right to and the facility must facilitate self-determination through support of resident choice, including: The right to choose . schedules . health care services consistent with your interests, assessments, plan of care . You have the right to make choices about aspects of your life . 2.) Interview, on 2/11/20 at 11:52 a.m., Resident 31 indicated, I'd like a shower every 3 days, or twice a week, but they haven't been doing that. On 2/12/20 at 3:00 p.m., Resident 31's clinical record was reviewed. [DIAGNOSES REDACTED]. Resident 31's Significant Change Minimum Data Set (MDS) assessment, dated 12/9/19, indicated the resident was moderately cognitively impaired and required transfer assistance with bathing. Resident 31's Resident Preference form, dated 5/2/19, indicated, . Your Showers/Baths are scheduled on (blank) on the AM (morning) shift. Will this work for you: (blank) . A blank space equated to task not completed. Resident 31's Skin and Body Assessment forms indicated the following: -For the week of January 5-11, the resident received 1 shower, on 1/7/20. -For the week of January 19-25, the resident received 1 shower, on 1/24/20. -For the week of January 26-31 through February 1, the resident received 1 shower, on 1/31/30. -For the week of February 2-8, the resident received 1 shower, on 2/4/20. Resident 31's Skin and Body Assessment form, dated 2/7/20, indicated, (Resident's Name) did not get her shower tonight it was almost 9 pm (9:00 p.m.) when I was able to get to her so time ran out. Will attempt again tomorrow. The next form in sequence was dated 2/11/20. Interview, on 2/12/20 at 3:04 p.m., the Minimum Data Set coordinator indicated she checked with the staff to see what days would work for their schedule in order to schedule the residents' showers. After she spoke with staff, she would go back to the resident and ask them if the assigned days worked for them. I don't want them (staff) to have 10 showers in one day. She looked at Resident 31's Resident Preferences form and indicated she needed to look at the computer to see what days she had assigned for the resident, since the form was blank in regard to a shower schedule. Interview, on 2/12/20 at 3:11 p.m., the MDS coordinator indicated Resident 31's showers were scheduled for evenings, on Tuesdays and Fridays. Interview, on 2/13/20 at 3:30 p.m., the Director of Nursing indicated staff should fill out a Skin and Body Assessment form after they gave a resident a shower. No other documentation was provided in regard to Resident 31's showers by survey exit, on 2/13/20 at 4:00 p.m. On 2/10/20 at 2:00 p.m., the Administrator provided the facility policy, Resident Rights, dated 3/15/17, and indicated it was the policy currently being used. Review of the policy indicated, . Self-determination. You have the right to and the facility must facilitate self-determination through support of resident choice, including: The right to choose . schedules . health care services consistent with your interests, assessments, plan of care . You have the right to make choices about aspects of your life . 3.1-3(v)(1)

Based on interview and record review, the facility failed to ensure a quarterly Minimum Data Set (MDS) assessments were completed every 3 months for 2 of 3 residents reviewed for Resident Assessment (Resident 1 and Resident 2). Findings include: 1. On 2/12/20 at 1:38 p.m., Resident 1's clinical record was reviewed. The [DIAGNOSES REDACTED]. Resident 1's admission MDS assessment was completed on 8/21/19. Resident 1's clinical record lacked documentation of a completed and an accepted quarterly MDS assessment within 3 months of the completed admission assessment which should have been completed by 11/21/19. Interview, on 2/12/20 at 3:03 p.m., the MDS nurse provided the Centers for Medicare and Medicaid Services (CMS) Submission Report, dated 12/10/19, and she indicated the quarterly MDS assessment, dated 11/9/19, was rejected from CMS. If a MDS assessment was rejected from CMS, the MDS assessment would have to be corrected and resent to CMS for completion of MDS assessment. Resident 1's quarterly MDS assessment was late, because the assessment needed corrected and resent to CMS for completion. On 2/13/20 at 2:45 p.m., the Administrator (ADM) provided the facility's policy, Resident Assessment Instrument and Person-Centered Care Planning, revision date of March 2018, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .Quarterly (Non-Comprehensive) MDS Completion Date + 14 calendar days . 2. On 2/12/20 at 1:40 p.m., Resident 2's clinical record was reviewed. The [DIAGNOSES REDACTED]. Resident 2's annual MDS assessment was completed on 9/20/19. Resident 2's clinical record lacked documentation of a completed and an accepted quarterly MDS assessment within 3 months of the completed annual assessment which should have been completed by 11/20/19. Interview, on 2/12/20 at 3:03 p.m., the MDS nurse provided the Centers for Medicare and Medicaid Services (CMS) Submission Report, dated 12/10/19, and she indicated the quarterly MDS assessment, dated 11/14/19, was rejected from CMS. If a MDS assessment was rejected from CMS, the MDS assessment would have to be corrected and resent to CMS for completion of MDS assessment. Resident 2's quarterly MDS assessment was late, because the assessment needed corrected and resent to CMS for completion. On 2/13/20 at 2:45 p.m., the Administrator (ADM) provided the facility's policy, Resident Assessment Instrument and Person-Centered Care Planning, revision date of March 2018, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .Quarterly (Non-Comprehensive) MDS Completion Date + 14 calendar days . 3.1.-31(d)(3)

Based on interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for 1 of 3 residents reviewed for Resident Assessment (Resident 48). Findings include: On 2/12/20 at 1:38 p.m., Resident 48's clinical record was reviewed. The [DIAGNOSES REDACTED]. Resident 48's State of Indiana Certification of Preadmission Screening and Resident Review (PASRR), dated 9/21/18, indicated the resident had [MEDICAL CONDITION] and anxiety. A significant change MDS assessment, dated 11/20/19, indicated .Preadmission Screening and Resident Review (PASRR). Is the the resident currently considered by the state level II PASRR process to have serious mental illness .? No . Interview, on 2/13/20 at 2:43 p.m., the Administrator (ADM) indicated Resident 48's significant change MDS assessment should have been coded, Yes for PASRR. On 2/13/20 at 2:45 p.m., the Administrator (ADM) provided the facility's policy, Resident Assessment Instrument and Person-Centered Care Planning, revision date of 3/2018, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .f. The recommendations of the PASARR level II determination and evaluation report will be incorporated into the assessment . 3.1-31(d)

Based on observation, interview, and record review, the facility failed to ensure a care plan was developed for a resident on an anticoagulant (blood thinner) medication for 1 of 5 residents reviewed for unnecessary medication use. (Resident 45) Findings include: Interview, on 2/10/2020 at 11:23 a.m., Resident 45 indicated she received blood thinners and had recently had blood drawn from her left arm. During the interview, a tennis ball size purple bruise was observed on the left outer forearm. Resident 45 indicated it must have been from the recent blood draw. On 2/12/2020 at 2:16 p.m., Resident 45 was lying in bed watching television. She was observed with a tennis ball size purple bruise on the left outer forearm. Resident 45's clinical record was reviewed on 2/13/2020 at 11:12 a.m. [DIAGNOSES REDACTED]. Resident 45's, February 2020, physician orders [REDACTED]. The Wolters Kluwer 2018 Nursing Drug Handbook, copyright 2018, Nursing Considerations for [MEDICATION NAME] included: Regularly inspect patient for . bruises on arms or legs . A review of Resident 45's care plans lacked documentation of a care plan for the [MEDICATION NAME]. On 2/13/2020 at 2:41 p.m., the Administrator indicated there was no care plan for the monitoring of the [MEDICATION NAME]. On 2/13/2020 at 2:45 p.m., The Administrator provided the facility's policy, Resident Assessment Instrument and Person-Centered Care Planning with a revised date of March, 2018, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . d. v. The care plan will be revised as often as necessary to ensure that it provides an accurate depiction of the care of the resident . 3.1-35(a) .

Based on interview and record review, the facility failed to ensure staff addressed and implemented pharmacy recommendations for 1 of 1 resident reviewed for pharmacy recommendations (Resident 51). Findings include: On 2/12/20 at 2:14 p.m., Resident 51's closed clinical record was reviewed. [DIAGNOSES REDACTED]. Review of Resident 51's, November, 2019, physician's orders [REDACTED]. -On 10/28/19, the resident was ordered [MEDICATION NAME] XL (antihypertensive medication) 50 mg (milligrams) every evening. A Consultant Pharmacist Recommendation to Physician document, dated 9/5/19, indicated, (Resident's Name) receives [MEDICATION NAME] XL 50 mg, . Her BPs (blood pressures) the past two weeks have ranged from 146-196/73-96 with pulses from 75-85. Almost every SBP (systolic blood pressures) is < (greater than) 150. Please consider assessing if an increase in [MEDICATION NAME] XL to 75 mg QD may be appropriate . The Medical Director agreed with the pharmacist's recommendation and signed the form, on 9/30/19; 25 days after the recommendation. Pharmacy order documentation dated 10/28/19; 53 days after the pharmacist recommendation; indicated [MEDICATION NAME] 75 mg QD was ordered Interview, on 2/13/20 at 10:46 a.m., LPN 1 indicated she faxed the pharmacist's recommendation, signed by the doctor, back to the pharmacy, on 10/28/19, after she found the form sitting out in the chart room. She indicated she thought it was strange that it was almost 2 months after the pharmacist made the recommendation. Interview, on 2/13/20 at 10:09 a.m., the Director of Nursing indicated she did not know why the order did not get passed through until 10/28/19. She indicated when she gets a pharmacist's recommendation, she takes them straight to the Medical Director. A Consultant Pharmacist Recommendation to Physician document, dated 12/10/19, indicated (Resident's Name) receives . [MEDICATION NAME] XL 75 mg QD . Her BPs continue to be elevated, ranging the past month from 137-198/75-97, with most SBPs > 160 . Please consider evaluating whether increasing the [MEDICATION NAME] XL to 100 mg QD may be appropriate . The Medical Director agreed with the pharmacist's recommendation and signed the form, on 12/12/19, two days after the pharmacy recommendation. On 2/13/20 at 3:30 p.m., the Administrator provided the facility policy, Drug Regimen Review - Pharmacy, revised May, 2018, and indicated it was the policy currently being used. Review of the policy indicated, . 3. The attending physician(s) is expected to review and sign the resident individual Medication Regimen Review and document that he/she has reviewed the pharmacist's identified irregularities within 10 days of receipt . c. If the medical director is also the attending physician physician, the director of nursing will escalate the issue to the facility administrator. 3.1-25(i)

Based on observation, interview, and record review, the facility failed to ensure a resident who received an anticoagulant (blood thinner) medication was monitored for adverse reactions for 1 of 5 residents reviewed for unnecessary medications. (Resident 45) Findings include: Interview, on 2/10/2020 at 11:23 a.m., Resident 45 indicated she received blood thinners and had recently had blood drawn from her left arm. During the interview, a tennis ball size purple bruise was observed on the left outer forearm. Resident 45 indicated it must have been from the recent blood draw. On 2/12/2020 at 2:16 p.m., Resident 45 was lying in bed watching television. She was observed with a tennis ball size purple bruise on the left outer forearm. Resident 45's clinical record was reviewed on 2/13/2020 at 11:12 a.m. [DIAGNOSES REDACTED]. Resident 45's, February 2020, physician orders [REDACTED]. The Wolters Kluwer 2018 Nursing Drug Handbook, copyright 2018, Nursing Considerations for [MEDICATION NAME] included: Regularly inspect patient for . bruises on arms or legs . A review of Resident 45's care plans lacked documentation of a care plan for monitoring [MEDICATION NAME]. Interview, on 2/13/2020 at 11:01 a.m., Qualified Medication Aide (QMA) 1 indicated she noticed the bruise a few days ago on Resident 45's left arm. The Certified Nursing Assistants (CNA) are to document on the shower sheets if there are any new skin areas. A review of shower sheets, dated 2/9/2020 and 2/12/2020, lacked documentation of a bruise on the left outer forearm for Resident 45. Resident 45's chart lacked documentation of monitoring for side effects including bruising for the [MEDICATION NAME]. On 2/13/2020 at 11:27 a.m., the Clinical Nurse indicated there is no documentation for monitoring of side effects nor any documentation that addresses the bruise on Resident 45's left forearm. On 2/13/2020 at 3:30 p.m., The Administrator provided the facility's policy, [MEDICATION NAME]-[MEDICATION NAME] Monitoring with a review date of 10/19, and indicated it was the policy currently being used by the facility. A review of the policy did not indicate to monitor side effects including bruising while the resident is on [MEDICATION NAME]. 3.1-48(a)(3)

Based on observation, interview, and record review, the facility failed to ensure the outside waste receptacle was kept covered for 1 of 1 dumpster observed during random observations. Findings include: On 2/11/20 from 11:00 A.M. through 3:40 P.M., the outside dumpster was observed to have 2 of 4 cover lids open, exposing the refuse within the dumpster. No staff were present, and the dumpster was not being filled or emptied. On 2/12/20 from 10:20 A.M. through 3:30 P.M., the outside dumpster was observed to have 2 of 4 cover lids open, exposing the refuse within the dumpster. No staff were present, and the dumpster was not being filled or emptied. On 2/13/20 from 1:00 P.M. through 2:20 P.M., the outside dumpster was observed to have 2 of 4 cover lids open, exposing the refuse within the dumpster. No staff were present, and the dumpster was not being filled or emptied. During an interview, on 2/13/20 at 9:45 A.M., the facility Administrator indicated the outside dumpster lids were to be closed rather than opened, exposing the refuse within the dumpster. No staff were present, and the dumpster was not being filled or emptied. On 2/13/20 at 10:00 A.M., a review of the RETAIL FOOD ESTABLISHMENT SANITATION REQUIREMENT MANUAL: 410 IAC 7-24-191, dated November 13, 2004, indicated, .Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered .(2) with tight-fitting lids or doors if kept outside the retail food establishment . 3.1-21(i)(5)

Based on observation, interview, and record review, the facility failed to ensure the bathroom floor tile seams and toilet grout were free from dark brown stains for 8 of 43 rooms reviewed for environment (Resident 10, Resident 18, Resident 21, Resident 23, Resident 24, Resident 31, Resident 36, and Resident 43 ). Findings include: On 2/25/19 at 2:15 P.M., during environmental observations, the bathrooms of Resident 10, Resident 18, Resident 21, Resident 23, Resident 24, Resident 31, Resident 36, and Resident 43 were observed to have brown stains in the floor tile seams and around the toilet grout. During an interview, on 3/1/19 at 3:00 P.M., the facility Administrator indicated the floor tiles and toilet grout was in need of cleaning and repair. On 3/1/19 at 2:15 P.M., the Social Services Director provided the Resident Rights, updated 3/15/17, and indicated these were the resident rights being used by the facility. A review of the Resident Rights indicated, you have the right to a safe, clean, comfortable and homelike environment . 3.1-19(f)(5)

Based on observation, interview and record review, the facility failed to ensure residents who smoke were supervised regarding their whereabouts, were safe to smoke independently and were provided with a safe place to smoke, resulting in residents having to leave facility property and sit and smoke on the city street in front of the facility, without sidewalks or lighting and without staff monitoring their coming and going to assure their safety and resulting in a resident smoking outside while wearing oxygen, for 2 of 2 smokers who were admitted after the new smoking policy took affect, in the sample of 3 residents (Residents B and C) The Immediate Jeopardy began on [DATE] when Resident B started smoking outside, was told she had to leave facility property in order to smoke, and was found outside smoking while wearing oxygen. The Administrator and Director of Nursing were notified of the Immediate Jeopardy at 1:37 P.M. on [DATE]. The Immediate Jeopardy was removed on [DATE], but noncompliance remained at no actual harm, with potential for more than minimal harm, that is not immediate jeopardy. Findings include 1. During interview with Resident B on [DATE] at 8:30 A.M., she indicated she had to smoke in the street and knew the facility was non smoking prior to admission. Resident B indicated she was surprised that she could not smoke in the front parking lot or outside. Resident B indicated at 12:00 P.M. this same day, she had a lot of concerns with smoking at night, and that was her usual time to smoke. She indicated she worried about getting hit on the street because people speed along. She indicated she had reflectors on her chair but was afraid she would not be seen and the street was narrow. Resident B indicated she had not told anyone about her concerns for her safety because (name of Social Service Director) had been so adamant about going to the street. Resident B indicated she had been very ill when first admitted and had not smoked for a few weeks. Resident B was observed sitting on the side of the road in her electric wheelchair on [DATE] at 1:00 P.M. She indicated she always tried to sit under the shade tree. She indicated Resident C usually smoked in the parking lot of the facility, and was not sure when he had started smoking on the road, too. She indicated he had been smoking in the parking lot for several weeks. LPN #2, Resident B's charge nurse, was interviewed on [DATE] at 10:00 A.M. She indicated the resident was typically up more at night and night shift would report to her the resident had normally been out three, four or five times during the night shift hours to smoke, and thought it was four times last night. LPN #2 indicated Resident B had commented it was hard for people to see her on the road. Resident B's clinical record was reviewed on [DATE] at 10:30 A.M. Resident B's admission Minimum Data Set (MDS) assessment, dated [DATE], indicated an admitted to the facility of [DATE]. The assessment indicated the resident was alert and oriented, and used a wheelchair for mobility. The preadmission inquiry indicated the resident was a smoker. A smoking assessment, dated [DATE], indicated "Resident informed that there is no smoking anywhere on facility property. Resident is able to verbalize understanding of policy. Resident is alert and oriented. Long term memory good, resident admits that short term memory poor...has attempted to quit smoking and was not smoking when first admitted but stated she thought she would lose her mind and had began to smoke again. During assessment she was able to turn off oxygen properly, light cigarette and extinguish safely. Needs assistance with opening door to exit and enter facility. Resident is aware that there is no smoking since she was admitted on facility property. She is aware of risks and safety concerns. She will let staff know when going out to smoke. Safety at night was discussed with her and she said that she is going to try to not go out after dark but does plan to get some sort of reflector on her electric wheelchair." The ADON indicated, on [DATE] at 11:00 A.M., this was the first smoking assessment. Nurses notes first mentioned smoking with the following entry: "[DATE] 9:48 p.m. Res was noted to be in parking lot smoking with oxygen in place. Pt education provided concerning unsafe smoking. instructed to turn off oxygen and walk away from power chair if she feels she has to smoke, offered nicotine patch...." A nurse's note, dated [DATE] at 11:20 a.m. indicated, "call to discuss resident observed smoking across the street, concern for safety if not managing oxygen each time and turning it off, fall risk...." A note dated [DATE] at 6:48 A.M. indicated, "Resident went outside at front of building at least twice to smoke and was seen one of those times smoking in fire lane circle drive (driveway of facility)." Nurses notes also indicated: "witnessed fall, [DATE] 9 a.m. location outside...was walking...roommate outside too...immediate intervention; have resident ask for assistance when outside...." The care plan, dated [DATE], included a problem of "Potential for uncontrolled bleeding and/or prone to bruise easily due to coumadin (blood thinning medication) therapy" and "Potential increased respiratory difficulty", approaches included Oxygen at 3.5 liters per nasal cannula. Another problem, dated [DATE], indicated "Potential for Injury trauma, related to new environment, respiratory, weakness, multiple psychiatric medications...." 2. On [DATE] at 8:10 A.M., a gentleman smoking a pipe was observed sitting on the an electric scooter at the side of the street, just to the left of the facility parking lot. He was to the left of the facility parking lot. The gentleman identified himself as Resident C, and had an arm band with his name and the facility phone number on his arm. He indicated he had to smoke on the city street because the facility would not allow him to smoke in the parking lot as he had been doing. He indicated (Social Service Director name) and told him yesterday he was not allowed to smoke in the parking lot and had to go to the street. He indicated he had been able to smoke in the parking lot for the past two months but now could not. Resident C indicated he had been told on his admission to the facility he could use the smoke hut in back of the facility, but another resident did things that bothered him and he could not stand to be in the shack because of that resident. Resident C was observed to take a lighter from his pocket and refill his pipe and light it up again. Resident C indicated he hated living at the facility and was going to get out one way or another even if he had to run away. He indicated he would rather have died at home. Resident C was observed to be outside through 8:30 A.M. Resident C drove his scooter down the side of the street, crossing the entry to the facility and going across a side street to a gate, turning around and then coming back and sitting under a tree on the street in front of the facility. Resident C indicated the staff all smoked in their cars in the parking lot and his scooter was his car so did not understand why he had to sit in the road. He indicated one other resident, a lady, also had to go to the road to smoke. No staff members were observed outside the facility on [DATE] or to have checked on the resident. Several cars and trucks were observed to drive by, and a pedestrian walking was observed to pass. Upon entry to the facility at 8:30 A.M. on [DATE], the Assistant Director of Nursing indicated she thought Resident C was either in the dining room, his room, or outside smoking in the driveway. When told he was on the city street, she indicated he was his own person and sometimes signed himself out of the facility. The sign out book was checked and Resident C had not signed himself out of the facility. The ADON indicated Resident C was "grandfathered" into the facility (since the new smoking policy) to smoke, and he could smoke in the smoke hut on facility grounds if he wanted to. She indicated Resident B also smoked and went to the city street as she had not been grandfathered into smoking on facility grounds. In an interview with the Assistant Director of Nursing, on [DATE] at 9:40 A.M., she indicated the residents who smoked kept their cigarettes and lighters with them at all times unless they required supervision. She indicated there were six residents in the facility who smoked, only one of whom required supervision with smoking (not Resident B or C). Of the six, two had been admitted after the new policy of no smoking on facility grounds took affect, Resident C and Resident B. During interview on [DATE] at 8:45 A.M., the Social Service Director indicated she had told Resident C the day before he could not sit in the parking lot and smoke, and knew he was then going to the city street to sit and smoke. Resident C was observed to be sitting under a tree on the city street in front of the facility at 8:45 A.M.; no staff were observed in the parking lot or outside the facility. At 12:40 P.M. this same day, the resident was observed sitting in his electric chair on the side of the street smoking a pipe. The facility was observed on [DATE] at 8:10 A.M. to have a street running in the front of the facility and then a side street which bordered facility property. The facility was set back from this front street with the parking lot, with was a half circle with two entries in between the facility building and the street. Several trees lined both sides of the narrow city street, and no side walks were available by the street. There were three security lights in the parking lot but no street lights. Resident C's clinical record was reviewed on [DATE] at 9:00 A.M. [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was admitted to the facility on [DATE], was moderately cognitively impaired, with a deficit in short term memory. The assessment indicated the resident had verbal behavior that affected others. A smoking assessment, dated [DATE] at 6:13 P.M., was provided by the Social Service Director on [DATE] at 9:00 A.M. She indicated there was not one on the chart and it must still be in the computer. The assessment indicated: "Resident informed that he can only smoke in designated area outside and no other areas on the property or anywhere inside," recall ability - "not consistent." Cognitively status - "alert and oriented to self and location." Decision making skills - "can make decisions related to activities of daily living, may make poor choices," "smokes pipe and can hold it independently." Is physically capable of managing smoking materials and smoking safely, "uses an electric wheelchair due to left leg amputated." The care plan included a problem, dated [DATE], for "resident is at risk for falls related to history of falls, fluctuation in blood sugars (chooses not to follow prescribed diet) left leg amputation at hip, periods of paranoia and impulsive/poor safety awareness." Another problem, dated [DATE], was "Resident displays moderate impairment with cognition as evidenced by score of 12 out of 15 on bims completed [DATE]. He has potential for poor judgement with some decisions but appears able to make routine decisions." Approaches included: "offer conversation and give reminders as needed when forgetful, assist as needed, praise efforts, report any unsafe observations to nurse." Another problem, dated [DATE], indicated "Resident becomes easily angered and displays verbal abuse by using curse words at others when angry...rejects care and will state he does not need it such as medications, treatments or ADLs (activities of daily living) with assistance." The care plan did not address the resident's smoking. During interview the facility Administrator on [DATE] at 10:00 A.M., she indicated the resident had been admitted after the smoking policy was changed; however, he had been accidentally told he could smoke at facility outside in the smoke hut, so had been allowed to smoke on facility property. During interview with the ADON on [DATE] at 11:10 A.M., she indicated the resident went down the side street this past week to a yard sale off facility property. The sign out form indicated he had signed himself out on [DATE] and was gone from 9:15 A.M. to 10:15 A.M. The ADON and SS (Social Service) Director, at this same time, indicated they had not been aware of the resident going off the property to smoke on the street until yesterday. 3. The Resident Policy Manual, no date, was provided by the Social Services Director on [DATE] at 9:00 A.M. The policy indicated "...Smoking- There is only one designated smoking area on the facility property. This is the semi-enclosed area outside the facility family room. This is for residents only. New admissions after [DATE] are not permitted to smoke on the facility property. Some residents will need to have their cigarettes kept at the nursing station for their safety. This will be addressed with the resident and responsible family members. The facility does plan to be completely smoke free. Some residents may require supervision while they are smoking. This means that a responsible family member or staff member must be with the resident when they smoke. These residents will have their cigarettes and lighters kept at the nursing station for safety reasons. Residents will be evaluated at admission or as needed to assess smoking safety status. Residents requiring staff supervision will have designated scheduled smoking times. Designated smoking time will be posted...." The admission packets for Residents B and C were provided from the business office on [DATE] at 1:00 P.M. Both residents had signed their own admission paper work on admit to the facility which included the smoking policy. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility provided a safe place for residents to smoke on facility property, but the noncompliance remained at isolated, no actual harm with potential for more than minimal harm, that is not immediate jeopardy, because the facility had not inserviced all employees on the new policy and procedure for smoking. This federal tag relates to Complaint IN 855. 3XXX,[DATE](a)(1) 3XXX,[DATE](a)(2)