Every finding on record at Woodbridge Health Campus

Based on interview and record review, the facility failed to ensure a resident's advanced directives were updated for 1 of 1 resident reviewed for advanced directives. (Resident 19) Finding Includes: The clinical record for Resident 19 was reviewed on [DATE] at 2:04 p.m. The diagnoses included, but were not limited to, right hip fracture, cognitive communication deficit, metabolic encephalopathy, chronic kidney disease, chronic obstructive pulmonary disease, congestive heart failure, and atrial fibrillation. A current care plan, dated [DATE], indicated Resident 19 had advanced directives. The care plan was not specific on what his advanced directives included. Interventions included, but were not limited to, advanced directives reviewed quarterly and as needed, code status as ordered, and honor durable POA's (Power of Attorney) decision. A current physician's order in Resident 19's electronic medical record, dated [DATE], indicated the resident was to be a full code. An out of hospital DNR form, dated [DATE] and signed by the resident's POA on [DATE], indicated the resident did not want to receive Cardiopulmonary Resuscitation (CPR) and wished to have a code status of DNR. The form was signed by the physician on [DATE]. During an interview, on [DATE] at 10:10 a.m., Registered Nurse (RN) 3 indicated once they had a signed DNR form, they should have changed the code order in the electronic record. During an interview, on [DATE] at 11:29 a.m., the Assistant Director on Nursing (ADON) indicated the nurses should have updated the code status order when they received the DNR form signed by the resident or resident representative, a witness, and the physician. A current facility policy, titled Guidelines for Advanced Directives, dated [DATE] and received from the Interim Executive Director on [DATE] at 10:42 a.m., indicated .Advanced Directives will be reviewed with resident and/or resident representative by the Admissions Representative or designee at time of admission .The nursing staff will confirm the desired code status and obtain an order from the physician .Designation of code status and obtainment of physician order will be part of the medical record . 3.1-4(f)(5)

Based on interview and record review, the facility failed to ensure a PASARR (Preadmission Screening and Resident Review) was completed when a resident received a new mental health diagnosis and was prescribed an antipsychotic medication for 1 of 1 resident reviewed for PASARR. (Resident 46) Findings include: The clinical record for Resident 46 was reviewed on 6/2/25 at 11:30 a.m. The diagnoses included, but were not limited to, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, dementia with psychotic disturbance, psychotic disorder with delusions due to a known physiological condition, and depression. A PASARR level I, dated 9/11/24, indicated the resident had a diagnosis of anxiety disorder and depression and no level II was required. A physician's order, dated 9/14/24, indicated quetiapine (an antipsychotic medication) 25 mg (milligram) twice a day related to a psychotic disorder with delusions due to a known physiological condition. The diagnosis of psychotic disorder with delusions due to a known physiological condition was added on 10/4/24. During an interview, on 6/2/25 at 2:11 p.m., the Social Service Director (SSD) indicated Resident 46 did have a PASARR completed without the antipsychotic medication listed and another screen should have been implemented. A current facility policy, titled Indiana PASARR, undated and received from the Executive Director (ED) on 6/2/25 at 3:10 p.m., indicated .Preadmission screening and resident review (PASARR) is a federal requirement to help ensure that individuals are appropriately placed in nursing facilities for long term care .A change in status and Level II follow up, SSD to ensure paperwork is submitted, print outcome letter and upload to Matrix file .Applicable supportive documentation is in place, SSD for Level II 3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

Based on observation, interview and record review, the facility failed to ensure daily weights were obtained as ordered and to ensure the physician was notified of weight changes as ordered for 2 of 2 residents reviewed for quality of care. (Resident 9 and 10) Findings include: 1. During an observation, on 5/28/25 at 11:04 a.m., Resident 9 was lying in bed and had audible wheezes. The clinical record for Resident 9 was reviewed on 5/28/25 at 1:30 p.m. The diagnoses included, but were not limited to, congestive heart failure, chronic obstructive pulmonary disorder, shortness of breath, acute kidney failure, hypertensive, and type 2 diabetes mellitus. A care plan, dated 3/26/25, indicated the resident had congestive heart failure and had the potential for complications. The interventions included, but were not limited to, obtain weights as ordered. A physician's order, dated 5/29/25, indicated to weigh the resident daily and notify the physician of a weight gain of 2 pounds or greater in one day, or for a plus or minus of 5 pounds in one week. A progress note, dated 5/30/25 at 6:56 p.m., indicated Resident 9 was concerned with the increased swelling to her bilateral lower extremities (BLE) and recent weight gain. A progress note, dated 5/31/25 at 12:24 a.m., indicated Resident 9's daughter was concerned about the resident's swelling in her legs. The nurse assessed Resident 9, and the resident had non-pitting edema (swelling) to her BLE. The electronic health record did not have any documentation the resident was weighed on 5/29/25 and 5/31/25. The physician was not notified of the missing weights. During an interview, on 6/3/25 at 11:10 a.m., the Executive Director (ED) indicated the resident had a new daily weight order added on 5/29/25. The weight for 5/29/25 was missed. The nurse inputted the order and did not hit the save button. It was unknown why the resident missed the daily weight on 5/31/25. The resident should have been weighed daily, and the weight should have been documented. During an interview, on 6/3/25 at 11:55 a.m., RN 7 indicated the daily weights with call parameters would be charted in the Medication Administration Record (MAR). A certified nursing assistant (CNA), qualified medical assistant (QMA), or a nurse could obtain a daily weight. 2. During an observation, on 5/29/25 at 12:10 p.m., Resident 10 had both legs elevated on her wheelchair foot pedals. The resident's legs were swollen and purple. The clinical record for Resident 10 was reviewed on 5/28/25 at 1:37 p.m. The diagnoses included, but were not limited to, congestive heart failure, right femur fracture, hypertension, chronic kidney disease, Parkinson's disease, psychotic disorder with hallucinations, depressive disorder, and anxiety disorder. A care plan, dated 11/22/19, indicated the resident had congestive heart failure and had potential for complications. The interventions included, but were not limited to, obtain weights as ordered. A physician's order, dated 4/16/21, indicated daily weights before breakfast and to notify the physician of a weight gain of 2 pounds or greater in one day, or for a plus or minus of 5 pounds in one week. The resident's weight on 3/12/25 was 116.9 pounds and on 3/13/25 the weight was 119.4 pounds. This was an increase of 2.5 pounds. The resident's weight on 3/18/25 was 107.5 pounds and on 3/19/25 the weight was 110.1 pounds. This was an increase of 2.6 pounds. The resident's weight on 4/12/25 was 108.9 pounds and on 4/13/25 the weight was 111.8 pounds. This was an increase of 2.9 pounds. During an interview, on 6/3/25 at 12:05 p.m., Licensed Practical Nurse (LPN) 6 indicated daily weights were obtained in the morning between 6:00 a.m., and 10:00 a.m. The staff were responsible for making sure the weights were completed, added to the MAR, and recorded in the residents' progress notes. The clinical record did not have any documentation the physician was notified of the weight gains. A current facility policy, titled Clinical Services-Weight Monitoring, dated 12/20/24 and received from the Executive Director on 6/2/25 at 3:33 p.m., indicated .Weight monitoring is essential to the well-being of the residents we serve and requires a multidisciplinary approach .Daily weights as ordered .May be delegated to clinical leaders .Re-weigh as needed .Correct weights as needed 3.1-37(a)

Based on interview and record review, the facility failed to ensure medications were prescribed as ordered to prevent significant medication errors for 1 of 1 resident reviewed for medication errors. (Resident 202) Findings include: The clinical record for Resident 202 was reviewed on 5/28/25 at 2:40 p.m. The diagnoses included, but were not limited to, a history of a deep vein thrombosis (a blood clot in a deep vein), peripheral vascular disease, hyperlipidemia, anemia, hypertension. Resident 202 was admitted to the facility from the hospital on 5/23/25. An admission observation and data collection form, dated 5/23/25, indicated that the resident would be free from complications and adverse side effects from any medications and administer anticoagulant medications as ordered. A hospital discharge note, dated 5/23/25, indicated Resident 202 was to continue taking the medication Eliquis (an anticoagulant or a blood thinner used to prevent and treat blood clots in various cardiovascular conditions) twice a day for blood clots. A physician's order, dated 5/28/25, indicated to give Eliquis (apixaban) 5 mg tablet twice a day. The MAR (Medication Administration Record) indicated the first dose of Eliquis was administered on 5/28/25 at 10:18 a.m. This was 5 days after the resident was admitted to the facility. A nursing progress note, dated 5/28/25 at 11:10 a.m., indicated a medication error had occurred. The resident was admitted on [DATE] and the hospital discharge orders indicated the resident was to receive Eliquis 5 mg twice a day. The order was not transcribed into the MAR. The nurse practitioner completed a chart review and indicated the Eliquis was needed due to the resident's medical history. An admission checklist, dated 5/23/24, had the admitting nurse's signature, however the second nurse signature on the form was missing. During an interview, on 6/2/25 at 3:55 p.m., the Executive Director (ED) indicated the order for the medication was not found in Resident 202's medical record. The mistake was discovered on 5/27/25 and the medication order was entered on 5/28/25. During an interview, on 6/2/25 at 3:18 p.m., RN 2 indicated the hospital discharge medication orders should be entered into the computer. During an interview, on 6/3/25 at 11:30 a.m., the Assistant Director of Nursing (ADON) indicated when a nurse entered the physician's orders a second nurse was required to review and sign off on the orders within 24 hours. A current Registered Nurse (RN) job description, received by the interim ED on 6/3/25 at 11:49 a.m., indicated .role and responsibilities .lead a team of direct care providers to ensure appropriate execution of medications and treatments, documentation .in compliance with the Health Campus Policies and Procedures A current RN new hire checklist, dated effective 2/21/18 and received by the interim ED on 6/3/25 at 11:49 a.m., indicated .admissions .admission verification of orders and order entry A current facility policy, titled Guidelines for Medication Orders, dated 12/17/24 and received by the Interim ED on 6/3/25 at 11:49 a.m., indicated .the admitting nurse shall review the standing order list with the physician when verifying admission orders .standing orders shall be in the medical record with the other physician orders 3.1-48(c)(2)

Based on observation and interview, the facility failed to ensurefood was handled to maintain food safety related to discarding and thawing. 52 of 52 residents residing in the facility ate food prepared in the kitchen. Findings include: During an Observation of the kitchen on 4/22/24 at 9:10 AM with Dietary Staff 3, on the bottom of the large rack located in the walk in cooler, there was two containers with of poultry stacked on top of each other. The top one was a mid-size container with a label: prep on 4/19/24 at 12:54 PM and use by 4/21/24 end of day. The bottom one was a large size container with a label: prep pan 4/19/24 at 12:54 PM and use by 4/21/24 end of day. At 9:12 AM right above the two large containers of poultry in a large silver sheet pan, was a package turkey. underneath the package turkey there was a reddish, brown liquid. The turkey nor the pan was dated to indicate when the thurkey had been thawed At 9:15 AM, on the shelf there was a large clear bag with 2 pizza doughs inside. The prepared date indicated 4/12/24 and use by 4/19/24. At 9:17 AM, on the shelf there was a small jar of base-ham with a prepared date of 3/18/24 and use by date of 4/17/24. An observation of the walk-in freezer at 9:19 AM there was a bag of french fries with a prepared date 3/17/24 and use by 4/16/24. In an interview at 9:30 AM Dietary Staff 3 and Dietary Staff 4 indicated they were going to use the chicken in the two containers with a use by date of 4/21/24. They were aware the current date was 4/22/24 but were prepared to use the chicken. Dietary Staff 3 indicated the kitchen served both the Health Care and Residential from the kitchen. In an interview at 11:17 AM, the Dietary Manager indicated the labels were misprinted. The manager indicated staff were a bunch of young kids and they put the wrong label on the chicken. The other items, the staff should have discarded. The staff should have not thawed the turkey that way. A current facility policy, Food labeling and dating policy,dated 4/26/22, was provided by the Director of Nursing and Executive Director on, 4/25/24 at 11:00 AM. The policy indicated . to provide knowledge and direction on how to properly label and date all food items and food products 3.1-21(i)(1) and (3)

Based on interview and record review, the facility failed to ensure nonpharmacological interventions were implemented prior to administering a duplicate antianxiety medication, to document potential medication side effects and to ensure a duplicate antianxiety medication had a clinical rationale for the continued use of the medication for 1 of 3 residents reviewed for unnecessary medication. (Resident C) Finding includes: During an interview, on 1/18/24 at 12:22 p.m., an anonymous family member indicated, on 1/7/24 after 12:00 p.m., Resident C was scared, acting differently, and was not able to form words. The resident was able to talk just fine a day later and could not remember the previous day. The staff were aware of the resident not being able to form words and acting differently than usual when the family talked to the staff on 1/7/24 and on 1/8/24. The record for Resident C was reviewed on 1/18/24 at 11:35 a.m. Diagnoses included, but were not limited to, malignant neoplasm of unspecified bronchus or lung, chronic obstructive pulmonary disease, anxiety disorder, and rheumatoid arthritis. A care plan, dated 12/31/22, indicated the resident was at risk for adverse consequences related to receiving antianxiety medication. The goal was the resident would not exhibit signs of drug related side effects or adverse drug reactions. The approaches included, but were not limited to, attempt non-pharmacological interventions prior to administering as needed antianxiety medication, monitor for drug effectiveness and adverse consequences, and to provide the lowest effective dose possible. A physician's order, dated 10/19/23 and open ended, indicated to give diazepam (an antianxiety medication) 5 milligram (mg) three times a day routinely for anxiety. A physician's order, dated 11/22/23 through 1/1/24, indicated to give hydroxyzine hydrochloride (HCL) (an antihistamine given for anxiety) 25 mg twice daily as needed for increased anxiety. A pharmacy recommendation, dated 12/29/23 at 11:52 a.m., indicated the pharmacy recommended assessing the psychotropic as needed (prn) medication hydroxyzine HCL 25 mg which had been active since 11/22/23. The Federal regulations required all prn psychoactive initially be limited to 14 days of therapy. The order may be extended, by a prescriber, if the following two conditions were met and documented in the chart: 1. The rationale for extending the order beyond 14 days. 2. How long the order was to remain an active order by providing a stop date. The response indicated the physician agreed with the recommendations. The physician's response did not include a clinical rationale for continuing the hydroxyzine HCL 25 mg. A physician's order, dated 1/1/24 through 1/15/24, indicated to give hydroxyzine HCL 25 mg twice daily as needed for anxiety. A Medication Administration Record (MAR), dated January 2024, indicated the resident received the as needed dose of hydroxyzine HCL on 1/7/24 at 12:10 p.m., and on 1/8/24 at 12:43 a.m. The comment section of the MAR included the resident had anxiety on 1/7/24 and on 1/8/24. The Electronic Health Record (EHR) did not include the non-pharmacological interventions attempted prior to the administration of the as needed hydroxyzine. A social services progress note, dated 1/9/24 at 9:41 a.m., indicated the Social Services Designee (SSD) had talked with the resident the prior day about her concerns with the medications. The resident felt like she was not able to talk or form words and was concerned. The resident had the potential to be sleepy or over sedated with her routine medications and her prn medications. The resident's medications would be reviewed with the hospice nurse and the physician. The progress notes did not include documentation from nursing staff on 1/7/24 or 1/8/24 about the resident not being able to talk or to form words. During an interview, on 1/18/24 at 2:24 p.m., the Executive Director (ED) indicated there was no clinical rationale for the continued use of the prn hydroxyzine HCL from the physician. During an interview, on 1/18/24 at 3:05 p.m., the Clinical Support Nurse indicated there was no documentation in the EHR to show non-pharmacological interventions had been attempted prior to the administration of the prn hydroxyzine. A current Nursing Drug Handbook indicated hydroxyzine HCL use was indicated for anxiety and in older adults to observe closely. The nursing considerations included to watch for oversedation and to monitor older adults for dizziness, excessive sedation, and confusion. A current policy, titled Specific Medication Administration Procedures, dated as revised on 11/18 and received from the ED on 1/18/24 at 3:05 p.m., indicated To administer medications in a safe and effective manner .Monitor for side effects or adverse drug reactions immediately after administration and throughout each shift .When administering an 'as needed' [PRN] medication, document reason for giving, observe for actions/reactions and record efficacy A current policy, titled Psychotropic Medication Usage and Gradual Dose Reductions, dated as revised on 10/09/17 and received from the ED on 1/18/24 at 3:05 p.m., indicated .orders for PRN medications will have designated purpose for use .Administration of PRN medications will be documented in the e[electronic]MAR and indicate prior interventions to include nonpharmacological interventions .PRN orders for psychotropic drugs are limited to 14 days. Except as provided if the attending physician or prescriber 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 indicate the duration for the PRN order This Federal Tag relates to Complaint IN00425685. 3.1-48(a)(1) 3.1-48(a)(2) 3.1-48(a)(3) 3.1-48(a)(4)

Based on observation, interview and record review, the facility failed to ensure staff members followed a resident's plan of care for transfers which resulted in an injury during a transfer with a two-person manual assist and failed to follow post-fall interventions after one resident fell twice sustaining an injury for 2 of 3 residents reviewed for accidents. (Residents B and G) Resident B suffered a left tibial plateau fracture during an incorrect transfer. Resident G suffered a head laceration and two skin tears to her left upper extremity prior to the fall interventions being put into place. Findings include: 1. A document, titled Indiana State Department of Health Survey Report System, dated 5/15/23 at 11:15 a.m., indicated the incident occurred on 5/7/23 at 4:25 p.m. On 5/7/23, Resident B complained of pain to her left knee after being transferred by staff. The type of injury she sustained was a nondisplaced medial tibial plateau fracture of the left lower extremity. The resident was evaluated in the ER (emergency room ) on 5/7/23. The resident had a surgical repair of the left lower extremity tibial plateau fracture. An Investigation Summary undated, indicated Resident B while being transferred by staff members on 5/7/23, complained of left knee pain. At 10:45 a.m., on 5/7/23, the resident complained of pain to her left knee with swelling. She was sent to the ER and was returned to the facility at 4:25 p.m. The summary of the investigation indicated the resident sustained a fracture during a transfer. A document, titled Musculoskeletal Events-Trilogy Musculoskeletal Event, dated 5/8/23 at 7:07 a.m., indicated Resident B sustained a nondisplaced medial tibial fracture to her left lower extremity (LLE). Type of injury was a suspected fracture. There was no description of how the injury occurred. The resident had verbal complaints of pain rated as a sharp pain. She had non-pitting edema to the area of injury with pain upon bearing weight. The examiner was unable to do range of motion to the area. The resident was sent to the ER for further evaluation. The record for Resident B was reviewed on 5/15/23 at 2:00 p.m. Diagnoses included, but were not limited to, unspecified fracture of right patella, subsequent encounter for closed fracture with routine healing, displaced fracture of fourth metatarsal bone, right foot, subsequent encounter for fracture with routine healing, unspecified fracture of second metacarpal bone, right hand, subsequent encounter for fracture with routine healing, displaced fracture of proximal phalanx of right lesser toe(s), subsequent encounter for fracture with routine healing, age-related osteoporosis without current pathological fracture, protein-calorie malnutrition, unsteadiness on her feet, and adult failure to thrive. Physician's orders, dated 4/8/23 to 5/8/23, included, but were not limited to the following orders: a. 3/18/23, the resident was to be a stand assist lift for transfers three times a day from 6:00 a.m.-2:00 p.m., 2:00 p.m.-10:00 p.m., and 10:00 p.m.-6:00 a.m. b. 5/7/23, send to the ER for left knee pain and swelling STAT (immediately). c. 5/7/23, NWB (non-weight bearing) to the left leg three times a day from 6:00 a.m.-2:00 p.m., 2:00 p.m.-10:00 p.m., and 10:00 p.m.-6:00 a.m. d. 5/7/23, Keep the knee immobilizer in place three times a day from 6:00 a.m.-2:00 p.m., 2:00 p.m.-10:00 p.m. and 10:00 p.m.-6:00 a.m. The progress notes included, but were not limited to, the following notes: On 05/07/2023 at 11:16 a.m., the resident complained of pain and swelling in her left knee. She was sent to the ER for evaluation. On 05/08/2023 at 12:42 p.m., a follow up appointment was made with the orthopedic surgeon for 5/9/23 at 10:45 a.m., by ambulance. On 05/09/2023 at 2:50 a.m., the resident had a non-displaced fracture to medial tibial plateau on LLE and continued to use the knee immobilizer to LLE and remained NWB. On 05/09/2023 at 1:56 p.m., (Recorded as Late Entry on 05/10/2023 at 1:56 p.m.) Rounding Providers Progress Note: Reason for visit: psychotropic medication review and management, continued evaluation of moods and behaviors. Met with patient today and she was sitting in her recliner. She had fallen since the last time the provider saw her. She currently had a non-displaced fracture to the medial tibial plateau on the LLE. She was supposed to have surgery in the next few days, and she had a little anxiety about the surgery. She indicated her leg did not hurt too bad if she did not move it. On 05/09/2023 at 5:21 p.m., the resident returned from her orthopedic consult appointment for a left tibial plateau fracture. Surgery was scheduled for Thursday (5/11/23). The resident was to remain NWB to her LLE. On 05/11/2023 at 10:55 a.m., the resident was scheduled for surgery for a nondisplaced medial tibial plateau fracture of the LLE at 1:30 p.m. On 05/12/2023 at 5:13 p.m., the resident returned from the hospital after her surgery, via ambulance on a stretcher at approximately 1:00 p.m. The resident's surgery included a metal plate and 5 screws to her LLE. Her incision was covered with an ace bandage and placed in a passive motion device and not to go past 60 degrees. On 05/15/2023 at 12:20 p.m., the resident was NWB to the LLE with a passive immobilizer in place. Lift evaluation was completed, and it was determined the resident was to be a Hoyer lift for transfers. Resident B's care plans were reviewed and included, but were not limited to, the following care plans dated prior to 5/15/23 (survey entrance date): The resident had a care plan with the problem she had an impairment in functional status related to bed mobility, transfers, toileting and eating related to falls, history of fractures and chronic obstructive pulmonary disease. The start date was 4/27/22, with a revised date of 2/17/23. Approaches included, but were not limited to, the following approaches: start date 3/20/23, stand assist lift for transfers, and start date 2/6/23, Broda chair, she required extensive assist (two-person physical assist) with transfers, bed mobility and toileting. MDS (Minimum Data Set) Annual assessment, dated 2/14/23, indicated the resident had a BIMS (Brief Interview of Mental Status) of 10 (indicated she was moderately cognitively impaired), she required physical two person assists for toileting and transfers. The resident had a care plan with a problem she had a diagnosis of osteoporosis and was at risk for fractures and increased weakness. The start date was 4/27/22, with a revised date of 2/17/23. The approaches included, but were not limited to, the following approaches: start date 4/27/22, assist as needed with mobility. The resident had a care plan with a problem she was at risk for falling related to, she required assistance with her ADL's (Activities of Daily Living), she had a history of falls with fractures, she had cognitive losses and a diagnosis osteoporosis (bones are brittle and fracture easily). The emergency room documentation, dated 5/7/23 at 11:30 a.m., indicated the resident complained of pain to her left knee at a level 8 on a pain scale of 0 to 10 with 0 being no pain and 10 being the worst pain. X-ray results of her left knee, dated 5/7/23 at 12:36 p.m., indicated she had a nondisplaced (a fracture in which the bone cracks or breaks, but maintains the proper alignment of the bone) left medial tibial plateau fracture. Her CT (Computerized Tomography) results, dated 5/7/23 at 1:55 p.m., indicated there was subcutaneous (fatty layer of tissue) edema particularly involving the upper calf. The impression indicated there was a medial tibial plateau fracture. Hospital discharge instructions, dated 5/7/23 at 3:16 p.m., indicated the resident had a visit at the ER (emergency room ) on 5/7/23 at 11:30 p.m., and was being discharged with a diagnosis of a left medial tibial plateau (a bony surface on the top of the lower shin bone which connects with the thigh bone. It was the surface on the side corresponding to the big toe) fracture (Knee fracture). She was to keep a knee immobilizer (used to support and protect an injured and painful knee) in place until seen by the Orthopedic surgeon the following day. During an interview, on 5/15/23 at 2:02 p.m., CNA 1 indicated when she came in the morning of 5/6/23, the night shift CNA told her Resident B had been complaining of leg pain throughout the night. When she went to greet the resident that morning, she requested to go to the bathroom. She and CNA 2 transferred Resident B from the bed to her Broda chair and from her Broda chair to the toilet by a two-person physical assist manual lift transfer without a gait belt. While transferring the resident, she indicated the word Ouch while being transferred from the bed to the Broda chair and the Broda chair to the toilet. She notified the nurse the resident complained of knee pain while being transferred. When she came in the next day on 5/7/23, Resident B's left knee was swollen. She notified the nurse caring for the resident, her left knee was swollen, and she was sent out to the hospital. During an interview, on 5/15/23 at 2:10 p.m., Resident B was observed lying in bed. She indicated she fractured her lower leg when she was taken to the bathroom by two staff members. They were attempting to lift her onto the toilet from her Broda chair when her top half of her body turned, but the bottom half didn't turn, and she got a sharp pain in her lower left leg. A review of a typed statement, dated 5/7/23, indicated CNA 6 indicated Resident B complained of knee pain while transferring her from the bed to the Broda chair with another staff member. The nurse caring for the resident was notified. During an interview, on 5/15/23 at 2:45 p.m., the DON indicated when Resident B's LLE was fractured the staff was doing a two-person physical assist transfer without a gait belt, instead of using the stand-up lift as ordered by the physician and per her care plan. During an interview, on 5/15/23 at 3:15 p.m., PTA (Physician Therapy Assistant) 7 indicated the resident was a stand up lift instead of a two person physical manual lift because she was twisted at the top of her body from scoliosis, which made it difficult for her to turn her lower body at the same time as her upper body, she was not able to initiate movement to pivot and her body strength was poor. He had to position her so her pelvis was in position where he could ambulate her because her upper body was twisted, and it was pushing one side of her pelvis to the other side making it difficult for her to move. 2. The record for Resident G was reviewed on 5/15/23 at 10:30 a.m. Diagnoses included, but were not limited to, Parkinson's disease, peripheral vascular disease, muscle weakness (generalized), age-related osteoporosis without current pathological fracture, unsteadiness on feet, difficulty in walking, lack of coordination, and protein-calorie malnutrition. The progress notes included, but were not limited to, the following notes: a. On 2/9/23 at 8:10 p.m., the resident was found on the floor after yelling for help. She indicated she was pushing her wheelchair out of the bathroom, and she fell . No injuries. Her brief was very wet, so she was assisted to the toilet. Discussed with the resident about toileting every 2 hours while awake and the resident agreed it would be helpful. On 2/10/23 at 10:17 a.m., the Interdisciplinary Team (IDT) identified the root cause of the resident's fall while in the bathroom was her brief was soiled. The intervention for the fall was staff were to offer assistance with PM care. b. On 2/28/23 at 8:50 a.m., LPN 8 was called to Resident G's room by a QMA (Qualified Medication Aide). The resident was observed sitting on the floor in front of her recliner. The resident indicated she did not remember what she was doing prior to her fall, but she remembered falling and hitting her head. She had a large skin tear to the left forearm, left elbow, and a hematoma with a laceration to the back of her head. 911 was called immediately. On 2/28/23 at 3:56 p.m., Resident G was returned to the facility from the hospital with four staples placed to the back of her scalp due to the head laceration and she sustained a skin tear to the left forearm times two wounds. X-rays at the ER showed a possible fractured left radius (wrist). (Recorded as a late entry on 3/2/23 at 1:43 p.m.) On 3/1/23 at 9:41 p.m., IDT reviewed the resident's fall for 5/7/23, indicating the root cause of the fall was the resident was self-transferring in her room. The new intervention put into place indicated there would be a soft touch call light exchanged for the push button call light. On 3/6/23 at 1:57 a.m., indicated a splint remained to the left upper extremity. The skin tears to the left upper extremity were not able to be visualized due to the splint being in place. The resident continued to have staples intact to the laceration to the back of her head. On 3/7/23 at 1:06 p.m., IDT note indicated the resident was on an antibiotic for left forearm cellulitis with signs and symptoms of redness, swelling, tenderness, drainage, and acute functional decline. On 3/7/23 at 10:01 p.m., the resident continued the antibiotic prescribed by the orthopedic doctor. On 3/8/23 at 12:34 p.m., four staples were removed from the laceration on the back of the resident's head. c. On 3/29/23 at 1:47 p.m., resident was found sitting on her floor on her buttocks. Her bilateral lower extremities were straight out and even. She indicated she was reaching for an object on the floor and slid off the edge of the recliner. The immediate temporary intervention was to place a cushion to her recliner with Dycem on it. On 3/30/23 at 9:38 p.m., the IDT reviewed the resident's fall from 3/29/23. The root cause was she was reaching for an object. The intervention was to supply her with a Reacher. Resident G's care plans were reviewed, which included, but were not limited to, the following: The resident had a care plan which indicated she was at risk for falling related to she required assistance with transfers, she had diagnoses of hypertension, depression and osteoporosis and she received anxiety medications. Approaches included, but were not limited to, start date was 3/29/23-supplied with a Reacher, start date was 2/28/23-supplied with a soft touch call light, and start date 11/22/19-the staff was to assist the resident with transfers as needed. On 5/15/23 at 1:50 p.m., the Director of Plant Operations and the Housekeeping Supervisor were in attendance when Resident G's room was observed to be missing a soft touch call light and a Reacher. A regular call light was observed attached to the resident's recliner. The Director of Plant Operations indicated he was not told Resident G required a soft touch call light however, he was going to get her one at that time. During an interview, on 5/15/23 at 1:57 p.m., the Housekeeping Supervisor was in attendance during the interview. Resident G indicated she was never given a soft touch call light or a Reacher. She indicated her roommate was given the soft touch call light and the Reacher. During an interview, on 5/15/23 at 2:10 p.m., the DON was in attendance during the interview. When the DON asked Resident G about her Reacher and call light, she indicated to the DON she was never given a soft touch call light or Reacher. She indicated a different call light and Reacher was given to her roommate, but not to her. A current policy, titled Fall Management Program Guidelines, dated with a revised date of 3/16/22 and provided by the DON on 5/15/23 at 1:00 p.m., indicated .Definition: A fall is considered to be: 'an unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor a fall is considered to have occurred .Should the resident experience a fall the attending nurse shall complete the 'Fall Event.' This includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode and a review by the IDT to evaluate thoroughness of the investigation and appropriateness of the interventions .Any orders received from the physician should be noted and carried out. 5. The resident care plan should be updated to reflect any new or change in interventions .7 .communicate interventions during shift report. A current policy, titled Resident Transfers, with a revised date of 3/21/22 and provided by the DON on 5/15/23 at 3:45 p.m., indicated OVERVIEW: To ensure the safety of residents and staff when performing mobility/transfer tasks. SOP DETAILS: 1. Upon admission the admitting nurse and/or therapy department shall determine the type of transfer device, amount of assistance required to assist with safe mobility based on assessments in the area of: a. Cognition-ability to follow simple instructions b. Weight bearing status- full, partial, toe touch, non-weight c. Resident's weight d. Upper and lower body strength. e. Trunk stability f. Skin condition g. Mobility status-supervision, limited, extensive, dependent. 2. Nurse may use Lift Evaluation to assist with determining type of lift needed. 3. Campuses determine the amount of assistance required for transfers and record this on the Admission Observation, the Care Assist profile, and the Resident Care Plan to provide communication to all staff regarding safe transfers. 4. Transfer status will be reviewed at least quarterly with Quarterly Observation and as needed. A current policy, titled Comprehensive Care Plan Guideline, dated with a revised date of 12/31/22 and provided by the DON on 5/15/23 at 3:45 p.m., indicated .To ensure appropriateness of services and communication that will meet the resident's needs, severity/satiability of conditions, impairment, disability, or disease in accordance with state and federal guidelines .Care plan interventions should be reflective of risk area(s) or disease processes that impact the individual resident. c. Should new identified areas of concern arise during the resident's stay, they should be addressed on the care plan .Address problems that become ongoing or chronic with a new comprehensive care plan .Pertinent care plan approaches are communicated to the nursing staff per the Care Assist profile dependent on campus preference. 5. If the resident is readmitted to the campus, the previous care plan will be reviewed and updated to meet the resident's current needs .6. Comprehensive care plans need to remain accurate and current. a. New interventions will be added and updated during or directly following CCM meeting. b. Newly recognized problems will have a care plan developed and added after CCM meeting. This Federal tag relates to Complaints IN00401863 and IN00402369. 3.1-45(a)(2)

Based on record review and interview, the facility failed to complete a new Preadmission Screening and Resident Review (PASARR) for a resident who was prescribed an antipsychotic medication for 1 of 1 resident reviewed for PASARR. (Resident 42) Finding includes: The record for Resident 42 was reviewed on 1/23/23 at 3:52 p.m. Diagnoses included, but were not limited to, unspecified dementia with behavioral disturbances, Alzheimer's disease with late onset and major depressive disorder. A PASARR Level I screen, dated 5/9/22, indicated the resident's mental health condition was anxiety. The resident had a diagnosis of dementia and had not received any mental health services in the past. The medication used for the anxiety was Ativan (a benzodiazepine used to treat anxiety). The Level I screen indicated there was no evidence of a serious behavioral health condition and if changes occurred or new information refuted the findings, a new screen must be submitted. A physician's order, dated 11/7/22, indicated to give Zyprexa Zydis (an antipsychotic in orally disintegrating tablets) 7.5 mg (milligram) twice a day for unspecified dementia with behavioral disturbance. A physician's order, dated 11/8/22, indicated to give Zyprexa (an antipsychotic not orally disintegrating) 7.5 mg twice a day. During an interview, on 1/24/23 at 2:34 p.m., the SSD (Social Services Director) indicated the resident only had one PASARR completed and should have had another one completed when the Zyprexa was added. A current policy, titled Indiana PASRR, not dated and received from the Clinical Support Nurse on 1/24/23 at 4:20 p.m., indicated .Preadmission Screening and Resident Review [PASRR] is a federal requirement to help ensure that individuals are appropriately placed in nursing facilities for long-term care. PASRR requires .all applicants to a Medicaid-certified nursing facility be evaluated for serious mental illness .and/or intellectual disability .be offered the most appropriate setting for their needs .and the services they need in those settings .PASRR Level I complete for change in status 3.1-16(d)(1)(B)

Based on observation, interview and record review, the facility failed to assess for edema and notify the physician of a significant weight gain for 1 of 6 residents reviewed for quality of care. (Resident 155) Finding includes: During a wound care observation, with RN 3 on 1/24/23 at 3:11 p.m., Resident 155's legs were elevated on a pillow and appeared swollen. RN 3 indicated the resident had edema off and on in the past. The record for Resident 155 was reviewed on 1/20/23 at 3:16 p.m. Diagnoses included, but were not limited to, dementia unspecified severity, depressive disorder, and hypertension. A physician's order, dated 1/4/23, indicated the resident was to be weighed every Monday between 6:00 a.m., and 10:00 a.m. A care plan, dated 1/11/23, indicated the resident was at risk for malnutrition due to inadequate nutrients. The interventions included, but were not limited to, assist with meals, and obtain weights as ordered. The resident had the following weights: a. On 1/4/23, the weight was 163.8 pounds. b. On 1/9/23, the weight was 168.0 pounds. c. On 1/16/23, the weight was 175.8 pounds which was a significant weight gain of 6.84% from 1/4/23 in 12 days. d. On 1/23/23, the weight was 180.2 pounds which was a significant weight gain of 10.1% from 1/4/23 in 19 days. e. On 1/24/23, the weight was 187 pounds which was a significant weight gain of 14.16% from 1/4/23 in 20 days. The physician was not notified of the resident's edema or the significant weight gain. During an interview, on 1/20/23 at 3:06 p.m., RN 4 indicated the resident had edema and was elevating her legs. During an interview, on 1/24/23 at 4:54 p.m., the Director of Nursing indicated the management team discussed Resident 155's weight on 1/16/23. The physician was not notified, and no new interventions were started for the resident's weight gain. The physician should have been notified of the edema and weight gain. A current policy, titled Guidelines for Weight Tracking, dated as revised on 1/16/21 and received from the Clinical Support Nurse on 1/23/23 at 2:30 p.m., indicated .To ensure resident weight is monitored for weight gain and/or loss to prevent complications arising from compromised nutrition/hydration .Resident will have their weight taken and recorded upon admission to establish a baseline .The facility dietitian or representative will review the resident's nutritional status, usual body weight and current weight to implement a nutritional program when warranted .Residents who have a weight that seem out of normal range shall be re-weighed to determine the accuracy of the original weight .The physician, resident representative and dietitian shall be notified of a weight variance of 5% in 30 days, 7.5% in 90 days, and 10% in 180 days (unless on a planned weight loss or gain program) .Residents with a significant weight change can be added to Clinically At Risk A current policy, titled Physician-Provider Notification Guidelines, dated as revised on 9/12/17 and received from the Clinical Support Nurse on 1/23/23 at 2:13 p.m., indicated .To ensure the resident's physician or practitioner (may include NP, PA, or clinical nurse specialist) is aware of all diagnostic testing results or change in condition in a timely manner to evaluate condition for need of provision of appropriate interventions for care .Resident assessments for change in condition, suspected injury, event of unknown or ordered lab and/or other diagnostic tests should be completed in a timely manner .Attempts to notify the physician/provider and their response should be documented in the resident electronic health record .The 24 Hour report shall be utilized for nurse to nurse communication regarding the status of notification and response back 3.1-37(a)

Based on interview and record review, the facility failed to ensure the consultant pharmacist made recommendations for irregularities in diagnoses and medications prescribed for 1 of 2 residents reviewed for unnecessary psychotropic medications. (Resident 42) Finding includes: The record for Resident 42 was reviewed on 1/23/22 at 3:52 p.m. Diagnoses included, but were not limited to, unspecified dementia with behavioral disturbance, Alzheimer's disease with late onset, restlessness and agitation, major depressive disorder, chronic kidney disease stage 3, and anxiety disorder. A physician's order, dated 11/7/22 through 11/29/22, indicated to give lithium carbonate (used to treat bipolar disorder) 300 mg (milligram) once a day for unspecified dementia with behavioral disturbance. A physician's order, dated 11/29/22 through 12/2/22, indicated to give lithium carbonate 300 mg once a day on Sundays, Tuesdays, Wednesdays, Fridays, and Saturdays for unspecified dementia with behavioral disturbance. A physician's order, dated 11/8/22, indicated to give Zyprexa (an antipsychotic not orally disintegrating) 7.5 mg twice a day. A pharmacy review, dated 11/11/22, indicated the medication review was completed. There were no recommendations with the pharmacy review. During an interview, on 1/26/23 at 11:42 a.m., the Consultant Pharmacist indicated the Zyprexa was ordered for dementia with behaviors. The diagnosis was not appropriate although it was ordered at the psychiatric hospital. The indication for the use of lithium was depression although the medication was ordered for dementia with behaviors. The pharmacist did not make recommendations to the facility for the inappropriate diagnoses for the medications. A Nursing Drug Handbook 2023 indicated lithium was used to treat bipolar disorder. The contraindications for the use of the medication included severe renal disease and the elderly. A Nursing Drug Handbook 2023 indicated Zyprexa was indicated for the treatment of schizophrenia, short term treatment of manic episodes with bipolar disorder and treatment resistant depression. The black box warning included the drug may increase the risk of death in elderly patients with dementia. The drug was not approved to treat patients with dementia-related psychosis. A Consultant Services Provider Requirements, dated as revised 11/18 and received from the Clinical Support Nurse on 1/24/23 at 4:59 p.m., indicated .The Consultant Pharmacist and/or pharmacy representative provide consultation of all aspects of the provision of pharmacy services in the facility. In collaboration with facility personnel, the Consultant Pharmacist helps to identify, communicate, address, and resolve concerns and issues related to provision of pharmaceutical services. This may include, but is not limited to .Identifying one or more current medication references to facilitate the identification of medications and information on contraindications, side effects and/or adverse effects, dosage levels and other pertinent information .Reviewing the medication regimen [medication regimen review] of each resident at least monthly or more frequently under certain conditions .incorporating federally mandated standards of care in addition to other applicable professional standards .and documenting the review and findings in the resident's medical record or in a readily retrievable format .Communicating to the responsible prescriber and the facility leadership potential or actual problems detected and other findings relating to medication therapy orders including recommendations for changes in medication therapy and monitoring of medication therapy as well as regulatory compliance issues A current policy, titled Psychotropic medication Usage and Gradual Dose Reduction, dated as revised on 11/7/22 and received from the Clinical Support Nurse on 1/24/23, indicated .To ensure every effort is made for residents receiving psychoactive medications to obtain the maximum benefit with minimal unwanted side effects through appropriate use, evaluation and monitoring by the interdisciplinary team .Resident shall receive psychotropic medications only if designated medically necessary by the prescriber, with appropriate diagnosis or documentation to support its usage. The medical necessity will be documented in the resident's medical record and in the care planning process .Regular monthly review of antipsychotics in CAR [clinically at risk] for continued need, appropriate dosage, side effects, risks and/or benefits will be conducted, to ensure the use of psychopharmacologic medications are therapeutic and remain beneficial to the resident .Reviews of medication use will be conducted by the consultant pharmacist monthly and will 3.1-25(i)

Based on interview and record review, the facility failed to ensure a physician's order for antibiotics was followed for 1 of 5 residents reviewed for unnecessary medications. (Resident 19) Finding includes: The record for Resident 19 was reviewed on 1/23/23 at 10:37 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, type 2 diabetes mellitus, and Parkinson's disease. An emergency department note, dated 10/26/22, indicated the resident had redness and swelling to the right lower leg. The assessment/plan indicated cephalexin (an antibiotic) 500 mg (milligram) every 12 hours for 20 doses and doxycycline (an antibiotic) 100 mg twice daily for 20 doses. A physician's order, dated 10/27/22 through 11/5/22, indicated to give cephalexin 500 mg every 12 hours for cellulitis. A physician's order, dated 10/27/22 through 11/5/22, indicated to give doxycycline 100 mg twice daily for cellulitis. A physician's clinic note, dated 10/27/22, indicated the resident was seen in the nursing home by the physician. The resident was seen in the emergency room for cellulitis. The resident was on cephalexin. The assessment/plan indicated to complete outpatient antibiotic therapy with cephalexin. The physician's clinic note did not include the continuing use of the doxycycline. A progress note, dated 10/27/22, indicated the interdisciplinary team (IDT) reviewed the associated infection event. The resident had returned to the facility from the emergency department with a diagnosis of lower extremity cellulitis and new order for antibiotics for 10 days. A progress note, dated 10/29/22 at 12:49 p.m., indicated the resident continued doxycycline and cephalexin as ordered. During an interview, on 1/24/23 at 4:20 p.m., the Clinical Support Nurse indicated the resident's physician only included to continue the cephalexin. The facility continued to administer the doxycycline along with the cephalexin and did not clarify this order. A current policy, titled Antibiotic Stewardship Guidelines, dated as last reviewed on 12/01/2021 and received from the Clinical Support Nurse on 1/24/23 at 4:20 p.m., indicated .Optimize the treatment of infections by ensuring that residents who require an antibiotic, are prescribed the appropriate antibiotic. Reduce the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use. Encompass a facility-wide system to monitor the use of antibiotics .New orders for antibiotic usage will be reviewed during the campus Clinical Care Meeting on regular business days .Pharmacy provider will assist in review of all antibiotic usage for appropriateness 3.1-48(a)(1)

Based on interview and record review, the facility failed to ensure a resident with dementia had an appropriate diagnosis for the use of an antipsychotic medication and a mood stabilizing medication and to ensure recommendations for parameters of laboratory levels were followed for 1 of 2 residents reviewed for unnecessary psychotropic medications. (Resident 42) Finding includes: The record for Resident 42 was reviewed on 1/23/22 at 3:52 p.m. Diagnoses included, but were not limited to, unspecified dementia with behavioral disturbance, Alzheimer's disease with late onset, restlessness and agitation, major depressive disorder, chronic kidney disease stage 3, and anxiety disorder. A discharge summary from the inpatient psychiatric facility, dated 11/7/22, indicated the resident was admitted to the psychiatric facility, on 10/23/22, due to increased behaviors of physical aggression over a 72-hour time period. The resident was prescribed Zyprexa for dementia with behaviors and lithium for dementia with behaviors. The goal was to keep the lithium level less than 0.6 due to the resident's advanced age and debility. A physician's order, dated 11/7/22 through 11/29/22, indicated to give lithium carbonate (used to treat bipolar disorder) 300 mg (milligrams) once a day for unspecified dementia with behavioral disturbance. A physician's order, dated 11/8/22, indicated to give Zyprexa (an antipsychotic) 7.5 mg twice a day. A pharmacy review, dated 11/11/22, indicated the medication review was completed. There were no recommendations regarding the inappropriate diagnoses for the use of Zyprexa and lithium with the pharmacy review. A physician's order, dated 11/16/22 through 11/18/22, indicated a CMP (comprehensive metabolic panel) and lithium level weekly on Thursday due to the lithium use. The physician's order did not include the parameters of a lithium level of less than 0.6 as indicated by the inpatient psychiatric discharge notes. A lab report, dated as received on 11/17/22 and reported on 11/18/22, indicated the resident had a lithium level of 1.2 with a reference range of 0.5-1.2. This was out of the range of less than 0.6 as recommended by the inpatient psychiatric facility. The lithium dosage was not changed. A physician's order, dated 11/18/22 through 12/13/22, indicated a CMP and lithium level weekly on Tuesday due to lithium use. A lab report, dated as received on 11/22/22 and reported on 11/23/22, indicated the lithium level was 1.0. This was out of the range of less than 0.6 as recommended by the inpatient psychiatric facility. A physician's order, dated 11/29/22 through 12/2/22, indicated to give lithium carbonate 300 mg once a day on Sundays, Tuesdays, Wednesdays, Fridays, and Saturdays for unspecified dementia with behavioral disturbance. A NP (Nurse Practitioner) progress note, dated 12/1/22 at 10:17 a.m., indicated the resident was currently on lithium and olanzapine (Zyprexa) after an inpatient psychiatric stay. The resident seemed to have a general decline after starting those medications. The resident was drooling, her gait was not steady, and she was not sleeping well at night. The available labs were reviewed and some of the labs were still pending. The assessment/plan included an altered mental status, unsteady gait, general decline, and drooling. The drooling was likely related to the antipsychotics and the Zyprexa was decreased to 5 mg daily. The labs were pending. The dose of Zyprexa was not decreased until after the resident had a decline of condition. A progress note, dated 12/2/22 at 10:39 a.m., indicated the CMP results were sent to the NP and the lithium level was not available. A progress note, dated 12/2/22 at 2:25 p.m., indicated the lab called with a critical lithium level of 1.5 and the NP was notified. A new order to discontinue the lithium was received. A facility psychiatry progress note, dated 12/13/22, indicated the resident's lithium had been discontinued since the last visit. The lithium level had gone up to 1.8 which was considered a toxic level. The family disclosed the resident only had one kidney and had renal impairment. The primary care physician also decreased the Zyprexa to 5 mg daily. The resident had remained stable without any mood or behavioral issues reported. The plan included to continue the Zyprexa with a diagnosis of psychotic disorder with delusions due to a known physiological cause. There were no reported distressing delusions. The facility did not change the diagnosis for the use of the Zyprexa to a psychotic disorder with delusions due to a known physiological cause as indicated in the facility psychiatry progress note. During an interview, on 1/26/23 at 11:42 a.m., the Consultant Pharmacist indicated the lithium and Zyprexa were ordered for dementia with behaviors. The diagnosis was not appropriate although it was ordered at the psychiatric hospital. The lithium could be used for depression and the resident had a diagnosis for depression, so she did not recommend the facility look at the diagnosis for the medication since the diagnosis was listed somewhere. If a resident with chronic kidney disease was prescribed lithium, usually a lower dose would be ordered, and the kidney function and lithium levels would be monitored weekly for a few months. She did not have a chance to make the recommendation for the weekly labs since they were already ordered. The resident returned to the facility, on 11/7/22, and she did the pharmacy review on 11/11/22 with no recommendations. She did not include recommendations about lithium use with decreased kidney function. The facility had already completed one lithium level. The lithium was discontinued on 12/2/22 due to a high lithium level. A Nursing Drug Handbook 2023 indicated lithium was used to treat bipolar disorder. The contraindications for the use of the medication included severe renal disease and elderly. The adverse reactions were drowsiness, confusion, incoordination (lack of coordination) and hand tremor. A black box warning indicated lithium toxicity could occur at doses close to therapeutic levels. Provisions for prompt and accurate determination of serum lithium levels should be available before the start of therapy. Monitor and discontinue drug for signs and symptoms of lithium toxicity which include ataxia (impaired balance or coordination), drowsiness, weakness, tremor, and vomiting. The overdosage signs and symptoms included drowsiness, muscular weakness, lack of coordination, ataxia, slurred speech, myoclonic (involuntary twitching or jerking) limb movements. A Nursing Drug Handbook 2023 indicated Zyprexa was indicated for the treatment of schizophrenia, short term treatment of manic episodes with bipolar disorder and treatment resistant depression. The black box warning included the drug may increase the risk of death in elderly patients with dementia. The drug was not approved to treat patients with dementia-related psychosis. A current policy, titled Psychotropic medication Usage and Gradual Dose Reduction, dated as revised on 11/7/22 and received from the Clinical Support Nurse on 1/24/23, indicated .To ensure every effort is made for residents receiving psychoactive medications to obtain the maximum benefit with minimal unwanted side effects through appropriate use, evaluation and monitoring by the interdisciplinary team .Resident shall receive psychotropic medications only if designated medically necessary by the prescriber, with appropriate diagnosis or documentation to support its usage. The medical necessity will be documented in the resident's medical record and in the care planning process .Regular monthly review of antipsychotics in CAR [clinically at risk] for continued need, appropriate dosage, side effects, risks and/or benefits will be conducted, to ensure the use of psychopharmacologic medications are therapeutic and remain beneficial to the resident .Efforts to reduce dosage or discontinue psychotropic medications will be ongoing .Reviews of medication use will be conducted by the consultant pharmacist monthly and will .Monitor psychotropic drug use in the campus to ensure that medications are not used in excessive doses or for excessive duration 3.1-48(a)(3) 3.1-48(a)(4) 3.1-48(a)(5)

Based on observation, interview and record review, the facility failed to post the current visitation guidelines which included visitation for residents in transmission based precautions and to ensure the residents, staff and family/responsible parties were aware of the current visitation guidelines for residents in transmission based precautions for 1 of 3 residents reviewed for visitation (Resident B). Finding includes: 1. During the entrance to the facility, on 12/27/21 at 11:55 a.m., the facility did not have the Visitation Requirements Guidelines for Long-Term Care Facilities posted at the facility entrance. During an interview, on 12/27/21 at 3:30 p.m., the Campus Clinical Support indicated the facility did not have the sign Visitation Requirements Guidelines for Long-Term Care Facilities posted at the facility anywhere and the visitation guidelines were posted on the facility website. During an interview, on 12/28/21 at 12:24 p.m., the Campus Clinical Support indicated the daily communication to resident's family/responsible party would only go to one person and not to multiple contacts or family members. The person receiving the information would have to share the information with the other family members. The daily communication did not include the sign from the Long Term Care Newsletter although the communication did include other visitation guidelines. 2. During an interview, on 12/27/21 at 1:04 p.m., a family member indicated Resident B was taken off isolation on 12/8/21. Resident B had called the family everyday crying. The family member was not allowed to visit on the residents birthday and had not received any visitation guidelines from the facility. During an interview, on 12/27/21 at 3:57 p.m., a family member indicated Resident B had been in isolation several times. Resident B's mental health was being affected. The resident had been placed in isolation 3 times even though she tested negative for Covid-19. He was notified from the Social Service Director he could visit on a compassionate care visit. He was unaware of the visitation guidelines, but indicated nothing was going to stop him from visiting Resident B. The record for Resident B was reviewed on 12/27/21 at 1:43 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note, dated 8/13/21 at 3:00 p.m., indicated the resident was admitted and put in isolation. A progress note, dated 8/22/21 at 9:48 a.m., indicated the resident was readmitted and put in isolation. A progress note, dated 11/23/21 at 9:27 p.m., indicated the resident was moved to a different room and was put in 14 day isolation. A progress note, dated 11/30/21 at 10:04 a.m., indicated the Social Services Director started a Covid care plan and the resident's son was aware he could visit with compassionate care visits. A progress note, dated 12/1/21 at 4:38 p.m., indicated the Social Service Director called the son to ask if he could come visit the resident and re-educated the son on compassionate care visits. A care plan, dated 11/30/21, indicated the resident was at risk for a decline in mood due to isolation related to the covid pandemic and guidelines/precautions. The interventions included, but were not limited to, arrange resident compassionate care visits as permitted and encourage and assist the resident to phone friends and family. During an interview, on 12/28/21 at 12:39 p.m., the Social Services Director indicated compassionate care visits meant a resident could have a person visit during isolation when visitation was restricted due to the isolation. She called the resident's son to inform him he could visit with a compassionate care visit and did not talk to any other family members. She did not know when the visitation restrictions for residents in transmission based precautions had changed to allow unrestricted visitation. She had initiated the care plan with the compassionate care visits on 11/30/21. During an interview, on 12/28/21 at 1:47 p.m., QMA 3 indicated she was not aware of the visitation policy for the residents in transmission based precaution. During an interview, on 12/28/21 at 1:50 p.m., the Life Enrichment Assistant indicated she was not aware of visitation guidelines and rules for residents in isolation. During an interview, on 12/28/21 at 1:56 p.m., QMA 2 indicated she was not aware of the visitation guidelines for the residents in isolation. She would have to ask someone due to the rules were changing all the time. During an interview, on 12/29/21 at 2:44 p.m., Resident B's family member indicated on Thanksgiving Day they were told by the staff at the entrance of the building Resident B could not have visitors due to being in isolation. The family member went to the resident's room anyhow. Then a nurse came into Resident B's room and instructed the family member to put on a yellow gown after she had already been in the resident's room. The Long Term Care Newsletter Issue 2021-28, indicated, Visitation Requirements Guidelines for Long-Term Care facilities-Signage .The Indiana Department of Health (IDOH) has created a sign that summarizes each facility's visitation obligations. By direction of the Commissioner, every facility must print and post this sign conspicuously (e.g., next to other required notices) so it is visible for all residents and their visitors. In addition, all residents' families/representatives must receive this notification. This can be done electronically or with current family notification procedure. IDOH surveyors will check to make sure each facility has posted the sign as required, along with confirming that required visitation is, in fact, being provided The Visitation Requirement Guidelines for Long-Term Care facilities, dated 11/22/21, indicated .Visitation While a Resident Is In Transmission Based Precautions .While not recommended, residents who are on transmission-based precautions (TBP) or quarantine can still receive visitors. In these cases, visits should occur in the resident's room and the resident should wear a well-fitting face mask (if tolerated). Visitors should be made aware of the potential risk of visiting and precautions necessary in order to visit the resident in TBP. Visitors should adhere to the core principles of infection prevention and follow the signage that indicates the proper PPE [personal protective equipment] to wear during the visit A current facility policy, titled Health Center Covid-19 Visitation Policy, revised on 11/15/21 and received from the Clinical Campus Support on 12/28/21 at 2:26 p.m., indicated .To mitigate the physical and emotional impact long-term isolation has on our residents by permitting indoor and outdoor visits while still ensuring risk mitigation measures are in place to reduce the spread of Covid-19 .Campuses will send letters or emails to families as well as post entrance signs reminding them of the importance of vaccination, recommendations for source control, physical distancing, and any other facility instructions related to visitation, including refraining from visiting if they have any of the following .A positive [CONDITION(S)] test for [CONDITION(S)]-CoV-2 .Symptoms of Covid-19 .If they currently meet criteria for quarantine .Campuses must allow indoor visitation at all times. Facilities can no longer limit the frequency and length of visits for residents, the number of visitors, or require advance scheduling of visits This Federal Tag relates to Complaint IN 976.

Based on interview and record review, the facility failed to ensure a resident was offered activities while in transmission based precautions and to complete a resident specific care plan for activities for 1 of 3 residents reviewed for activities (Resident B). Finding includes: During an interview, on 12/27/21 at 1:04 p.m., a family member indicated Resident B would call them daily crying. The resident was left in her room with nothing to do. The family was worried about Resident B's mental health from being in isolation. During an interview, on 12/27/21 at 3:57 p.m., Resident B indicated she had been in isolation three separate times. She told the staff she was very upset and depressed. The staff did not offer any activities while she was in isolation. The staff offered her a newspaper 3 days after she was out of isolation. The record for Resident B was reviewed on 12/27/21 at 1:43 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note, dated 8/13/21 at 3:00 p.m., indicated the resident was admitted and put in isolation for 14 days. An activity log, dated 8/14/21, 8/17/21 and 8/19/21, indicated the resident participated in bingo for 60 minutes. A progress note, dated 8/22/21 at 9:48 a.m., indicated the resident was readmitted and put in isolation for 14 days An activity log, dated 8/24/21, indicated the resident participated in bingo for 60 minutes. A progress note dated 11/23/21 at 9:27 p.m., indicated the resident was moved to a different room and was put in 14 day isolation. The resident was in isolation on 8/14/21, 8/17/21, 8/19/21 and 8/24/21. A Life enrichment assessment, completed on 8/16/21 at 9:29 a.m., indicated it was very important to the resident to have books, newspapers and magazines to read. She also enjoyed bingo, crochet, puzzles and word finds. The care plans did not include an activity care plan. During an interview, on 12/28/21 at 1:56 p.m., QMA 2 indicated Resident B told her she was depressed and the activity staff did not come in to offer her any activities to do. During an interview, on 12/28/21 at 3:21 p.m., the resident's activity record was reviewed with the Life Enrichment Director. She indicated she did not take the resident to bingo while the resident was in isolation in August. The information was recorded in error. The resident liked bingo, crafts, books and reading the newspaper. During an interview, on 12/28/21 at 4:04 p.m., Clinical Support indicated Resident B did not have a care plan for activities and she was not sure why the activity care plan was missing. A current facility policy, titled Comprehensive Care Plan Guidelines, revised on 5/22/18 and received from Clinical Support on 12/28/21 at 2:57 p.m., indicated .To ensure appropriateness of services and communication that will meet the resident's needs, severity/stability of conditions, impairment, disability, or disease in accordance with state and federal guidelines .The 48-hour baseline care plan will be completed within 48 hours of admission and will be the temporary working care plan until the comprehensive care plan is competed per RAI guidelines .A comprehensive care plan will be developed within 7 days of completion of the admission comprehensive assessment (MDS 3.0) A current facility policy, titled Policies and Procedures Life Enrichment, dated 6/2/16 and received from Clinical Support on 12/28/21 at 3:18 p.m., indicated .Regular scheduled programming will be provided to all residents/patients who are not able to attend group programs .Individual programming ensures that all residents/patients who are unable or unwilling to participate in group programs have consistent, goal oriented, and individualized recreation opportunities .Goal directed individual interventions are provided for residents/patients who, because of physical or cognitive impairments, cannot attend group programs This Federal Tag relates to Complaint IN 976. 3.1-33(a)

Based on interview and record review, the facility failed to ensure a resident was free from abuse for 1 of 3 residents reviewed for abuse (Resident C). Finding includes: A facility incident report, dated 10/1/21 at 7:30 p.m., indicated CNA 3 had spoken rudely to Resident C during ADL (activities of daily living) care. The investigation was completed, the allegations were unsubstantiated and CNA 3 was returned to work. The record for Resident C was reviewed on 10/13/21 at 11:55 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 4/8/2020, indicated the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The approaches included, but were not limited to, observe and record any non-verbal signs of pain such as guarding, restlessness and withdrawal and to provide assistance with ADLS as needed. A care plan, dated 4/8/2020, indicated the resident required staff assistance to complete ADL tasks completely and safely. The goal was to have the resident's ADL needs met safely by staff. The approaches included, but were not limited to, no blood pressure, lab draws or IVs in the left upper arm, allow the resident sufficient time to complete all or parts of task, do not rush the resident and encourage the resident to do as much as safely possible for herself. A care plan, dated 9/22/21, indicated the resident demonstrated physically abusive and resistive behaviors toward staff during hands on care. The approaches included, but were not limited to, alternate caregiver or offer at different time of day, approach resident in a calm and unhurried manner to deliver care and to provide services and to offer choices in all hands on care and contacts. A written statement, from CNA 2, dated 10/1/21, indicated on 10/1/21 at 6:30 p.m., CNA 3 was in Resident C's room and had a hold of the resident's arm. CNA 3 kept yanking on the resident and yelling. CNA 3 was asked to leave the room and responded with I don't know why no one can let me do my f*****g job. CNA 3 grabbed the resident's pajamas and threw them full force at the residents head. The resident kept yelling to get CNA 3 out of the room and to tell her to leave now. The resident said to call the cops. In the facility's Statement of Witness Form, dated 10/5/21, indicated CNA 3 had Resident C's pajamas in her hand and tossed them towards CNA 2 when she exited the room. CNA 2 indicated CNA 3 had used inappropriate language and threw the resident's pajamas in her direction. During an interview, on 10/13/21 at 12:32 p.m., CNA 2 indicated she and CNA 3 were in Resident C's room on 10/1/21 during the evening shift and CNA 3 threw pajamas. The pajamas touched Resident C's head. The resident said to call the cops. During an interview, on 10/13/21 at 2:45 p.m., CNA 3 indicated on 10/1/21 in the evening she was assisting Resident C to the toilet and to the shower. Resident C started to holler and said she was not getting a shower. CNA 2 then entered the room and asked if she needed help and she responded with yes. The resident had asked for CNA 3 to leave the room and CNA 2 also requested for CNA 3 to leave the room. CNA 3 was upset and got pajamas out of the drawer and tossed them over the resident's head. The pajamas landed on the resident's lap. During an interview, on 10/12/21 at 2:35 p.m., CNA 4 indicated CNA 3 made rude comments when talking with residents. She talked with the Executive Director (ED) and the ED told her she didn't know which other unit she could have CNA 3 work since she did not do well with dementia residents. During an interview, on 10/14/21 at 12:49 p.m., the ED indicated the investigation of the alleged abuse was completed by the divisional vice president. The ED completed interviews with the staff, however none of the interviews were documented. The ED did not have information if the investigation for Resident C had included if any physical abuse was ruled in or ruled out. A current policy, titled Abuse and Neglect Procedural Guidelines, revised 8/29/2019 and received from the Clinical Support on 10/13/21 at 1:55 p.m., indicated .has developed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse and neglect .The Executive Director and Director of Health Services are responsible for the implementation and ongoing monitoring of abuse standards and procedures .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitation 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 .Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability .staff to resident-any episode .physical abuse .includes, but is not limited to, hitting, slapping, punching, biting, and kicking .Investigation .The Executive Director is accountable for investigation . This Federal Tag relates to Complaint IN 083. 3.1-27(a)(1) 3.1-27(b)

Based on record review and interview, the facility failed to monitor a resident's Leave of Absence (LOA) status to ensure they were safely returned to the building for 1 of 3 residents reviewed for supervision. (Resident B) Finding includes: The record for Resident B was reviewed on 10/13/21 at 12:10 p.m. Diagnoses included, but were not limited to, Alzheimer's, dementia, hypertension (elevated blood pressure) and weakness. The MDS (minimum data set) assessment, dated 10/7/21, indicated the resident had a BIMS (Brief Interview for Mental Status) score of 3 (severe impairment). A facility form, titled Resident Sign Out Sheet, had 9 days Resident B was not signed back into the facility after going LOA. (3/30/21, 5/15/21, 7/3/21, 7/24/21, 8/7/21, 8/28/21, 10/1/21, 10/10/21 and 10/11/21). During an interview, on 10/13/21 at 1:30 p.m., QMA 5 indicated the procedure for a resident leaving the facility was to take the residents temperature, document the date, time and who the resident was leaving with on Resident Sign Out Sheet located in a book at the nurses station. When the resident returned, their temperature and the time they returned was documented on the form. During an interview, on 10/13/21 at 2:15 p.m., CNA/LEA (Life Enrichment Assistant) 4 indicated on 10/1/21 around 2:00 p.m., she noticed the resident sitting in a recliner in the Assisted Living (AL) living room. She walked by the resident at 6:30 p.m., and noticed the resident asleep in the recliner. CNA/LEA 4 helped the resident back to her unit around 7:00 p.m., and assisted her with her meal. CNA/LEA 4 reported the incident to the Executive Director (ED) and stated the ED had told her the resident returned at 12:00 p.m. During an interview, on 10/13/21 at 2:35 p.m., CNA 3 indicated on 10/1/21 she was taking care of the resident. CNA 3 thought the son was taking the resident out to dinner and shopping. CNA 3 could not remember what time the resident left or what time the resident returned. CNA 3 was upset during her shift and left early. During an interview, on 10/14/21 at 1:55 p.m., the ED indicated she was working at the front desk on 10/1/21. She did not see the resident return from LOA. She indicated the resident had severe dementia and ambulates with a walker around the facility. During an interview, on 10/14/21 at 3:00 p.m., the Director of Food Services indicated he was serving dinner at 5:30 p.m., in the dining room. He asked where the resident was and the staff told him the resident was out with the family. At 6:30 p.m., he noticed the resident in the dining room eating her meal. During an interview, on 10/14/21 at 3:45 p.m., RN 6 indicated she worked on 10/1/21. She was getting report at 6:00 p.m., and noticed the residents son pushing the resident to her room. The staff interviews did not have correlating information of the resident's return time to the facility. There was no documentation to support the interviews. During an interview, on 10/14/21 at 10:23 a.m., the resident's daughter picked the resident up at 11:00 a.m., on 10/1/21. She indicated they usually stayed out 2 or 3 hours and was unable to recall the time the resident was returned on 10/1/21. A current policy, titled Guidelines for Leave of Absence, revised 5/23/2018 and received from the Clinical Support on 10/14/21 at 12:15 p.m., indicated .To ensure responsible party and/or resident has knowledge of medication administration, precautions and activity level when leaving or discharged from the campus .Nursing documentation should include: a. the date and time the resident left, b. who they left with, c. expected time of return This Federal tag relates to Complaint IN 083. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a cognitively impaired resident was safe from elopement of a secured dementia unit for 1 of 3 residents reviewed for wandering (Resident B). Finding includes: During an interview, on 8/30/21 at 4:09 p.m., a family member indicated on 8/1/2021 the resident was outside of the building without staff present and was walking toward the main entrance. The facility alarm was sounding and the staff were trying to find out what had triggered the alarm. The resident was between the exit door of the dementia unit and the main entrance. The family member had just arrived to the facility and saw the resident outside without staff present. The record for Resident B was reviewed on 8/30/21 at 2:45 p.m. Diagnoses included, but were not limited to, vascular dementia without behavioral disturbance, major depressive disorder, anxiety disorder and generalized muscle weakness. A care plan, dated 6/2/21 and revised on 8/30/21, indicated the resident demonstrated exit seeking behaviors including wandering and going to the front door. The interventions included, but were not limited to, move to the secured dementia unit and to monitor for wandering triggers such as the need for toileting and offer diversional activities as needed. There was no documentation in the electronic record of Resident B being outside of the facility on 8/1/21 without staff present. During an interview, on 8/31/2021 at 12:59 p.m., CNA 2 indicated on 8/1/2021 she was the only staff on the dementia unit and QMA 3 was on another unit passing medications. Resident B walked down the hallway towards her room which was also close to the exit door. CNA 2 heard an alarm and went to the unit next to the dementia unit since she thought this was the door which triggered the alarm. She did not see Resident B on this unit and did not see Resident B exit the building. She then went to the glass door to the outside, the door was locked and she did not see the resident. She opened and shut the glass door and the alarm stopped. She then saw the resident outside of the building with her family. The resident was outside for a few minutes before she was seen. During an interview, on 8/31/2021 at 1:36 p.m., the Executive Director (ED) indicated on 8/1/2021, Resident B's family had planned a party for the resident after lunch and she was assisting the family to get an ice cream scoop. The resident's son then told her the resident was outside. The alarm was sounding on the dementia unit and CNA 2 did not know how to shut off the alarm. CNA 2 had gone to the inside locked door first which was an exit to the assisted living unit and then went to the glass outside exit door. CNA 2 was educated to go to the outside door first during an alarm. A current policy, titled Guideline for Elopement/Missing Resident, dated 3/20/17 and received from the ED on 9/1/2021 at 6:40 p.m., indicated .To establish guidelines to report and investigate all reports of elopement/missing persons. It is the responsibility of all personnel to report any resident attempting to leave the premises or suspected of being missing to the charge nurse as soon as practical .Door Alarm Sounding/Missing Resident .Staff should respond promptly to a sounding door alarm .The charge nurse, facility supervisor or Executive Director should call staff to a central area and designate the following .A staff person to perform a facility head count to determine who may be missing .Two additional staff members to exit the alarming doorway and go in opposite directions around the building perimeter until they meet each other and return to the central area of the facility .If necessary one or more staff members to expand the search to the facility premises .Upon return of the Resident to the facility [unwitnessed exit events] .Complete an exit seeking event form This Federal Tag relates to Complaint IN 202. 3.1-45(a)(2)

Based on interview and record review, the facility failed to document the reason for a resident's transfer to another facility and to provide a 30 day notice of the transfer for 1 of 3 residents reviewed for transfer and discharge (Resident B). Finding includes: During an interview, on [DATE] at 2:20 p.m., Resident B's family member indicated the Executive Director (ED) told the resident and family during the first visit allowed after the Covid pandemic restrictions had lifted, the resident and family would need to find placement at another facility. The family, resident and facility had a meeting on [DATE] and the facility indicated they could put everything behind them. The family member thought this meant the resident would not have to move to another facility. The resident called the family on [DATE] and told them the facility stated she would have to move to another facility in a different city. The resident had made comments in the past about leaving the facility although it was due to the resident having difficulty since her roommate died during the Covid pandemic and not being allowed to have visitors from her family during the Covid restrictions. The record for Resident B was reviewed on [DATE] at 12:30 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS (Minimum Data Set) assessments, dated [DATE], [DATE], [DATE], [DATE] and [DATE], indicated the resident had no physical, verbal or others behaviors. The MDS assessments, dated [DATE], [DATE], [DATE], [DATE] and [DATE], indicated the resident's BIMS (brief interview for mental status) score ranged from a 6 (which indicated a severe cognitive impairment) to a ,d+[DATE] (which indicated moderately cognitively impaired) to a 14 (which indicated intact cognition). A Psychiatry Progress note, dated [DATE], indicated the resident was seen for routine follow up for depression, sleep disorder and anxiety. The medical history was remarkable for a stroke and end stage renal failure on hemodialysis. The facility staff and SSD (social services designee) reported no changes in mood and no new or worsening behaviors. The resident had a noted increase in complaints since her roommate passed away. The resident had no aggression, no self harm, no suicidal ideation and no homicidal ideation. The resident's cognitive status was forgetful and impulsive. A Psychology Progress note, dated [DATE], indicated the resident had been short tempered. She had yelled at a male resident who was diagnosed with severe dementia when he approached her. The male resident was redirected although approached Resident B again and she yelled at the nurse to get the resident away from her. The facility staff indicated the male resident did not understand his boundaries and Resident B would yell at him at least once a day to stay away and would yell at the staff to make him stop. Supportive therapy and empathic listening were provided and the resident was to continue behavioral health services. A Psychology note, dated [DATE], indicated the resident was not a danger to self or others. The treatment goals were to reduce frequency, severity and/or intensity of anxiety symptoms and to reduce frequency, intensity and/or severity of depression symptoms. The resident responded positively to interventions and reinforcements. The facility staff had reported no new concerns. The resident was cooperative, had a stomach ache, body aches and a headache. A progress note, dated [DATE] at 6:00 p.m., indicated the resident was in the door frame of her room, facing the hallway and was being verbally agitated. The resident wanted to leave. The resident was educated her isolation would end in 3 days and she would be free to leave her room at her leisure. A Psychiatry Progress note, dated [DATE], indicated the resident was seen for routine follow up for depression, sleep disorder and anxiety. The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The SSD reported the resident continued to have irritability mostly in the evening and had yelled at staff and other residents. The resident was not currently a danger to self or others. The [CONDITION(S)] depression was moderately stable and recommended to increase the [MEDICATION(S)] (an antidepressant) to 75 mg (milligrams). The plan included for the cognitive changes post stroke to include behavior management of distraction, redirection and relaxation techniques. An Observation report, dated [DATE] at 2:50 p.m., for the Resident First Meeting Minutes (a care plan meeting) indicated the Discharge plan included the resident was anticipated to remain in the facility long term. The resident was present at the meeting and the resident's family member was present by telephone. The Observation report did not include anything about a transfer to another facility or a request from the resident or her family to transfer. A progress note from social services, dated [DATE] at 9:05 a.m., indicated the resident's family member was called and made aware of the recent behaviors/mood. The resident continued to be verbal to others and to act as if she would hit out at others. Psych continued to see the resident and adjusted medications. It was suggested to the resident and her family an alternate placement may be necessary. This suggestion of the alternate placement was not 30 days in advance of the transfer. A progress note from social services, dated [DATE] at 1:54 p.m., indicated she spoke with the ED and the resident's family about a referral to another facility, information was faxed and awaiting reply. A progress note from social services, dated [DATE] at 3:21 p.m., indicated the resident and family member met with the ED and DHS (Director of Health Services) to discuss the move to another facility. Resident said she understood as did mother. discharge date uncertain yet. The progress notes did not include the resident or her family had requested the discharge. A progress note from social services, dated [DATE] at 8:44 a.m., indicated a facility had accepted the resident and the resident would discharge tomorrow when the bus was available. A progress note from social services, dated [DATE] at 2:36 p.m., indicated the resident and her family member were informed of a facility accepting the resident and there was an opening tomorrow and the transfer was scheduled. The discharge packet was prepared. A progress note, dated [DATE] at 8:02 p.m., indicated the resident was upset and tearful. The note did not include the reason the resident was upset or tearful or interventions implemented. A progress note from social services, dated [DATE] at 12:35 p.m., indicated the resident was helped to pack her personal belongings. The resident was made aware she would have a private room and would continue to go to the same [CONDITION(S)] center unless she decided differently. The staff took the resident to the new facility with her belongings. A Discharge Summary and Recapitulation of Stay, dated [DATE], indicated the date of discharge was [DATE], it was a planned discharge, the resident requested the discharge and had talked about the resident happiness at the facility and she was not happy. The resident demonstrated behaviors listed as false accusations with staff and others and physical and verbal behaviors. The summary of social services care and progress indicated the resident verbalized she was not happy here any longer, she felt she could be happier in a new environment, offered to look for alternate placement and she and the mother were agreeable but [NAME] of the change. The progress notes did not include any documentation of physical behaviors from the resident. A progress note from social services, dated [DATE] at 1:32 p.m., indicated the ombudsman called after meeting earlier today. He had talked with the resident's mother and had two questions. 1. Would the facility ever reconsider taking the resident back into the facility if strict stipulations were made? The SSD responded it was not inconceivable, but the whole readmit process with an assessment of physical and mental needs would need completed. 2. Would the facility meet with the family member and the ombudsman to close the loop because the family feels uncertain about the discharge and how it happened? The ombudsman stated it would be a good gesture to meet with him and the family so the family could get closure. The ombudsman was available any Wednesday. The SSD would discuss with the ED when she returned to set up a date and time for the meeting. A current facility policy, titled Guidelines for Transfer and Discharge, dated as reviewed on [DATE] and received from the ED on [DATE] at 2:17 p.m., indicated .The resident has the right to refuse involuntary transfer out of, or discharge from, the facility under certain circumstances .According to federal regulations, the facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless .The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility .The safety of individuals in the facility is endangered .Non Emergency Transfers or Discharges .This portion of the policy applies to transfers or discharges that are initiated by the facility, not by the resident or the resident's representative .The Social Service Designee or other designated staff should handle all non-emergency transfers or discharges .Notify the resident in writing, and if known, a family member or legal representative, 30 days in advance, of the transfer or discharge, the effective date of transfer or discharge .the reasons for the transfer or discharge .Exceptions to a 30-day requirement are if/when a resident is endangering the health or safety of themselves or others This Federal Tag relates to Complaint IN 905. 3.,d+[DATE](a)(4)(A) 3.,d+[DATE](a)(7)

Based on record review and interview, the facility failed to ensure a resident received the appropriate medication for 1 of 3 residents reviewed for dementia care (Resident B). This resulted in harm when the resident received 13 medications which had not been prescribed for her and resulted in a hospitalization for a drug overdose. Finding includes: The record for Resident B was reviewed on 2/18/2021 at 2:25 p.m. [DIAGNOSES REDACTED]. The facility documentation of the incident, dated 12/21/2020 at 7:40 a.m., indicated LPN 2 went to Resident B's room to administer medications. When LPN 2 returned to the medication cart, she realized she administered the wrong medications to the wrong resident. Vital signs were checked twice with the blood pressure results being 107/69 and 92/59. At 7:53 a.m., the resident's physician was paged. At 8:05 a.m., the physician gave an order to send the resident to the emergency room . During an interview, on 2/18/2021 at 3:27 p.m., the DON indicated on 12/21/2020, LPN 2 gave Resident B the morning medications prescribed for Resident F. The list of medications given were: a. [MEDICATION NAME] (to treat high blood pressure) 0.3 mg (milligrams) b. [MEDICATION NAME] (to treat high blood pressure) 10 mg c. [MEDICATION NAME] (an antiplatelet) 75 mg, d. [MEDICATION NAME] (a medication to treat high blood pressure) 50 mg e. levetiracetam (to treat [MEDICAL CONDITION]) 1000 mg f. [MEDICATION NAME] (an antidepressant) 20 mg g. [MEDICATION NAME] (to treat high blood pressure) 75 mg h. pantaprozole (to treat stomach ulcers) 40 mg i. renal vitamin 0.8 mg j. [MEDICATION NAME] (reduces amount of phosphorous in the blood or patients receiving kidney [MEDICAL TREATMENT]) 800 mg k. Senna (a stool softener) 8.6 mg l. [MEDICATION NAME] (an antianxiety) 5 mg m. [MEDICATION NAME] ( an [MEDICATION NAME]) 10 mg. A (name of hospital) Discharge Documentation, dated 12/22/2020, indicated Resident B presented with [MEDICAL CONDITION] (a slow heart rate) and [MEDICAL CONDITION] (low blood pressure) after being given the wrong medications. She was given 2 liters of fluid in the emergency department for persistent [MEDICAL CONDITION]. The [DIAGNOSES REDACTED]. The hospital Discharge Documentation, dated 12/22/2020, also indicated the resident received Depokate (an anticonvulsant) 500 mg. A current policy, titled SPECIFIC MEDICATION ADMINISTRATION PROCEDURES, revised 11/18 and received from the Director of Nursing (DON) on 2/18/ at 4:10 p.m., indicated .To administer medications in a safe and effective manner .Identify resident before administering medication ( .photo, plus verbal confirmation of last name, photo and confirmation by family member .) This Federal Tag relates to Complaint IN 970. 3.1-48(c)(2)

Based on interview and record review, the facility failed to ensure all door alarms and locks were working properly which allowed a resident to elope from the Assisted Living entrance doors for 1 of 3 residents reviewed for accidents (Resident B). Finding includes: The record for Resident B was reviewed on 12/1/2020 at 2:18 p.m. [DIAGNOSES REDACTED]. A progress note, dated 10/19/2020 at 1:15 a.m., indicated the resident was heard outside the building and was asking for help to get back inside the facility. During an interview, on 11/30/2020 at approximately 2:20 p.m., LPN 2 indicated the resident would get confused in the evening and would wander. The resident would think his vehicle and garage were outside the building. During an interview, on 11/30/2020 at 3:30 p.m., the Director of Nursing (DON) indicated the resident exited the building through the Assisted Living (AL) main entrance by pushing the handicap button. The handicap button was not connected to the alarm system or the lock system. The facility video showed the resident exited through the AL doors at 12:20 a.m. on 10/19/2020 and was returned inside the building at 12:40 a.m. The resident was seen in the parking lot close to the front entrance, of the Health Center side, of the building by a housekeeping staff who was taking trash to the outside trash bin. The door alarm to the AL door did not alarm so the staff were not aware the door had been opened. During an interview, on 12/1/2020 at 2:04 p.m., the Maintenance Director indicated all the doors in the facility were locked due to the COVID pandemic. The door locks were checked daily Monday through Friday and the door alarms were checked weekly. The Maintenance Director would not respond to the question which asked if the handicap button was checked during the daily door lock checks or the weekly alarm checks. A Maintenance Log, dated 10/12/2020 through 10/16/2020, received from the Maintenance Director on 12/1/2020 at 2:22 p.m., indicated the Main building doors including the AL Main Entrance remained locked during the COVID Operation. The log did not include if the handicap buttons were checked for the alarms or the locks. A current policy, titled Guidelines for Alarm Checks, revised on 5/22/18 and received from the Executive Director on 12/2/2020 at 3:30 p.m., indicated .Guidelines for Alarm Checks .To ensure resident and door alarms are properly functioning to protect the safety of the campus residents .All door alarms should be checked for proper functioning by the Director of Plant Operations or designee daily during typical business days .The Executive Director, Director of health Services and/or Director of Plant Operations should be notified immediately of non-functioning door alarms .Interventions shall be implemented to protect the safety of the resident until the door alarm has been repaired This Federal Tag relates to Complaint IN 727. 3.1-45(a)(1)

Based on observation, interview and record review, the facility failed to assess and treat an injury in a timely manner, resulting in unrelieved pain, for 1 of 6 residents (#44) reviewed for pain in a sample of 14. Findings include: On 12/1/11 at 2:35 P.M., an interview with the resident and the resident's daughter indicated the resident had an accident on 11/21/11 in which she hit her left foot on her walker and had an injury (the DNS later clarified the actual date of the accident as 11/22/11 at 4:00 A.M.). The resident's daughter indicated she was not contacted concerning the injury but first found out about the injury when she went for a routine visit on 11/22/11 at 10:00 A.M. The resident's daughter indicated when she saw the injury on 11/22/11 at 10:00 A.M., the left foot had a moon shaped open area and it was purple. Resident #44's daughter was concerned the foot was not x-rayed until 11/25/11. When resident #44 was asked to rate her pain in her left foot during the interview, the resident indicated it was a 5-6 on a scale of 1-10. At the end of the interview, the resident's left foot was observed with significant [MEDICAL CONDITION] and a reddish/purple bruise approximately 8 centimeters (cm) x 12 cm on the top of the foot. Review of an accident report from 11/22/11 at 4:00 A.M., provided by the Assistant Director of Health Services (ADHS), on 12/2/11 at 9:45 A.M., indicated the resident hit her foot on her walker causing a bruise while transferring to the bathroom. Left foot [MEDICAL CONDITION] was noted, and the resident complained of pain but not any more than normal. Resident #44's clinical record was reviewed on 12/1/11 at 3:20 P.M. The record indicated the resident was admitted to the facility on [DATE] and was post hip surgery and at the facility for rehabilitation. Review of a skin impairment assessment, dated 11/22/11, indicated the resident had a bruise on the top of her left foot, 5 cm x 6 cm. The report indicated the color was purple and the resident complained of pain. The report indicated the treatment was to monitor. The skin impairment assessment sheet indicated a second assessment was conducted on 11/29/11 but not documented until 12/2/11. The assessment indicated the foot was purple and less [MEDICAL CONDITION] today than previous, 1+. The assessment did not include any measurements of the bruising. Review of a skin impairment circumstance, assessment and intervention form, dated 11/22/11, indicated the location of impairment as left foot and type of impairment as bruise. Treatment required type was "observe bruise." Under prevention update, the interventions were listed as staff training and check circulation, [MEDICAL CONDITION]. The form was filled out 3 times daily for 72 hours and each entry indicated assessment completed and no complaints of pain. The form ended on 11/24/11. Review of the nurse's notes indicated no entries from 11/16/11 at 5:40 P.M. until 11/23/11 at 3:30 P.M. The nurse's note on 11/23/11 indicated physician's orders [REDACTED]. On 11/25/11 at 7:40 P.M., a nurse's note indicated the x-ray of the left foot had been completed and was negative. A nurse's note on 11/28/11 at 1:35 P.M. indicated a physician's orders [REDACTED]. A nurse's note on 11/28/11 at 2:30 P.M. indicated a Doppler ultra sound had been completed and laboratory blood tests had been drawn. A nurse's note from 11/29/11 at 1:30 P.M. indicated a physician's orders [REDACTED]. A nurse's note dated 11/30/11 at 5:30 P.M. indicated the physician came to see the resident and assessed her left foot. The note indicated the left foot continues to be discolored, swollen and warm to touch. physician's orders [REDACTED]. Review of skilled nursing assessment and data collection forms indicated the following: On 11/22/11 at 6:30 A.M., in the skin section, the resident had no skin impairment (the box for bruise was not checked) and in the pain section the resident had no pain. The same form's nursing notes/comments dated 11/22/11, no time listed, indicated the resident had pain med (medication) upon request. Another nursing notes/comments dated 11/23/11 at 5:00 A.M., indicated no complaints of pain at this time and left foot bruise continues. On 11/23/11 at 7:45 A.M., in the skin section, the resident had no skin impairment (the box for bruise was not checked) and in the pain section the resident had no pain. The same form's nursing notes/comments dated 11/23/11, 2-10, indicated no change with assessment and indicated no complaints and no signs and symptoms of distress. Another nursing notes/comments dated 11/23/11, 10-6, indicated the resident complained of left foot pain and area swollen and bruising noted. On 11/24/11 at 10:30 A.M., in the skin section, the resident had no skin impairment (the box for bruise was not checked) and in the pain section the box indicating scheduled pain regime was checked. The frequency boxes for pain were unchecked. The frequency boxes in the pain section included: none; occasionally; frequently; constantly. Pain intensity boxes were unchecked also. The pain intensity boxes included: mild; moderate; severe; horrible/excruciating; scale of 1-10. The same form's nursing notes/comments dated 11/24/11, no time listed, indicated the resident had pain med upon request. On 11/25/11 at 6:30 A.M., in the skin section, the resident had no skin impairment (the box for bruise was not checked) and in the pain section the resident had no pain. The same form's nursing notes/comments dated 11/25/11, 2:25 P.M. indicated the resident had no pain at present. On 11/26/11 at 7:00 A.M., in the skin section, the resident had skin impairment, and the bruise box was checked. In the pain section, the box indicating scheduled pain regime was checked. The frequency boxes for pain and pain intensity boxes were unchecked. The same form's nursing notes/comments dated 11/26/11, 8:45 A.M., indicated the resident had no signs or symptoms of distress. Another nursing notes/comments dated 11/27/11 at 5:00 A.M. indicated left foot [MEDICAL CONDITION] and bruising remains. On 11/27/11 at 7:15 A.M., in the skin section, the resident had skin impairment, and the bruise box was checked. In the pain section, the box indicating scheduled pain regime was checked. The frequency boxes for pain and pain intensity boxes were unchecked. The same form's nursing notes/comments dated 11/27/11, 2-10, indicated the resident had no signs or symptoms of distress. Another nursing notes/comments dated 11/28/11 at 5:00 A.M., indicated left foot [MEDICAL CONDITION] and bruising remains. On 11/29/11 at 8:10 A.M., in the skin section, the resident had no skin impairment (the box for bruise was not checked) and in the pain section the resident had no pain. The same form's nursing notes/comments dated 11/29/11, no time noted, indicated the resident had PRN (as needed) pain medications upon request. Another nursing notes/comments dated 11/29/11, 11:40 P.M., indicated the resident was resting quietly and denies pain. A fax, dated 11/27/11, to the physician indicated the left foot remains dark purple-brown with 2+ non-[MEDICAL CONDITION]. The fax indicated the resident has [MEDICATION NAME] 5/500 (a pain medication) order routinely three times daily and resident complains of pain to left foot and leg as well as weak and light headed. The fax indicated the aides who help her regularly state she is reversing in progress as she has difficulty bearing weight, whereas prior to injury she was ambulating with walker and one assist. The fax noted no PRN's (as needed) pain medications were on-board. No response regarding PRN pain medications was received. A review of the resident's most recent medication orders, dated 11/27/11, indicated the resident had no PRN pain medications ordered. She did have a physician's orders [REDACTED]. She also had a physician's orders [REDACTED]. An interview with the Director of Health Services (DHS) on 12/2/11 at 9:05 A.M., indicated the delay in the x-ray was due to the mobile x-ray company chose the original date of 11/28/11 but actually did the x-ray on 11/25/11. The DHS did not know why the x-ray was not ordered and completed before 11/25/11. An interview with the DHS on 12/2/11 at 10:50 A.M., indicated the resident already had routine pain medications ordered before the accident on 11/22/11. The DHS did not have any information why the resident did not have PRN pain medications ordered after the accident. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure an oral skin infection was thoroughly and consistently assessed and treated for [REDACTED]. (Resident #1) Finding includes: During the initial tour of the facility, conducted on 01/17/12 at 10:15 A.M., the medical records nurse, LPN #2, indicated Resident #1 had recently been treated for [REDACTED]. The clinical record for Resident #1 was reviewed on 01/18/12 at 10:00 A.M. Review of the physician's orders [REDACTED]. Another physician's orders [REDACTED]. Finally, an order, dated 01/09/12, discontinued the [MEDICATION NAME] because the resident was already receiving the [MEDICATION NAME] medication. Nursing notes for Resident #1, dated 01/04/12, indicated the physician's orders [REDACTED]. The order changes were again documented on 01/05/12, but there was no assessment of the resident's mouth. There were no nursing notes on 01/06/12 and 01/07/12. On 01/08/12 at 8:30 A.M., there was a nursing note indicating the following: "Res daughter called et wanted res. totally assessed. Neuro check done, PEARL (pupils equal and reactive to light), grips equal ...Oral cavity tongue etc has some patchy areas.. [MEDICATION NAME] cont (continues) for thrush. (physician's name) on call at this time. Beeped." A subsequent nursing note, dated 01/08/12 at 9:10 A.M., indicated the physician returned the call and gave an order for [REDACTED]. Another undated note, written at 12:30 A.M., indicated the following: "at 1910 (7:10 P.M.) daughter (daughter's name) voices concern regarding father's condition at this time resident was in his w/c (wheelchair) with eyes closed head forward. daughter states 'he holds his arm with his hand et shakes.' Further states his words are slurred et he is 'more confused than usual.' Resident arouses does speak with difficulty. Recognized daughter but not staff. Upon inspection resident's tongue is swollen et has large white plaques. Smaller plaques noted to inner lips accounting for cautious speech. Resident's mental status has changed as he attempts to chew his medication rather than swallow whole. further, he chokes on water. Offered Nectar thick apple juice et drinks without incident. Resident is on [MEDICATION NAME] Daughter request Dr be called." At 19:20 (7:20 P.M.) "Attempts x3 to page (physician's name) on call for (physician's name) each time recording line no longer in service." 19:35 (7:35 P.M.) "resident assisted to floor by staff CNA. no open areas abrasions, bruising or bumps noted. Bilateral lower extremities equal in length. no inward/outward rotation. 20:50 (10:50 P.M.) daughter notified of lowering to floor et inability to contact physician call...." Interview with the Interim Director of Nursing, on 01/19/11 at 10:00 A.M., indicated the nurse who made the undated entry was requested, on 01/09/12, to make an entry for events which occurred on the evening of 01/07/12. The Interim Director of Nursing indicated RN #4, who had not documented any of the events of 01/07/12 and had failed to contact the physician due to Resident #1's change of condition, was no longer employed by the facility. However, nursing notes, after 01/08/12 again failed to assess the resident's oral thrush infection, even though a note, dated 01/09/12 at 18:10 (6:10 P.M.), indicated there were still orders obtained to treat the resident's infection. There was also no care plan initiated regarding the resident's oral skin infection. Interview with the Interim Director of Nursing (DON), and a Corporate Director of Nursing, RN #6, on 01/19/12 at 2:00 P.M., indicated the facility policy was to document all types of acute issues, including skin issues, on a "circumstance" form which then had assessments documented on the back for at least 72 hours. The DON indicated she could not locate a circumstance form for Resident #1. In addition, staff were to utilize a "team leader follow up form" daily by unit, completed by the unit manager, to review all new orders, and new occurrences to ensure the proper documentation and follow-up occurred. Review of the "team leader follow up forms" for 01/04/12 for all units, indicated the order for the medication for Resident #1 was not listed on the form. The only documentation of any type of assessment presented, was a 24 hour nursing report form, dated 01/04/12, which indicated the resident had complained of a sore throat and had white spots and a fax had been sent out to the physician. A copy of the fax was also presented which did include an assessment of the resident's oral cavity but both documents were not routinely kept as part of the medical record. Observation of the resident's mouth, on 01/19/11 at 2:10 P.M. indicated there were pink rough patches noted on the resident's tongue. The resident was unable to recall any recent discomfort with his mouth and indicated his mouth did not hurt. The resident's tongue and oral mucosa did not appear swollen and his speech was not noted to be slurred. He was noted to display some confusion. This deficiency was cited on 12/02/11. The facility failed to implement a systemic plan of correction to prevent recurrence. 3.1-37(a)

Based on interview and record review, the facility failed to prevent a fall resulting in fractures for 1 of 8 residents reviewed with falls (Resident #39) in a sample of 14. Findings include: 1. During an interview on 11-29-2011 at 2:55 p.m., Resident #39's family member indicated RNA #5 (Restorative Nursing Assistant) had raised Resident #39's feet, to put her feet on pillows, and tipped her wheelchair over backwards. Resident #39's family member further indicated there had been no leg risers on the wheelchair, and the facility failed to further investigate the occurrence. Resident #39's record was reviewed on 12-1-2011 at 11:15 a.m. Resident #39's [DIAGNOSES REDACTED]. A review of nurse's notes, dated 1-17-2011 at 11:15 a.m., indicated Resident #39 had been receiving Restorative care. After completing the program for the morning, RNA #5 attempted to elevate Resident #39's feet onto the seat of a reclining chair in her room. Resident #39 had been seated in a wheel chair to receive her Restorative care. While elevating Resident #39's feet to the seat of the recliner, Resident #39's wheelchair tipped backwards, and she fell back onto the floor. Resident #39 remained in the wheelchair. An x-ray report of Resident #39's spine, taken 1-17-11, indicated Resident #39 had fractures of undetermined age to the vertebrae T-3 and T-6, T-7 and T-8. A follow up MRI on 2-22-2011 indicated fractures of the vertebrae T-3 and T-6 were likely to be related to osteoporosis and trauma. The fall circumstance report, dated 1-17-2011, indicated Resident #39 had a witnessed fall, wheelchair brakes were not locked, but no further information was documented on the form regarding where the resident was in the room, circumstances of the fall nor statements from the witness. The preventative measure to be taken was indicated to place anti tip bars on the wheel chair. An Interdisciplinary Fall Team note, dated 1-19-2011, indicated RNA #5 had been lifting Resident #39's feet to place them in the recliner. The wheel chair tipped back. The Restorative CNA indicated he had assisted the chair backward and Resident #39 had not hit her head. There was no further investigation noted on the form. The nurse's notes indicated the Interdisciplinary Fall Team review met on 1-18-2011 at 10:45 a.m. The note further indicated Resident #39 had indicated RNA #5 had placed the pillows too high, but there was no further indication of review of Resident #39's wheelchair. In an interview on 12-1-2011 at 4:07 p.m., the Executive Director indicated she had spoken with Resident #39 in February after Resident #39's family asked RNA #5 not work with Resident #39 again. Then, in August, Resident #39's family member indicated the desire to talk to the highest person available in the facility. The Executive Director indicated she had the Regional Director speak with her. An internal memo dated 10-3-2011, provided by the Executive Director on 12-2-2011 at 10:10 a.m., indicated the Regional Director had spoken with Resident #39's family member, but was referring more in depth investigation to a clinical support person. The clinical support person had replied on 10-18-2011. The memo indicated she had called Resident #39's family member, but had terminated the call. There was no indication of further action taken. An accident/incident investigation report was provided by the Executive Director on 12-2-2011 at 11 a.m. The form indicated the fall had occurred due to RNA #5 had elevated Resident #39's feet and her wheelchair fell backwards with her in it. An interview with Resident #39, written in the Executive Director's hand, dated 1-18-2011, indicated Resident #39 had felt the pillows were too high and she had hit her head. There was no further investigation into these statements. In an interview on 12-2-2011 at 9:45 a.m., RNA #5 indicated Resident #39 was to have her legs elevated because of swelling, so the staff had been placing Resident #39's feet up in her recliner chair. RNA #5 further indicated there were no leg risers on Resident #39's chair or the staff would have used them. In an interview on 12-2-2011 at 10:00 a.m., LPN #16 indicated staff had been placing Resident #39's feet up in the reclining chair because her legs needed elevated due to increasing edema the week prior. LPN #16 indicated there were no leg risers on Resident #39's chair because she would not use them. Resident #39's most recent Minimum Data Set (MDS) assessment, dated 11-12-2011, indicated she was alert and oriented. The MDS also indicated the resident required maximum assist with two staff members to transfer and was non-ambulatory. In an interview on 12-2-2011 at 10:50 a.m., Resident #39 indicated she had told RNA #5 she thought the pillows were too high and he had acted in a hurry, not really talking to her very much that day. Resident #39 further indicated she did not recall RNA #5 slowing the wheelchair during the fall, and she felt she hit her head. Resident #39 additionally indicated her wheel chair did not have leg risers on the chair at the time of her fall, she further indicated no one had talked to her about leg risers, but she would have used them if they would have been on her chair. Resident #39 further indicated she did not recall talking with the Executive Director about the fall. A review of care plans, dated 1-13-2011, indicated Resident #39 was at risk for falls due to osteoporosis, weakness and she used a wheelchair. The care plan indicated to provide and monitor the use of the wheelchair and to lock brakes before transferring. Leg risers were not mentioned in the care plan. A current policy dated 11-2010, titled Guidelines for Investigation, indicated an accident or incident should be thoroughly investigated including interviews of witnesses, contributed to the occurrence, who had, residents, witnesses, and the person involved in the incident, reviewing nursing notes, and medications. 3.1-45(a)(2)

Based on record review and interview, the facility failed to provide CPR (cardio-pulmonary resuscitation) to 1 of 2 residents, with signed advance directives directing the facility to provide CPR, thus resulting in the death of the resident, in a sample of 3 (Resident A). Findings include: 1. Resident A's clinical record was reviewed on [DATE] at 2:05 P.M. Resident A's [DIAGNOSES REDACTED]. Resident A's CPR Consent form indicated the section for "It is my desire that I be given:" the box next to CPR had an "x" in it. This form was signed by the resident's daughter on [DATE]. Resident A's nurse's notes for [DATE] indicated: 1520 (3:30 P.M.) "Aid needed (name of CNA #1) help pulling res (resident) up in bed (sic) went (sic) into room. Res. was lying on side et was pale, spoke with Res he said he was not feeling well, I immediately check Res. blood sugar it was 146 check his O2 (oxygen) machine was set on 5L et was feed (sic) oxygen SAT 98%. Res smelled of urine (changed indicated by a triangle) Res brief. Went to get replacement sheets et then sat Res. up to move out of bed since Res couldn't help c (with) changing bed. When we had the Res standing his legs buckled. We then set him on the floor et went to get some help. (LPN #1) et (CNA #2) both came in the room. O2 SAT was still at 97% et held. Res was still responsive. Respriations (sic) 26, Pulse 95 et was unable to get B/P. While trying to get a B/P the O2 monitor started dropping steadly (sic). Then Res was quickly moved back into bed assist x 4. Res was unresponsive thoratic (sic) chest rubs were done by self et (LPN #1) then I went et called 911. When I returned (LPN #1) et (RN #1) were trying to arouse Res. (RN #1) called his death at 1540 (3:40 P.M.). Late note before going to call 911 we did try getting a pulse could not feel one. (LPN #1) was getting a weak apical pulse...." signed by LPN #2 1540 (3:40 P.M.) (Name of RN #1) heard nurse say that (Resident A) was unresponsive arrived in (Room #). Saw pts. feet were cyanotic bilaterally. I approached resident and no signs of life were present. Auscultated (sic) Carotid pulse nothing (indicated by a circle with a line through it). Auscultated apical pulse nothing (indicated by a circle with a line through it). No B/P. No SaO2 sat level noted on oximety (sic). Gave 3 sternal rubs c (with) no response. Resident time of death 1540 (3:40 P.M.) signed by RN #1 1610 (4:10 P.M.) "@ 1525 (3:25 P.M.) writer heard Maple Wood nurse state 'I need help picking (Resident A) up (indicated by an arrow pointing up).' Writer went in to room resident unresponsive, went for V/S equipment while doing this told Med Rec. (Medical Records). RN (RN #1) resident was unresponsive gathered equipment went into room. O2 97%, P 95, R 26, V/S held for 3 minutes then rapidly declined to O. Never able to attain B/P. 911 called." signed by LPN #1. The "Cardiopulmonary Resuscitation Circumstance, Assessment and Intervention" form was provided by the Administrator on [DATE] at 3:30 P.M. This form indicated on [DATE] Resident A was assessed by RN #1, LPN #1, and LPN #2. RN #1 and LPN #1 had identified the resident's condition. His skin was pale, pulse was 95, he had a pacemaker, no blood pressure, respirations were ,[DATE] and shallow with an O2 Saturation of 97%. The "resident went unresponsive during the assessment." The "Res. was a full code & CPR Not initiated." The comments were "Res. had been a full code & nurses did not initiate CPR. Senior nurse RN stated time of death 1540 (3:40 P.M.)." The "24 hour nursing report" form with the date of [DATE] was reviewed. Resident A's instruction were reviewed. He was listed as a "full code." There was a notation of "Res. passed away 1540 (3:40 P.M.)" The Administrator provided the facility's investigation regarding Resident A's lack of CPR on [DATE] at 3:30 P.M. LPN #2's statement obtained on [DATE] at 1700 (5:00 P.M.) indicated she was "Notified by (CNA #1) that (Resident A) was on the floor. Asked (LPN #1) for assistance due to (Resident A) on floor took vitals equipment & went to room. (CNA #2, CNA #1, LPN #1) and I were assessing & O2 sats OK but having trouble getting B/P. He was talking but hard to understand. Returned him to bed & O2 sats started dropping. Asked Code status & no one knew. Left to go check. Returned & told Code status then tried to call 911 from room did not work so went to station & called. Came back to room. (LPN #1 and RN #1) there (sic) and said at least 2 X's he is a full code are we going to do CPR. (RN #1) said no he is already gone & I already called it. Instinct said to do CPR but did not since they said no they were seasoned nurses. (LPN #1) had said at some time he had blood in his mouth." The facility attempted to get a statement from LPN #1; on [DATE] at 1705 (5:05 P.M.) she told the DON, "'Why would we do CPR, he had a pace maker & you are not going to save him.' Stated again he was a full code & I needed her statement as to what she saw. 'Why would I rewrite what is in NN (nurses' notes)'.... Did not get any written statement from (LPN #1)." RN #1 and LPN #1 were suspended on [DATE]. The record from EMS was obtained on [DATE] at 12:50 P.M. The EMS record indicated on [DATE] at 15:42 (3:42 P.M.) a call was received from (address of facility) for a "full code." EMS responded, but found "no patient." The notes indicated "On arrival at extended care facility found ECF (extended care facility) staff at nurse (sic) station. When asked by EMS where patient located? (RN #1) in charge stated 'Pt. already gone." Asked by EMS 'gone where'? and if there was a 'code' ([MEDICAL CONDITION]) in progress. Same nurse stated, 'Pt in room but had already passed.' EMS crew dismissed at that time, no patient information was obtained at that time or contact made with patient." There was a time line on the form "Call received 1542 (3:42 P.M.) Crew Enroute 1542 (3:42 P.M.) Arrive at scene 1543 (3:43 P.M.) Cleared scene 1546 (3:46 P.M.) Back at hospital 1550 (3:50 P.M.)" CNA #1 was interviewed on [DATE] at 4:45 P.M., she indicated on [DATE] she had answered Resident A's call light. She had gotten LPN #2 because the resident had said he didn't feel well and LPN #2 had come into the room to assess him, but they had smelled urine, so they changed him, but needed to change the bed as it was urine soaked. They got him out of bed, but when he was standing up, his knees buckled. They sat him on the floor and LPN #1 came into the room and helped to place him back into the bed. As he was on the floor, he went unresponsive. When he was back in the bed, RN #1 came into the room, rubbed his chest and called his time of death. She indicated LPN #2 told them 2 times that Resident A was a full code. She indicated EMS came to the facility, but never made it to the room. CNA #2 was interviewed on [DATE] at 4:56 P.M. He indicated he only came into the room to help get the resident off the floor and back into bed. He indicated the resident had no signs of response, but he left the room as soon as the resident was back in bed. RN #1 was interviewed on [DATE] at 4:50 P.M. She indicated she was working in the Medical Record room. She indicated she looked out her door and saw a CNA running and CNA #1 coming back down the hall. She said the CNA was tearful and said Resident A had passed. She went to Resident A's door and his feet were cyanotic. She said LPN #1 and LPN #2 were in the room. She said they told her Resident A had passed. She took the stethoscope, listened, and heard no pulse or breathing and he was cold to touch. She said his pacemaker had stopped. She called the time of death at 3:40 P.M. LPN #2 then asked "What do we do now?" She indicated she told her to call the family and the mortuary. She said she asked if he was a code or no code. She indicated she froze when she heard he was a code and her mind went blank. She said she had been in the room for ,[DATE] minutes. She said when EMS arrived she had told them "He's gone" and EMS never went to the resident's room. LPN #1 was interviewed on [DATE] at 1:15 P.M. She indicated on [DATE] at 15:25 (3:25 P.M.) the CNA and LPN #2 asked for help. She got CNA # 2 and the Hoyer lift. She said CNA #1 was holding Resident A up and holding his head up. He had no B/P, but his pulse oximetry was 92% with a pulse of 95. He had shallow respirations for 3 minutes and then none. She hollered for RN #1. She told LPN #3 and the DON as she got the items she needed to take his vital signs and then went back into the room. They got Resident A into bed by physically lifting him. He had no blood pressure. A sternal rub was attempted. RN #1 came into the room. LPN #2 had attempted to call 911 in the room, but she couldn't get the phone to work. She left the room and called 911 from the nurses' desk. RN #1 had come into the room and said Resident A's feet were blue. She said LPN #2 had returned to the room, but she had her back to her and didn't hear what she said. RN #1 said "No, I'm calling time of death 1540 (3:40 P.M.)." She indicated they left the room and went to the nurses' desk where she helped LPN #2 with the paperwork. EMS arrived and RN #1 told them he was gone. She indicated she never asked what Resident A's code status was. She indicated she had never heard if he was a code. She indicated she did not know who had called 911. LPN #2 was interviewed on [DATE] at 2:00 P.M. She indicated on [DATE] CNA #1 had came out of Resident A's room and had stopped her and pulled her into Resident A's room. Resident A said he didn't feel good. She had assessed him and checked his blood sugar which was 146 and his oxygen was on with a saturation of 98%. He was wet and had diarrhea. They changed him, but his entire bed was wet, so they assisted him out of bed to change the bed and to try to dry the bed out as he was on an air flow mattress. She indicated her plan was to leave him up for a while for the bed to dry out. When he stood up his knees buckled so he was lowered to the floor. She left CNA #1 with him to get help. She got LPN #1 who came first and then CNA #2 came into the room. By this time his head was hanging. LPN #1 went out of the room for a BP cuff and she went out of the room for clean linens. His pulse was 95, but his B/P was unable to be heard. His pulse oximeter was 92% and then slowly dropped. They had 4 people who lifted him into bed. He was no longer responsive before they got him back in bed. He had been talking when he was sitting on the floor. LPN #2 said she gave him some chest rubs and he had no radial pulse. She asked if anyone knew if he was a code. She left and pulled his chart which indicated he was a full code. She returned to the room and told CNA #1 and LPN #1 that he was a code and attempted to call 911 from the room, but was unable to get a line. She returned to the nurses' desk and called 911 about 3:30 P.M. or 3:35 P.M., she was unsure of the time. She then returned to his room and told them she had called 911 and they were on their way and shouldn't we start CPR. RN #1 said "he's gone" and "No." She indicated this was the first she had noticed RN #1 was in the room. She indicated she had left the room, but stopped outside the door, and comforted CNA #1 who was crying. She then walked to the nurses' desk and EMS had arrived. She indicated RN #1 had called his death at 15:40 (3:40 P.M.). She could not remember if RN #1 was in the room when she had called 911. She said she didn't know why she didn't do CPR, but she was a new nurse and still had questions and RN #1 had been her supervisor and she had not done CPR. The personnel files of LPN #1, LPN #2, and RN #1 were reviewed on [DATE] at 4:00 P.M. All of 3 had been CPR certified and had gone over CPR during their orientation. Review of the CPR certification listing maintained by the facility indicated 42 of 66 nursing staff members were CPR certified. RN #1 and LPN #1 were terminated on [DATE]. On [DATE] at 3:30 P.M., the Administrator provided a packet of information which included the facility's investigation of the CPR not being administered to Resident A. In this packet were inservices on the "Cardiopulmonary Resuscitation Policy." All employees in the building were given this inservice and had signed they were in the inservice. This packet of information included a form with all residents in the building listed. The facility had used this to check every chart in the building in ensure the advanced directives, physician's orders [REDACTED]. The facility had reviewed all deaths in the building occurring in the past 6 months to ensure the resident's advanced directives had been followed and found all who had died were no codes, and the advanced directives were honored. On [DATE] between 4:40 P.M. and 4:45 P.M., seven resident clinical records were reviewed, with all seven having agreement of the advanced directives, physician's orders [REDACTED]. Review of the undated policy for Cardiopulmonary Resuscitation (CPR) was provided by the DON on [DATE] at 3:30 P.M. The policy indicated "....5. If the resident is a 'Full Code" and is found to be in cardiopulmonary arrest campus staff will: a. Assess for viable signs of life, measurable blood pressure, skin temperature, skin color/cyanosis, pulse (absence, rhythm, quality), respirations (absence, rhythm, quality, level of consciousness). b. Initiate CPR. c. Call 911 to have the emergency medics transport the resident to the nearest hospital. d. Notify the attending physician or medical director for instructions...." This federal tag relates to complaint IN 588. 3XXX,[DATE](a)