**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain timely treatment and assessments of a full thickness burn to a resident's left foot resulting in actual harm when the resident required hospitalization and surgical interventions at an acute care hospital for 1 of 4 reviewed for timely care and treatment (Resident B). Findings include: During an interview on 6/2/25 at 12:07 p.m., Resident B indicated on 5/19/25 his left foot was burned when the nurse was providing wound care. He indicated the nurse brought over a basin of water for him to soak his foot in prior to applying a treatment to the sore on the bottom of his left foot. When he put his foot into the water, he felt like it was too hot and pulled his foot out. The nurse told him she had felt the water, and it was not too hot, but to hold on and she would go get some supplies. She had been out of the room for a couple of minutes when she passed by his door and told him to go ahead and try again. She had not checked the water temperature. When he returned his foot into the water, it felt hot but tolerable. When she returned about five minutes later, she was surprised to see a blister on the top of his foot. His feet were numb a lot because of his diabetes, and he had not realized the water was still hot. Cross reference F689. A review of Resident B's clinical record was completed on 6/2/25 at 10:53 a.m. Diagnoses included burn of unspecified degree of left foot, diabetes mellitus type II, and degenerative disease of the nervous system. A nurse practitioner progress note completed by Nurse Practitioner (NP) 2, dated 5/19/25 at 3:30 p.m. and created on 5/24/25 at 8:18 p.m., included Resident B was seen at the request of nursing for a blister to his left foot. The resident .was found seated with both feet resting on a towel and a wash basin visibly placed in front of the patient. Nursing indicated that foot washing was initiated as a preparatory measure before the administration of previous treatment .for an unrelated skin condition. Nurse reports that she facilitated foot washing by preparing water and directing the patient to immerse his feet. Subsequently, the patient raised concerns regarding the water temperature. Nurse reports, 'the water temperature was found to be within an acceptable range.' Following this, the nurse advised the patient to 'hold on' while she retrieved treatment supplies. Nurse reports, upon her return to the room, the patient presented with a fluid-filled blister on the top of left foot, after removing his foot from the water. Notable clinical findings included the presence of loose skin and mild erythema on the affected foot. A Weekly Skin Assessment, dated 5/19/25 at 6:58 p.m., indicated the resident had a new impairment of skin integrity. The description indicated a fluid filled blister to the top of the left foot. Wound interventions indicated the NP/physician was notified, a treatment as ordered, and monitor for signs or symptoms of infection. A current physician's order, dated 5/19/25 at 7:00 p.m., indicated to cleanse left foot with sterile water, pat dry, and apply a non-adherent dressing. Staff were to wrap foot with gauze and secure with tape. Treatment was to be completed every day and night shift. A Weekly Skin Assessment, dated 5/20/25 at 6:01 a.m., indicated the resident had a new impairment of skin integrity. The description indicated left toes. Wound interventions indicated the NP/physician was notified and treatment as ordered. The clinical record lacked documentation regarding an assessment and description of the resident's burn wound on 5/20/25. A nursing progress note by LPN 7, dated 5/21/25 at 5:06 p.m., indicated the dressing to Resident B's left foot was hard to get off and had blisters noted to top of all five toes, sloughing, copious amount of serous drainage, skin peeling, and very painful to touch. The wound NP was notified, and treatment was completed as ordered. A NP progress note completed by NP 2, dated 5/21/25 at 7:46 p.m. and created on 5/25/25 at 9:15 p.m., included Resident B was seen at the request of nursing for pain to his left foot. The patient seen for a follow-up visit concerning their left foot pain, which presented with new symptoms during recent care. The patient has a significant history of diabetes and frequent cellulitis episodes, necessitating careful management of skin integrity and related complications. The patient reports new onset pain in the affected area (Left foot). The patient describes the pain as moderate but constant, located specifically to the left foot where he has a previous blister .The treatment plan includes continued monitoring and education, with an emphasis on prompt notification of any acute changes, underscoring the need for vigilance given the patient's predisposition to complications due to his underlying conditions. Nursing staff have been briefed on these updates and are prepared to report any further developments promptly .Derm: Dressing intact to left foot A nursing progress note completed by RN 3, dated 5/21/25 at 10:03 p.m., indicated the resident had complained of excruciating pain to his left foot. The resident indicated his foot was submerged in hot water prior to the scheduled treatment on 5/19/25. RN 3 had changed the dressing and indicated the foot appears to be a 3rd degree burn, yellow slough, red, draining & toes matted. RN 3 contacted 911 and the resident was taken to an acute care burn unit for further evaluation and treatment. A Clinically at Risk report, dated 5/23/25 at 12:51 p.m., indicated the reason for review was for a chronic wound. Team members in attendance were listed as the DON and registered dietician. The comment included that the resident had been admitted to the hospital on [DATE] for a diabetic foot ulcer. Under the Skin/Wounds section of the report, concerns were listed regarding left foot plantar, diabetic foot ulcer. Cleanse with wound cleanser, apply hydrogel and bordered gauze. The report indicated the care plan had been updated and was signed on 5/25/25. The report lacked indication of the resident sustaining and being hospitalized due to a burn sustained during care at the facility. During an interview on 6/2/25 at 11:46 a.m., LPN 4 indicated she was preparing to complete Resident B's wound care orders, and she wanted to complete foot care prior to his left foot treatment. As she was running the water into the basin for the resident to soak his foot, she ran her hand under the running water and felt it was warm and finished filling the basin. She had not checked the temperature of the water in the basin after it was filled. She instructed the resident to put his left foot in the water. Resident B placed his foot in the water and indicated the water was hot and removed his foot. She indicated to him that she had just checked the water and told him to hang on and she would go get his wound care supplies. She was gone for about five minutes and when she returned to his room his foot was in the basin. She noticed his skin had developed a small lemon sized blister on the top of his foot. She had not intended for the resident to put his foot in the basin when she left the room. He indicated to her his foot hurt and she administered an as needed dose of pain medication. She requested another staff member inform NP 2, and she called the unit's manager who both came to the resident's room. She had not documented in a progress note, as the NP was going to document. During an interview on 6/2/25 at 12:40 p.m., NP 2 indicated she had been called to Resident B's room. She had not noticed a blister, but the resident's left foot was sorta red with a small open area. She had visualized the resident's foot following the incident, but had not had staff remove the resident's dressing during her follow-up visits. She had not examined the wound during her 5/21/25 visit with the resident for increased pain. The physician was completing rounds the following day (5/22/25), and she wanted the physician to look at the left foot at that time. During a telephone interview on 6/2/25 at 2:41 p.m., RN 3 indicated Resident B had been in so much pain and his wound looked bad. He had not been in a lot of pain the night before. When she had completed his wound treatment on 5/21/25, she had been unaware the resident had sustained a burn to his left foot. She had prepared to complete his treatment for his diabetic ulcer to the bottom of his left foot. The resident had a hard time tolerating the treatment. She had called the DON and received approval to send him to the emergency room for treatment. A Burn Service Team History and Physical Note, dated 5/22/25, from the acute care provider, indicated the resident had presented with scald burns to his left foot, sustained three days ago. The Assessment/Plan indicated the patient had a three day old full thickness scald burn to the left foot. An Inpatient Discharge summary, dated [DATE], from the acute care provider, indicated the resident had two surgical procedures on 5/22/25 and 5/27/25 for debridement of left foot and skin graft application. A current facility policy, dated 8/2024, titled, Change in a Resident's Condition or Status, provided by the Corporate Nurse on 6/3/25 at 12:06 p.m., included the following: .Policy Interpretation and Implementation .8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status This citation relates to Complaint IN00460578. 3.1-37(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect a resident during care resulting in actual harm when the resident sustained a full thickness burn to his left foot requiring surgical interventions for 1 of 4 reviewed for accidents (Resident B). The deficient practice was corrected on 5/23/25, prior to the start of the survey, and was therefore past noncompliance. Findings include: A review of Resident B's clinical record was completed on 6/2/25 at 10:53 a.m. Diagnoses included burn of unspecified degree of left foot, diabetes mellitus type II, and degenerative disease of the nervous system. A quarterly Minimum Data Set (MDS) assessment, dated 4/11/25, indicated the resident was cognitively intact, used a wheelchair for mobility, required partial to moderate assistance of staff to put on and remove footwear, complete lower body dressing, transfer from chair to bed, and had a diabetic foot ulcer and received dressings to his feet. A health care plan, initiated 2/4/25, indicated Resident B had diabetes mellitus with neuropathy. Interventions included to avoid exposure to extreme heat or cold. A nurse practitioner progress note completed by Nurse Practitioner (NP) 2, dated 5/19/25 at 3:30 p.m., included Resident B was seen at the request of nursing for a blister to his left foot. The resident was found seated with both feet resting on a towel and a wash basin visibly placed in front of the patient. Nursing indicated that foot washing was initiated as a preparatory measure before the administration of previous treatment .for an unrelated skin condition. Nurse reports that she facilitated foot washing by preparing water and directing the patient to immerse his feet. Subsequently, the patient raised concerns regarding the water temperature. Nurse reports, the water temperature was found to be within an acceptable range.' Following this, the nurse advised the patient to 'hold on' while she retrieved treatment supplies. Nurse reports, upon her return to the room, the patient presented with a fluid-filled blister on the top of left foot, after removing his foot from the water. Notable clinical findings included the presence of loose skin and mild erythema on the affected foot A nursing progress note by LPN 7, dated 5/21/25 at 5:06 p.m., indicated the dressing to Resident B's left foot was hard to get off and had blisters noted to top of all five toes, sloughing, copious amount of serous drainage, skin peeling, and very painful to touch. The wound NP was notified, and treatment was completed as ordered. A NP progress note completed by NP 2, dated 5/21/25 at 7:46 p.m., included Resident B was seen at the request of nursing for pain to his left foot. The patient seen for a follow-up visit concerning their left foot pain, which presented with new symptoms during recent care. The patient has a significant history of diabetes and frequent cellulitis episodes, necessitating careful management of skin integrity and related complications. The patient reports new onset pain in the affected area (Left foot). The patient describes the pain as moderate but constant, located specifically to the left foot where he has a previous blister .The treatment plan includes continued monitoring and education, with an emphasis on prompt notification of any acute changes, underscoring the need for vigilance given the patient's predisposition to complications due to his underlying conditions. Nursing staff have been briefed on these updates and are prepared to report any further developments promptly .Derm: Dressing intact to left foot A nursing progress note completed by RN 3, dated 5/21/25 at 10:03 p.m., indicated the resident had complained of excruciating pain to his left foot. The resident indicated his foot was submerged in hot water prior to the scheduled treatment on 5/19/25. RN 3 had changed the dressing and indicated the foot appears to be a 3rd degree burn, yellow slough, red, draining & toes matted. RN 3 contacted 911 and the resident was taken to an acute care burn unit for further evaluation and treatment. During an interview on 6/2/25 at 11:33 a.m., the DON indicated there was no order as part of Resident B's wound care to soak his foot. LPN 4 wanted to make sure the area was clean prior to completing the ordered treatment to the diabetic ulcer on the bottom of his left foot. She should not have soaked his foot as this was not part of his wound care treatment orders. During an interview on 6/2/25 at 11:46 a.m., LPN 4 indicated she was preparing to complete Resident B's wound care orders, and she wanted to complete foot care prior to his left foot treatment. As she was running the water into the basin for the resident to soak his foot, she ran her hand under the running water, and it felt warm. She finished filling the basin. She had not checked the temperature of the water in the basin after it was filled. She instructed the resident to put his left foot in the water. Resident B placed his foot in the water and indicated the water was hot and removed his foot. She indicated to him that she had just checked the water and told him to hang on and she would go get his wound care supplies. She was gone for about five minutes and when she returned to his room his foot was in the basin. She noticed his skin had developed a small lemon sized blister on the top of his foot. She had not intended for the resident to put his foot in the basin when she left the room. He indicated to her his foot hurt and she administered an as needed dose of pain medication. She informed NP2 and the unit manager and both came to the resident's room. During an interview on 6/2/25 at 12:07 p.m., Resident B indicated his left foot was burned when LPN 4 was providing wound care. He indicated the nurse brought over a basin of water for him to soak his foot in prior to applying a treatment to the sore on the bottom of his left foot. When he put his foot into the water, he felt like it was too hot, and he pulled his foot out. The nurse told him she had felt the water, and it was not too hot, but to hold on and she would go get some supplies. She had been out of the room for a couple of minutes when she passed by his door and told him to go ahead and try again. She had not checked the water temperature. He put his foot into the water, it felt hot but tolerable. When she returned about five minutes later, she was surprised to see a blister on the top of his foot. His feet were numb a lot because of his diabetes, and he had not realized the water was still hot. During an interview on 6/2/25 at 12:40 p.m., NP 2 indicated she had been called to Resident B's room on 5/19/25. She had not noticed a blister, but the resident's left foot was sorta red with a small open area. She had visualized the resident's foot following the incident, but had not had staff remove the resident's dressing during her follow up visit on 5/21/25 due to increased pain. The physician was completing rounds the following day (5/22/25), and she wanted the physician to look at the left foot at that time. During a telephone interview on 6/2/25 at 2:41 p.m., RN 3 indicated Resident B had been in so much pain and his wound looked bad on 5/21/25. He had not been in a lot of pain the night before. When she had completed his wound treatment on 5/21/25, she had been unaware the resident had sustained a burn to his left foot. She had prepared to complete his treatment for his diabetic ulcer to the bottom of his left foot. The resident had a hard time tolerating the treatment. She had called the DON and received approval to send him to the emergency room for treatment. A Burn Service Team History and Physical Note, dated 5/22/25, from the acute burn unit provider, indicated the resident had presented with scald burns to his left foot, sustained three days ago. The Assessment/Plan indicated the patient had a three day old full thickness scald burn to the left foot. An Inpatient Discharge summary, dated [DATE], from the acute burn care provider, indicated the resident had two surgical procedures on 5/22/25 and 5/27/25 for debridement of left foot and skin graft application. A current facility policy, dated 8/2024, titled, Change in a Resident's Condition or Status, provided by the Corporate Nurse on 6/3/25 at 12:06 p.m., included the following: .Policy Interpretation and Implementation .8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. The deficient practice was corrected by 5/23/25 after the facility implemented a systemic plan that included the following actions: water temperature adjustments and monitoring, resident interviews, staff interviews, resident skin assessments, education of staff, and continued monitoring. Cross reference F684. This citation relates to Complaint IN00460578. 3.1-45(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident received treatment that was in accordance with professional standards of practice when they failed to assess, document, provide timely diagnostic testing after a fall with severe injury, withhold blood thinning medication, and update the care plan with individualized interventions, for 1 of 2 residents reviewed for falls with severe injury (Resident B). Findings include, On 1/3/23 at 2:33 p.m., Resident B's responsible party indicated, on 12/25/22, she came to take the resident home for the holiday and found the resident to have a black and blue eye and a white bandage beside her right eye. Staff told her Resident B had fallen the night before, but staff had not contacted her about the fall, and she had doubts about the date and time of the fall due to the extent of the injury. The Responsible Party called the Executive Director (ED) at home and demanded details of the fall and why staff had not contacted her. The ED indicated she was unaware of the fall but would contact the facility immediately. Resident B told her staff would not answer her call light, and she fell out of bed while attempting to self-transfer hitting her head and side on an oxygen concentrator. Complainant did not know at that time but later found out the resident had a large and to her disturbing bruise on her right side. To her knowledge the physician was not immediately notified of the fall or injuries, and there were no immediate orders for x-rays or a CT scan to rule out a concussion or broken ribs until after the holidays. The resident did not have a CT scan scheduled until 1/5/23 almost 2 weeks after her fall. A Report of Concern/Grievance Log, dated 12/26/22, indicated documentation Resident B's daughter was concerned the resident's call light was not being answered or not being answered timely. On 1/3/23 at 3:40 p.m., Resident B was observed sitting in a wheelchair at bedside receiving oxygen per nasal cannula from a soft sided pack on the back of the wheelchair. An oxygen concentrator was sitting near the top of the bed turned off. The resident was alert, talkative and soft spoken. A bandaid was positioned vertically beside the right eye, dark discoloration and edema was observed around the top and bottom of the right eye. Resident B indicated she had attempted to get up alone and fell hitting the oxygen concentrator. They don't pay any attention to me. They don't answer my call light when I call. When asked if she had any other injury, pointed down to the right side of her torso and indicated, somewhere down there. During an observation of Resident B with the Regional [NAME] President of Nursing Services, on 1/4/23 at 2:45 p.m., resident was sitting in her wheelchair near the nurse's desk with her coat on preparing to leave for an outside nephrology appointment unrelated to her fall and injuries. The Regional VP of Nursing Services observed a bandaid on right side of resident's face near the eye extending across and stuck to the eyebrow, and with permission from the resident removed the bandaid revealing a half inch horizonal scab at the outer end of the eyebrow. When questioned by the Regional VP of Nursing Services, Resident B indicated she had fallen due to waiting on staff to answer her call light and they kept walking by and ignoring her, so she attempted to self-transfer and fell. She got a black eye and hurt her side, and staff immediately put a bandaid on her eye so her daughter would not get mad. She had blurred right eye vision since the fall. When the Regional VP of Nursing Services asked Resident B if it would be okay with her to move up the CT scan by a day, Resident B got visibly upset and indicated what made her mad was nobody did anything when she fell and now they were asking to treat her. Resident B's record was reviewed on 1/4/23 at 10:54 a.m. Diagnoses on Resident B's profile included, but were not limited to, end stage renal disease, vascular dementia moderate with agitation and anxiety, restlessness and agitation, repeated falls, and dependence on supplemental oxygen. A quarterly Minimum Data Set (MDS) assessment, completed on 10/26/22, assessed Resident B as having the ability to make herself understood and to understand others. A Brief Interview for Mental Status (BIMS) score of 9 indicated moderately impaired cognition. Extensive assistance of one person physical assist for bed mobility, transfers, dressing, and eating. No physical help from staff for walking in room. Limited assistance of one person physical assist for locomotion on or off the unit, and personal hygiene. Supervision of one person physical assist for toilet use. 1 fall since admission/readmission or prior assessment with no injury. A care plan for Resident B dated 3/29/22 indicated, the resident was at risk for falls/injury due to a history of falls, impaired cognition/safety awareness, incontinence, and weakness/disability. The goal was for the resident to not sustain serious injuries. Interventions included dycem to the wheelchair, maintenance to elevate refrigerator to safer height to prevent resident from bending over, re-educate resident to use call light and request assistance for transfers, anticipate and meet the resident needs, call light within reach, keep personal items in reach, anti-rollbacks to wheelchair, and non-skid/gripper socks. 12/28/22 revision: PT/OT/ST to evaluate and treat. A care plan for Resident B dated 10/20/22 indicated, resident is on anticoagulant therapy related to blood clot prevention. The goal was for the resident to be free from discomfort or adverse reactions related to anticoagulant use. Interventions included administer anticoagulant medications as ordered by physician and monitor for side effects and effectiveness every shift. Daily skin inspection and report abnormalities to the nurse. Labs as ordered and report abnormal labs to the physician. Monitor/document/report adverse reactions of anticoagulant therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden change in mental status, significant or sudden changes in vital signs. A Physician's order, dated 5/10/22, indicated oxygen at 2 liters (L) via nasal cannula, resident may remove at times. A Physician's order, dated 5/10/22, indicated Clopidogrel Bisulfate Tablet (Plavix a blood thinner) 75 milligrams (MG) give 1 tablet by mouth one time a day for blood clot. A Physician's order, dated 12/27/22 at 9:51 a.m., indicated obtain facial/skull x-ray. A physician's script, dated 12/29/22, indicated no contrast CT of the head, recent fall, hit head, patient on Plavix. Radiology Report Results, dated 12/28/22 at 9:30 a.m., indicated no acute findings considering the inherent limitations of skull radiology. If there was persistent clinical concern, consider CT. The resident record lacked documentation staff timely alerted the physician to Plavix use after the resident fell on [DATE] and developed extensive facial and torso bruising, or held the medication related to the extensive bruising or potential for internal bleeding. Pictures of Resident B, dated 12/25/22, indicated varying shades of purple and black discoloration and swelling to the right eye and eyebrow extending from top of the eyebrow, around the entire eye, down past the right cheekbone, and towards the right ear, white gauze taped on the right side of the face near the eye and over part of the eyebrow. Varying shades of dark to lighter purple bruising on the right side/flank area extending from bottom of the bra line down past the waistline, on the back and around towards the front of the torso. A skin assessment, dated 1/24/22, indicated some new discoloration or impaired skin integrity. Face small bruising on side of head. A fall risk assessment, dated 12/24/2022, indicated low risk for falls. Alert and oriented, 1-2 falls in the past 3 months. Ambulatory, continent, and gait normal. The resident record lacked documentation to describe the extent of Resident B's injures, treatment of the injuries, on-going monitoring of the injuries, or resident tolerance of injuries. Additional pain medication was documented in December as administered 1 time on 12/26/22. A Nurse's Note, dated 12/24/22 at 7:34 a.m., indicated Resident B had an unwitnessed fall. The nurse found the resident on the floor in room during hourly rounding, resident stated I was trying to get my robe. Full head to toe assessment done, resident had small bruising to head. Called family but no answer. Resident educated on the importance of the use of call light for anything. A Nurse's Note, dated 12/24/22 at 8:15 a.m., indicated no injures noted. A Nurse's Note, dated 12/26/22 at 12:01 a.m., indicated noticed right side of patients face and black eye bruised from recent fall. A Nurse's Note, dated 12/26/22 at 8:51 a.m., indicated observed pinpoint laceration to eyebrow and bruising to right eye and to right side. MD aware and was to put in a new order for X-ray, will notify family. A Nurse Practitioner's Note, dated 12/26/22 at 11:36 a.m., indicated resident seen today for follow up to a fall with injury. Resident complaint of right eye being sore. Resident reports she fell over the oxygen tank in her room trying to go to the bathroom. Resident reports hitting her head on the oxygen tank and hitting her side. Will order a stat chest X ray. Bruise around the right eye and right flank. An Interdisciplinary Note, dated 12/27/2022 at 10:41 a.m., indicated review of fall on 12/24/22. Patient reported fall while attempting to dress self, sustaining minor injuries. Nursing staff provided care for the resident upon notification and notified provider, family, and updated plan of care accordingly. Occupational Therapy/Physical Therapy/Speech Therapy (OT/PT/ST) will screen patient for any deficits and treat accordingly as intervention. A Psychotherapy Note, dated 12/27/22 at 3:55 p.m., indicated resident presented as fatigued, tearful, and depressed. She had a black eye and cut above her eye, which she reported that she fell and hit her oxygen tank. Speech rate slow and less talkative than usual. A Nurse Practitioner progress note, dated 12/28/22 at 11:58 a.m., indicated resident seen today for follow up to diagnostics. Resident denies any pain to the right eye, reports that the right eye was sore. Resident reported that her right flank continued to be sore, no fracture noted, bruise remains. On 12/28/22 a chest x-ray conclusion indicated modest cardiomegaly with mild congestive heart failure worse than 9/19/2022, fluid noted in minor fissure. Plan: repeated falls, continue to monitor. A Nurse's Note, dated 12/29/22 at 8:30 a.m., indicated small laceration remains to right brow area and bruising remains to right eye and right side. Discomfort noted with some movement but normal for baseline. A note on a calendar at nurse's desk indicated 1/6/23 at 10:10 a.m., Resident B had an appointment at a nearby radiology center for a CT scan of the head due to complaint of a fall. A Risk Management Report, dated 12/24/22 at 4:30 a.m., indicated Resident B was found on the floor by nurse during hourly rounding. Resident stated she was trying to go get her robe. Head to toe assessment completed. Resident educated on importance of using the call light whenever she needed anything. Bruise and laceration to face, bruise to right trochanter (hip). Resident alert and oriented to person, place, and time. Injury observed post fall. Notes: pinpoint 2 centimeter (cm) x 2 cm laceration right eyebrow. 5.5 cm x 8 cm dark purple bruising around eye. 7 cm x 9 cm dark purple bruising to right side. Director of Nursing (DON) notified 12/24/22 at 4:45 a.m., on-call MD notified 12/24/22 at 7:30 a.m. A radiology electronic ordering system report indicated, on 12/26/22 at 8:49 a.m., the DON ordered skull x-rays, and on 12/26/22 at 11:40 a.m. ordered chest x-rays. Reason for portability: patient weak/non-ambulatory (altered mental status/behavior issues). MRI results for Resident B, dated 1/4/23, indicated, there were compression fractures at thoracic (T)11, lumbar (L)3, L4, L5, age of these compression fractures was indeterminate. During an interview on 1/4/23 at 9:54 a.m., Qualified Medication Aide (QMA) 7 indicated, Resident B had skin discoloration due to a fall about a week ago. The resident required assistance for transfers, would put on her call light most of the time, but would get up alone. During an interview on 1/4/23 at 9:57 a.m., Registered Nurse (RN) 5 indicated, Resident B was fairly proficient in transfers, needed assist with dressing due to limited range of motion in her shoulders, and was one of the few that would use the bathroom call light. During an interview on 1/4/23 at 10:26 a.m., Certified Nursing Assistant (CNA) 6 indicated, he could not say when Resident B fell, he worked Christmas Eve and when he came back, she had bruises. The resident had told him she was reaching for a robe on her chair and fell out of bed. During an interview on 1/5/23 at 10:08 a.m., Licensed Practical Nurse (LPN) 18 indicated, on 12/24/22 when she arrived to work at 7:00 a.m., she was informed Resident B had fallen around 4:00 a.m. When the resident was assessed and left the facility that morning for dialysis, the resident had no injury to her face or dressing to her eye. When LPN 18 returned to work on 12/26/22 Resident B was observed to have extensive dark purple bruising on her right eyebrow with edema and bruising around the eye. LPN 18 asked the NP to exam the resident. LPN 18 indicated, there was no documentation of the resident's condition in the medical record on 12/25/22. Indicated, she could not answer if Resident B had another fall between 12/24 and 12/26 but knew there had been no injury found on 12/24/22. LPN 18 indicated, Resident B's right eye looked to have dark deep purple bruising in a circle approximately 1-2 inches around the entire eye, with edema. The right eyebrow was raised and sticking out due to edema with a white dressing. A pinpoint open area on outer right brow area, all swollen. During the eye exam Resident B was grimacing, moaning, and guarding her right side as she was being moved around, and her right side was found to have dark deep purple bruising raised with edema from under her right arm extending to torso and around her back, down towards her waistline. Measurements at the time for her right eye started above brow down to cheek bone then over toward ear. Her right side/rib area darker bruising approx. 8 in diameter x 3 length, and purple bruising fading around it. The NP was supposed to put in orders for skull and chest x-rays. During an interview on 1/6/23 at 12:33 p.m., CNA 14 indicated, she had worked on 12/23 and 12/24 7:00 a.m. - 7:00 p.m. and Resident B was not injured. When she arrived at work on 12/25/22 at 7:00 a.m., the resident was observed to have injuries on her face. On 1/5/23 at 1:01 p.m., the Executive Director (ED) provided a Fall Program Guidelines, dated 12/2022, and indicated the policy was the one currently being used by the facility. The policy indicated, To screen all residents to identify possible risk factors that could place a resident at risk for falls, evaluate those risks, implement interventions to reduce the risk and monitor the interventions for effectiveness .1. The resident will be assessed for fall risk upon admission and quarterly. 2. Interventions will be implemented if resident is determined to be at risk. 3. Should a fall occur, the nurse shall complete an assessment of the resident and circumstances surrounding the fall incident. The interdisciplinary team [IDT] should determine root cause and evaluate to ensure appropriate interventions are implemented. 4. The attending physician or medical director in the absence of the attending physician and the responsible party should be notified. 5. The resident care plan should be revised to reflect any new or change in interventions. 6. Effectiveness of interventions will be monitored through the Clinically At-Risk program . On 1/5/23 at 1:01 p.m., the ED provided a Call Lights policy and indicated the policy was the one currently being used by the facility. The policy indicated, Purpose: To respond to resident's requests and needs in a timely manner .All staff should assist in answering call lights. Nursing staff members shall go to resident's room to respond to call system and promptly cancel the call light when the room is entered . This Federal tag relates to Complaint IN00393356. 3.1-37(a) 3.1-37(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow professional standards of practice to prevent potential for accidents while using a mechanical lift, resulting in a fall with fracture, delay of diagnosis of a fracture despite resident continued complaints of severe pain, and ensuring individualized care plan interventions were implemented for 1 of 3 residents reviewed for accidents (Resident G). Findings include: An Indiana State Department of Health Survey Report System report, dated 11/16/22 at 5:01 p.m., indicated Resident G had a change in condition/shortness of breath so was transferred to the emergency room where they found a fracture of the distal femoral metadiaphysis (end of the bone near the growth plate, commonly caused by a fall from a height). On 1/5/23 at 10:30 a.m., Resident G indicated, on 11/3/22 around 7:00 p.m., Certified Nursing Assistants (CNA) 8 and 9 had come into her room with the Hoyer (a mechanical lift) to transfer her from the bed to a shower chair. She was placed on a lift pad, the pad hooked to the lift, and as they swung her around in front of the TV, she suddenly fell from the lift pad and landed on the metal feet of the Hoyer lift and bounced onto the floor. Resident G indicated, she was approximately 4 - 5 feet in the air at the time of the fall as her bed was in high position when they lifted her off it, and it happened so fast she only started to yell out when she hit the floor. It was her opinion the aides did not check the Hoyer pad to make sure it was in good working order before transferring her, and upon inspection the broken strap was dry rotted, the pad ripped, and it came apart causing the strap to break. Resident G indicated the lift pad should never have been in use since it was rotten. Observation of Resident G's Hoyer pad showed it to have frayed and missing binding around the perimeter, the strap material was frayed, and there was one broken strap the resident indicated had caused her fall. Resident G indicated, when she was dropped, she instantly felt pain from her mid upper right arm down through her right leg stump. Initially staff only gave her a mild pain medicine which did nothing for the pain and they ordered an x-ray of her upper body but not her lower body. The resident indicated, she would scream out every time staff touched her for care and refused dialysis due to not being about to stand the pain of being transferred. They let me suffer for 2 weeks, kept telling me nothing was wrong. Resident G indicated, she finally saw the Nurse Practitioner (NP) walking past her door one day and asked to be seen at the hospital, where she was diagnosed with a hairline fracture and kept for several days. The resident indicated, the NP said she was not told the resident had fallen from a Hoyer lift. Resident G indicated, she reported to the hospital staff the nursing home had ignored her complaints that something was wrong. Resident G's record was reviewed on 1/5/23 at 11:01 a.m. Diagnoses on Resident G's profile included, but were not limited to, acquired absence of right and left leg below the knee (amputation), end stage renal disease with dependence on renal dialysis, hemiplegia and hemiparesis (paralysis) following cerebral infarction affecting left non-dominant side, and chronic pain. A Physician's order, dated 11/4/22, indicated Ibuprofen tablet (anti-inflammatory/analgesic) 600 milligrams (mg) give 600 mg by mouth one time only for pain. A Physician's order, dated 11/4/22, indicated Hydrocodone -Acetaminophen (narcotic pain medication) tablet 5-325 mg give 1 tablet by mouth three times a day for 7 days related to pain to right leg. A Physician's order from the hospital, dated 11/15/22, indicated oxycodone HCl (narcotic pain medication) tablet 5 mg give 0.5 tablet by mouth three times a day for pain. A fall assessment for Resident G, dated 11/3/22, indicate the resident was a low risk for falls. She was alert and oriented and required assistive devices with transfers. A Nurse's Note, dated 11/3/22 at 8:29 p.m., indicated Resident G had a witnessed fall. Resident fell while aides were in the process of transferring her from the bed to the shower chair via Hoyer lift. No injury, denied hitting head, complained of right-side pain, took PRN (as needed or requested) Tylenol (analgesic). New X-ray order per the NP for right upper extremities, hip, and pelvis. Director of Nursing (DON) notified. A Nurse's Note, dated 11/4/22 at 6:11 a.m., indicated resident complained of right hip pain due to earlier fall, she refused hospital visit and requested for stronger pain medication than Tylenol. NP gave order for ibuprofen 600 mg one (1) time now then follow up by NP in the morning. An Interdisciplinary (IDT) note, dated 11/4/22 at 9:21 a.m., indicated recent fall on 11/3/22. Resident was being transferred from bed to shower chair and fell. No injuries noted. X-rays ordered. Discussed intervention of staff education on safe transfers. Family/MD notified. Assessments and care plans updated. A late entry NP note, dated 11/4/22 at 12:42 p.m., indicated the resident was seen today for follow up fall without injury, reports fall during transfer from bed to chair. Right lower extremity slightly swollen related to fall. A NP note, dated 11/7/22 at 3: 35 p.m., indicated patient being seen today to follow-up to right hip, arm and knee pain after a fall. Resident receiving Norco (narcotic) 5/325 mg. Resident is having breakthrough pain. Norco will be increased and Tylenol for breakthrough pain. Resident is crying today and stated, I am really hurting, and I need something stronger for the pain. Resident encouraged to move in bed as she is complaining on being stiff. Patient will be referred to Physical Therapy (PT). A NP note, dated 11/9/22 at 11:08 a.m., indicated resident seen today for follow-up to a fall without injury. Right lower extremity swelling resolving. Assessment/Plan for pain, Biofreeze (topical pain relief) to right hip, knee and arm. A Nurse's Note, dated 11/10/22 at 1:03 p.m., indicated slight edema to face and arm. Refused blood pressure and has been refusing dialysis. A Nurse's Note, dated 11/16/22 at 8:08 a.m., indicated resident seen today for follow-up to hospitalization. Patient discharge diagnosis was fluid overload and a commuted fracture involving the distal femoral metadiaphysis. Refer to Ortho within 1 to 2 weeks. Oxycodone (narcotic pain medication) discussed with nursing. The resident record lacks documentation of the resident being sent to the hospital on [DATE] or reason for the transfer. A hospital History and Physical, dated 11/14/22, indicated resident resented to the emergency department with over one (1) week of right and hip pain, being admitted for hyperkalemia and a right distal femur fracture. Right hip/leg pain due to a distal femur fracture. Complaining that current pain regimen ineffective. Orthopedic surgery was consulted and recommended posterior splint and clinic follow up. Patient will need outpatient with follow up and supportive care for pain control and bowel regimen. Pain control with scheduled low dose Percocet (narcotic) 2.5 mg three times daily (TID) and PRN, oxycodone 5-325 mg for breakthrough pain. Hospital In-Patent Discharge Summary indicated, in house 1-11-22 - 11/15/22, diagnosis fracture of distal end of right femur. A hospital instructions for care x-ray report, dated 11/11/22 at 10:40 a.m., indicated fell out of Hoyer lift 9 days ago, via emergency medical service (EMS) from facility, was dropped out of Hoyer lift last week. X-rays done by facility last week were unremarkable. Bilateral below the knee (BTK) amputee. On 1/6/23 at 10:45 a.m., the ED provided documentation of education she indicated was presented to the nursing staff due to prior citation related to Hoyer use to include, a. On 1/20/22 mechanical lift education. The policy was presented and verbal direction on use. CNA 9 signed as having received the education. b. On 5/9/22 mechanical lift education. Use of the Hoyer lift was presented. CNA's 8 and 9 signed as having received the education. A quarterly Minimum Data Set (MDS) assessment completed 10/21/22, assessed Resident G as having the ability to make herself understood and to understand others. A Brief Interview for Mental Status (BIMS) score of 15/15 indicated cognitively intact. Extensive assistance of 2+ persons physical assistance for bed mobility. Total dependence of 2+ persons physical assist for transfers. Mobility devices included a wheelchair. No history of falls. A care plan for Resident G indicated the resident had an assistance with daily living (ADL) deficit related to diabetes mellitus, osteoarthritis, and hemiplegia or hemiparesis of the left side. The goal was for the resident to remain clean and well groomed. Interventions included, but were not limited to, the resident required a mechanical lift with 2 staff assistance for transfers. A care plan for Resident G, dated 10/21/22, indicated the resident was at risk for falls/injury due to bilateral amputee, diabetes mellitus, and hemiplegia or hemiparesis of the left side. The goal was for the resident to be free from falls. Interventions included, anticipate and meet the resident's needs, call light within reach, and ensure pathways were free of clutter. Revision dated 11/4/22 staff education provided related to safe transfer techniques. Resident record lacked documentation the care plan was updated with individualized interventions to include, but not limited to, use of a right leg splint. During an interview on 1/4/23 at 10:05 a.m., Qualified Medication Aide (QMA) 7 indicated, staff would go in every morning at 7:00 a.m. to set the resident up for am care, she required ADL assistance for bathing, dressing, and transfers due to being a double amputee. During an interview on 1/5/22 at 12:02 p.m., the DON and Regional VP of Nursing Services indicted, Resident G had fell during a transfer with staff and a Hoyer (mechanical lift).The Regional VP of Nursing Services indicated, during her investigation the resident had told them she fell from the Hoyer due to a frayed Hoyer pad but would not give staff the pad or show it to them. On-going staff education on Hoyer lift use was presented on 11/5/22 to include how to use the lift, only keeping the Hoyer pads for one (1) year and dating the pad when they were put out for use. Indicated, the housekeeping/laundry supervisor was responsible for the monitoring and replacing of Hoyer pads. During an interview on 1/5/23 at 12:18 p.m., the housekeeping/laundry supervisor indicated, she ordered Hoyer pads when told to by the DON or when the pads were outdated. When new Hoyer pads were received they were initially kept in her office, where she dated them before they went to the floor for resident use. Laundry staff checked the dates on the pads when laundering, and at 12 months threw them away. She was hired in February 2022, from that date she knew she dated new Hoyer pads and the 2 or 3 that had been in the laundry room, she was not sure about the pads that were already in use on the floor. Indicated she could guess the number of Hoyer pads in use on the wings, but there was no system currently in place to track the Hoyer pads. Ultimately laundry and nursing were responsible for the residents having usable, safe Hoyer pads. During an interview on 1/5/23 at 12:25 p.m., CNA 8 indicated, she had worked in the facility for a year. On 11/3/22 she and CNA 9 had gone to give Resident G a shower. They placed a Hoyer pad under the resident, hooked her up to the mechanical lift, and when they went the lift without warning the pad broke and the resident fell hitting the metal feet of the lift. At the time of the fall the resident was about four (4) feet off the floor. Observation of the Hoyer pad indicated it had a broken strap. CNA 8 indicated, she did not remember paying an attention to the condition of the Hoyer pad prior to the fall. As for prior education on mechanical lift transfers, she had been told to always use 2 persons for transfers per Hoyer but thought the actual training for Hoyer use and examining pads started after the fall on 11/3/22 during an in-service. When Resident G fell, she complained of her legs/hips being sore, but she did not want to go out to the doctor. It was the responsibility of laundry to make sure Hoyer pads were inspected and someone went in there and got rid of those that were not safe. During an interview on 1/5/23 at 2:30 p.m., the Executive Director (ED) indicated, her understanding was that Resident G fell from the Hoyer pad onto the bed, so she had not questioned staff regarding the incident. The housekeeping supervisor was responsible for ordering and monitoring Hoyer pads and replacing them. The ED indicated she had followed up with the resident the day after the fall due to being told it involved a fall from a Hoyer, but she was not told the resident fell to the floor. Resident G had not shown or given the ED the Hoyer pad that supposedly broke. The ED indicated, she was not sure how long Hoyer pads were to be kept, but she approved to replace them anytime needed. On 11/5/22 the ED presented a staff in-service regarding customer service and phone use, and the DON added Hoyer use to the in-service. The DON told her she had spoken to the aides, but she was not sure which ones. Checking the Hoyer pad should be the first thing the aides did before using the mechanical lift, safety should always come first. It was the responsibility of the CNA's using the Hoyer lifts to report when the lift pads were ripped or no longer safe. During an interview on 1/6/23 at 12:07 p.m., the DON indicated on 11/3/22 a nurse (she did not remember the name) called and reported Resident G had fallen from a Hoyer lift due to a problem with the sling (Hoyer pad). CNA 8 had told her the sling broke. Resident G indicated the staff turned her when up in the lift going towards the shower chair and the sling broke. On 11/4/22 she and Resident G spoke with the Regional VP of Nursing Services on the phone, and the resident told them the same story about the sling breaking and how she fell on the floor. The resident would not show the sling to the staff. Upon inspection of the Hoyer slings currently in use on the floor some had been dated and some not. Nurse documentation of a fall was to be entered in the electronic medical record to include in a risk management form, fall assessment, and Skin assessment. Once the risk management form was done, the IDT notes were made and populates into the progress notes for others to see. The MDS nurse was responsible for updates to the care plan. During an interview on 1/6/23 at 12:12 p.m., the ED indicated, the details of Resident G's fall from a Hoyer lift had not been put on the state reportable incident as she was not aware she had to put all detail on the report. Reportable incidents were sent to corporate for approval before being sent. On 1/5/23 at 1:01 p.m., the ED provided a Fall Program Guidelines, dated 12/2022, and indicated the policy was the one currently being used by the facility. The policy indicated, To screen all residents to identify possible risk factors that could place a resident at risk for falls, evaluate those risks, implement interventions to reduce the risk and monitor the interventions for effectiveness .1. The resident will be assessed for fall risk upon admission and quarterly. 2. Interventions will be implemented if resident is determined to be at risk. 3. Should a fall occur, the nurse shall complete an assessment of the resident and circumstances surrounding the fall incident. The interdisciplinary team [IDT] should determine root cause and evaluate to ensure appropriate interventions are implemented. 4. The attending physician or medical director in the absence of the attending physician and the responsible party should be notified. 5. The resident care plan should be revised to reflect any new or change in interventions. 6. Effectiveness of interventions will be monitored through the Clinically At-Risk program . On 1/6/22 at 11:30 a.m., ED provided Invacare Patient Sling Owner's Manual, revised 7/99, and indicated this was the Hoyer manual currently being used in the facility. The manual indicated, warning: after each laundering, inspect sling(s) for wear, tears, and loose stitching. Warranty 1 year. Dawn Regional indicated to her this meant to replace after one year. On 1/6/23 at 11:55 p.m., the ED provided a Mechanical Lift Policy, dated 8/2022, and indicated it was the policy currently being used by the facility. The policy indicated, A mechanical lift is to be utilized for residents who are too heavy to be moved by one person, or who are disabled to the point of inability to assist with transfers. Two [2] personnel members must be present when a mechanical lift is utilized .1. Inspect the mechanical lift before each use . The policy lacked documentation for mechanical lift sling monitoring and maintenance. This Federal tag relates to Complaint IN00393356. 3.1-45(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. A record review was completed for Resident 81 on 9/20/22 at 9:41 a.m. She had the diagnoses including, but not limited to chronic obstructive pulmonary disease, atrial fibrillation, acute kidney failure, type 2 diabetes mellitus, congestive heart failure, and edema. A Nurse Practitioner progress note, dated 9/2/22 at 12:32 p.m., indicated a blood pressure of 99/58. It indicated that Resident 81 had pitting edema in her lower extremities and hands. Torsemide (diuretic) was increased on 8/29/22. A nursing progress note, dated 9/3/22 at 10:13 a.m., indicated that the resident refused to be weighed indicating that she did not feel good and did not want to be rolled (turned) yet. A nursing progress note, dated 9/3/33 at 2:33 p.m., indicated that Resident 81 refused torsemide indicating that the side effects, unusual dry mouth/thirst of torsemide and uncontrollable hand movement making it hard for her to eat. A nursing progress note, dated 9/4/22 at 1:36 p.m., indicated that the resident refused torsemide (a diuretic) indicating that she thought that the medication made her shake. There was no documentation to indicate that the physician was notified. A nursing progress note, dated 9/4/22 at 4:21 p.m., indicated that Resident 81 had a blood pressure of 129/84. A nursing progress note, dated 9/6/22 at 6:17 p.m., indicated a blood pressure reading of 109/57 and that resident was on daily diuretics but had to receive 80mg of Lasix intramuscular due to increased swelling. She was noted to be anxious with no shortness of breath and oxygen saturation of 96% on room air. It indicated that her blood pressure was slightly low the day prior and her metoprolol (a medication used to treat high blood pressure) was held as a result. She had labs ordered for later in the day, BMP (basic metabolic profile), CBC (complete blood count) and BNP (b-natriuretic profile) to evaluate volume status. Resident 81 was sent to the local hospital on 9/7/22 for unstable vital signs, weakness, dilated pupil, and difficulty speaking. There were no vital signs documented at time of transfer. Resident 81 was admitted to the hospital with hypotension (low blood pressure) and altered mental status. The VP of Clinical Services was interviewed on 9/20/22 at 12:49 p.m. She indicated that a discharge/transfer summary was not completed upon transfer of Resident 81 to the hospital to communicate Resident 81's pertinent information and assessment of her condition. A policy titled, Discharge/Transfer/Death with a date of 8/2022, was provided by the Administrator on 9/21/22 at 1:06 p.m., it indicated, .A copy of the following will be provided to the resident and receiving facility and a copy will be filed in the resident's medical records: a. An evaluation of the resident's discharge needs, b. The post-discharge plan, c. The discharge summary . 3.1-12(a)(4) 3.1-12(a)(6)(A) A. Based on observation, interview, and record review, the facility failed to ensure a resident admitted to the behavior unit with diagnoses of Alzheimer's disease, psychotic disorder with delusions, and schizoaffective disorder was not threatened to be discharged due to behaviors without documentation of failed interventions which resulted in psychosocial harm when Resident D was discharged from the facility to a homeless shelter due to not controlling his behaviors for 1 of 3 residents reviewed for discharge (Resident D). B. Based on observation, interview, and record review, the facility failed to communicate pertinent information, COVID status, and an assessment of a resident's condition to a receiving hospital for a change in condition for 1 of 3 residents reviewed for transfer and discharge (Resident 81). Findings include: A. During an interview, on 9/20/22 at 10:11 a.m., Resident D indicated the Social Services Director (SSD) did not like him. He came in from outside and the SSD indicated to him he needed to go to the local homeless shelter for no reason. He indicated he was given documents that were a 30 day notice and a right to appeal. He provided the documents to review. Resident D began shaking badly and indicated this conversation was upsetting to him. He said he received the papers but did not understand what the notice of discharge or request for a hearing meant. On the day of his discharge, he was in his room at the facility and the SSD indicated it was time to go. He had just been laying down. He indicated he was sent to the local homeless shelter and the staff at local homeless shelter indicated the facility had no right to send him there. He indicated the SSD used to say that she would send him to the local homeless shelter as a threat to get him to go the psych hospital. On the local homeless shelter day, he was mad and he faced the wall. The police came and got him to go to the front door. The police said if he didn't go to the local homeless shelter then he would go to jail in the police car. He had 3 or 4 big bags of clothes and medications. He indicated he did not know how to take medications or when. The people at local homeless shelter told him they do not dispense medications. He did not take any medications during his stay at local homeless shelter because he didn't know how to take it. The local homeless shelter staff called the facility and put all his stuff in a van and brought him back to the nursing facility. One resident at local homeless shelter tried to start something with him, he just turned and walked away. His medication remained locked in his locked locker the whole time he was at Local homeless shelter. Resident D indicated with his occasional severe shaking he was unable to read. He indicated he did not try to read the medication packaging. He did not know how to take the medication, he did not know what kind of medications he takes now, so he left them alone. He indicated sometimes he thought about killing people. He had never killed anyone or tried to kill anyone. He only thought about killing his brother and sister because they took his money and threw him out. He indicated he was mad at the SSD but had not thought about killing her. Sometimes he felt like fighting, but not fighting to kill them. During an interview on 9/20/22 at 10:47 a.m., the Administrator (ED) and SSD indicated they were trying to discharge Resident D from the facility because of his behaviors. The psych physician indicated he had a personality disorder, not behaviors. His behaviors were at a very high level compared to the other residents. The facility was trying to care for his needs. They were able to care for his needs. But this was a personality disorder. He did not need to be around other people. On 9/15/22 at 11:50 a.m., Resident D's record was reviewed. Resident D was admitted on [DATE]. His diagnoses included, but were not limited to, Parkinson's disease (progressive deterioration of motor function), Alzheimer's disease(progressive mental deterioration), Homicidal Ideations (thinking about, considering, or planning a homicide), Psychotic disorder with delusions (a mental disorder with a disconnection from reality with a belief in altered reality), anxiety disorder (mental health disorder of feelings of worry, or fear that interfere with daily activities), diabetes mellitus (blood sugar disorder), cognitive decline (reduction in cognitive ability such as memory, awareness, judgment and/or mental acuity), and Schizoaffective disorder, bipolar type (includes features of both schizophrenia, affects a person's thinking, sense of self, and perceptions, and a mood disorder such as bipolar disorder which includes mania and depression). He resided on the locked behavior unit. On 9/15/22 at 11:54 a.m., a review of Resident D's care plans was completed. They were created on 5/4/22. The care plans lacked documentation of no revisions after the resident's 2 psychiatric hospital stays, 2/24 to 3/11/22 and 7/20 to 7/29/22, and 5 incidents with other residents. The care plan problems were: 1. Resident D had a diagnosis of homicidal behavior. 2. The resident uses anti-anxiety medication related to anxiety disorder. 3. The resident uses anti-psychotic medications related to schizoaffective disorder, bipolar type. Behavior management, Potential for injury to self or others. 4. Resident D exhibits restlessness, nervousness and/or other anxiety symptoms related to a diagnosis of anxiety. 5. Resident D had impaired cognitive function/impaired thought process related to diagnosis of Alzheimer's and is at risk for decline. 6. Impaired thought processes/altered mental status related to diagnoses of schizoaffective disorder, bipolar type and Psychotic disorder with delusions due to known physiological condition. A care plan, revised on 9/22/22, indicated the problem was Resident D had (Auditory, Visual) hallucinations (perception of something not present), delusional episodes, talking to himself in hallway and in his room, he had a history of threatening behaviors towards others, history of verbal aggression towards others, abusive language, history of throwing items, making statements about females and wanting a girlfriend. He was manipulative towards others, lunging at staff making threats, and making threatening gestures. The goal and interventions had not been updated since the care plan was created on 5/4/22. Resident D's reportable incidents to the Indiana Department of Health for the last 8 months were as follows: a. On 2/17/22, it was reported that Resident D wanted to borrow Resident 16's cell phone. She denied him and he called her a b***h. b. On 5/10/22, it was reported that Resident D made contact with Resident 17. Resident 17 was hallucinating and was sent to the hospital. c. On 5/17/22, it was reported that Resident 83 made racial comments to Resident D, and Resident D made contact with Resident 83. d. On 6/2/22, it was reported that Resident 17 made racial comments to Resident D, and Resident D pushed Resident 17. It was known that Resident 17 was in need of psych services. e. On 6/22/22, it was reported that Resident 83 made contact with Resident D for no reason. f. On 7/16/22, it was reported that Resident D pushed Resident C. Resident C fell and fractured his wrist. On 9/15/22 at 11:50 a.m., Resident D's soft file was provided by the SSD. These were dated paragraphs of information regarding Resident D and his progress to discharge. No times were noted. - On 2/23/22 with no time noted, the Social Services Director (SSD) indicated she had a conversation with the Ombudsman 41. She recommended the SSD to schedule a discharge care plan meeting, issue 30-day notice and allow Resident D to make an appeal within 10 days. She stated if an appeal had not been made within 10 days, then the facility had the right to discharge Resident D to the local homeless shelter. She recommended the SSD set the resident up with an appointment with the local mental health outpatient center. SSD had told the Ombudsman 41 the resident had made sexual comments, verbal and physical aggression towards staff and peers, but was independent with all ADLs, scored high on BIMS (brief interview for mental status) and inquired about discharge to the local homeless shelter. -On 3/9/22 with no time noted, SSD indicated she contacted the office of the Ombudsman but was unable to get through, left a voicemail and emailed Ombudsman 43. The SSD received a phone number for the local homeless shelter. -On 3/9/22 with no time noted, SSD received a call from Ombudsman 42 who stated she was filling in. SSD provided information to Ombudsman 42 on Resident D. She explained safety concerns with the resident returning to the facility. She stated that the facility should decide based on the safety of the patients in the facility but indicated to understand that the psych hospital can call the board of health to file a complaint and there could be repercussions. Ombudsman 42 recommended that SSD try to work with psych hospital to find alternative placement that would agree to accept him, especially all male facility. -On 3/11/22 with no time noted, Resident D scored 13/15 on BIMS. SSD contacted Ombudsman 42 to discuss the facility's right to discharge Resident D to Local homeless shelter due to concerns with him. She stated the facility had the right to discharge him to the Local homeless shelter. SSD informed Ombudsman 42 that Resident D was independent with all ADLs, recommended for medication management, and informed Ombudsman 42 that SSD had already contacted the local mental health outpatient center regarding scheduling an appointment. The SSD had contacted the transportation number that was provided to SSD from the mental health outpatient center. SSD provided information of the discharge location to the transportation provider, and transportation stated they just needed a contact number at the local homeless shelter to inform them of pick-up times for Resident D on appointment days. The transportation provider stated the local mental health outpatient center would contact transportation to schedule transport with date and time, they stated SSD does not need to schedule this with them. -On 3/11/22 with no time noted, a care plan meeting was held with SSD, Assistant Director of Nursing (ADON) and Resident D. SSD discussed recently being readmitted to facility this morning from an inpatient psychiatric (psych) stay. SSD asked Resident D if he recalled the reason for the psych stay, Resident D indicated he got into a fight. SSD agreed and discussed behaviors of becoming very loud with threatening behavior yelling and screaming out. We discussed his ADL (activity of daily living) status of being independent with all ADLS except medication management., discussed his potential 30-day notice to Local homeless shelter due to safety concerns of other residents. Resident D became very agitated and began yelling and screaming at SSD and ADON, stated he's not leaving, and he wanted to stay at the facility. SSD had difficulty speaking to Resident D due to yelling, screaming out. SSD educated Resident D on current verbal behavior and disruption to other peers. Resident continued to yell and scream. SSD attempted to redirect him but was unsuccessful. He screamed at SSD and ADON to leave his room. - On 3/16/22 at 2:53 p.m., the SSD was notified by the DON of Resident D had become agitated with staff regarding the smoking time. He slammed his jacket on the chair in hallway. SSD spoke with Resident D this afternoon regarding his behaviors. He denied having these behaviors. SSD re-educated him on appropriate behaviors. He expressed understanding. No behaviors noted during this visit. - On 3/18/22 at 12:54 p.m., a Social Services (SS) note indicated Resident D was visited by Psych therapist on this day with no concerns regarding behavior, psychosocial well-being, or mood. The Social Service Director (SSD) also visited with Resident D who was pleasant. No signs or symptoms of psychosocial well-being, mood concerns, or behaviors noted. - On 3/21/22 with no time noted, the SSD was notified Resident D was upset with a female peer and told her she cannot have another boyfriend. SSD and ADON spoke with him. He admitted to having this behavior and state he was jealous. SSD educated Resident D of previous conversation of him having behaviors and the potential for a 30-day discharge. He expressed understanding that this behavior could cost him a 30-day notice. He asked for a second chance. SSD stated she would speak with the Administrator. They would speak to him again next week. - On 3/23/22 at 1:33 p.m., an SSD note indicated the SSD visited with Resident D who was in good spirits. He showed no behaviors, no signs or symptoms of psychosocial well-being or mood concerns. - On 3/24/2022 at 2:34 p.m., an SSD note indicated the SSD and ADON visited with Resident D. SSD discussed threatening behaviors towards staff with yelling and screaming out, his impulsive outbursts, and safety concerns. Resident D was educated on 30 Day Discharge Notice that was issued to him on this day. He was educated on the right to file an appeal, and provided details on how to do so, and educated Resident D that he would discharge to the local homeless shelter. Educated Resident D on being followed by the local mental health outpatient center for medication management after his discharge. Resident D became agitated and began to raise his voice, he continued to ask for another chance. SSD educated Resident D again on his behaviors. Writer emailed a 30-Day Notice to Discharge Resident D to the Ombudsman. -On 4/8/22 at 10:46 a.m., a nursing note indicated the Assistant Director of Nursing (ADON), currently the Interim DON, indicated Resident D scored at a high risk on an elopement assessment due to being independently mobile and having dementia. -On 4/22/22 12:21 a.m., the Nurse Practitioner (NP) 40 indicated in a late entry that she had a discharge visit with Resident D. She indicated he was being seen today for discharge planning to the local homeless shelter per the facility. He had a past medical history of psychotic disorder, Alzheimer's disease, Schizoaffective disorder, Parkinson's disease, diabetes mellitus type 2, age-related cognitive decline, anxiety disorder, tremor, muscle weakness, difficulty in walking, and insomnia. He did not appear to be in any acute distress at this time or during this visit. He was resting quietly in a chair. He was oriented to person and place with periods of confusion. He was pleasant and cooperative. Medications were sent with Resident D upon his discharge. - On 4/22/22 at 2:53 p.m., the Discharge Summary indicated the SSD had spoken with Resident D several times throughout this week regarding his upcoming discharge on [DATE]. She informed Resident D of the clinic providing transportation from the facility to their clinic for an initial appointment on 4/22/22, then would be transported to the local homeless shelter. Resident D became agitated throughout these visits and asked on different occasions for another chance. SSD attempted to redirect Resident D by educating him but was unable to due to him yelling at writer. Staff members visited with Resident D on this day regarding his discharge to the local homeless shelter related to the 30-day discharge notice. Resident refused to leave facility. He was yelling and screaming, with threatening behaviors. He told the staff the only way he was leaving was if the cops were called. Non-emergency police were contacted to assist with escorting Resident D to an outpatient clinic's vehicle. The police escorted Resident D outside and into van. He was discharged with medications, contact numbers, and discharge information. - On 4/25/22 at 5:56 p.m., the Staffing Coordinator/Unit Manager indicated Resident D returned to facility at 5:15 p.m. today. Resident returned with medications and his belongings. He was placed in a room on the locked behavior unit. Physician's orders were received to give him his 9:00 a.m. medication now per NP 40. He was alert and oriented times 3. He ambulated on own without an assistive device. His gait was steady. - On 4/25/22 at 6:00 p.m., Resident D's Admission/readmission form indicated he was admitted from the local homeless shelter. He was oriented to person, place, time, and situation. He had a diagnosis of dementia and used 9 or more medication. His cognition was intact. - On 4/26/22 with no time noted, the SSD indicated she spoke with the local homeless Shelter Director. He indicated the shelter sent Resident D back to the facility as no one contacted them to inform them of Resident D being dropped off. - On 5/26/22 SSD was notified of Resident D smacking a Certified Nursing Aide (CNA) on the buttocks. SSD asked Resident D why he did it, educated him on appropriate behaviors and explained this behavior was inappropriate. Resident D apologized. - On 6/1/22 with no time noted, SSD was notified of Resident D becoming agitated and verbally aggressive as he stated he was jealous of the other peers wanting a girlfriend. SSD was able to redirect him with conversation, walking on the unit and offered activities of interest. He appeared in a better mood with no further behaviors noted. - On 7/20/22 with no time noted, the SSD, DON and the Rounding Psych physician and the Rounding Psych NP discussed Resident D and his behaviors. Possible in-patient referral was discussed. The Rounding Psych physician who also works at the local inpatient Psych denied him for inpatient psych stating medications would not help his behaviors. This was his personality and medication would not change or help him. He recommended the facility send Resident D to the local mental health outpatient center emergency room and recommended the facility to not accept him back to the facility. - On 8/4/22 with no time noted, the SSD attempted to contact the local mental health outpatient center to discuss group home placement but was unable to get through and unable to leave a voice message. - On 8/9/22 with no time noted, SSD spoke with Ombudsman 44 and requested recommendations and thoughts regarding placement for Resident D. Ombudsman 44 indicated a place to try who accepted residents with behaviors. - On 9/19/22 at 8:31 a.m., Administrator indicated she received a call from the local homeless shelter, and he indicated they would not accept him. He said you must have our permission; we will not accept him. - On 9/19/22 at 2:32 p.m., the SSD indicated she had provided all transfer documents to Resident D. He did not sign any transfer or discharge documents. - On 9/19/22 at 2:35 p.m., the Administrator indicated Resident D did not have a behavioral contract with the facility. On 9/19/22 at 3:13 p.m., the Activity Director (AD) indicated Activity Aide 36 had a good relationship with Resident D and was able to redirect him. Resident D liked to do crafts, loved newspapers, and activity staff talked to him. She indicated she did not know if the evening/night shift or weekends had special activities for him, but they did know where the activity room key was kept so they could have had access to supplies for his leisure. The facility also bought him cigarettes when he was out. Activity personnel were in the building 7 days a week until 7:00 p.m. On 9/19/22 at 3:14 p.m., the SSD indicated Resident D loved cleaning and organizing things in his room. The staff knew the resident very well. He liked to talk about cars. He liked to compare prices. The AD indicated she would take a computer to him to look at ads. The SSD indicated she was looking into making a binder of activities of interest for him. On 9/20/22 at 10:53 a.m., the SSD indicated the psych physician indicated to the facility to send Resident D to the local mental health outpatient center emergency room and not accept him back. They did not follow these instructions. On 9/20/22 at 11:00 a.m., the SSD provided a list of referred facilities to whom she had applied to send Resident D. Many of these buildings did not have a locked unit. Her documentation indicated she referred him to 37 buildings, 3 of them twice. On 9/20/22 at 11:16 a.m., the SSD indicated the Director of the Local homeless shelter called and talked to SSD and Administrator. He was very upset about Resident D arriving at the homeless shelter. He indicated the facility had to have permission. He called on 4/25/22 and insisted Resident D come back to the facility. On 9/12/22, the Admissions Agreement was provided by the facility. A document within the admission Agreement titled, Indiana Resident Rights and Facility Responsibilities, was reviewed. It indicated, .The resident has the right to be cared for in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality .A copy of the resident's rights must be available in a publicly accessible area. The copy must be at least 12-point type .The transfer and discharge rights of residents of a facility are as follows .before an interfacility transfer or discharge occurs, the facility must .place a copy of the notice in the resident's clinical record and transmit a copy to the following .the local long term care ombudsman program for involuntary relocations or discharges only .the notice of transfer or discharge .must be made by the facility at least thirty (30) days before the resident is transferred or discharged .At the planning conference, the resident's medical, psychosocial, and social needs with respect to the relocation shall be considered and a plan devised to meet these needs .If the relocation plan is disputed, a meeting shall be held prior to the relocation with the administrator or his or her designee, the resident, and the resident's legal representative .The purpose of the meeting shall be to discuss possible alternatives to the proposed relocation plan

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident was oriented and prepared for discharge with no plan with the receiving facility, the resident experienced psychosocial harm for 1 of 3 residents reviewed for discharge (Resident D). Findings include: On [DATE] at 11:50 a.m., Resident D's chart and the soft file from the Social Services Director (SSD) were reviewed. The soft file, was provided by the SSD. These were dated paragraphs of information regarding Resident D and his progress to discharge. No times were noted. Resident D was admitted on [DATE]. His diagnoses included, but were not limited to, Parkinson's disease (progressive deterioration of motor function), Alzheimer's disease(progressive mental deterioration), Homicidal Ideations (thinking about, considering, or planning a homicide), Psychotic disorder with delusions (a mental disorder with a disconnection from reality with a belief in altered reality), anxiety disorder (mental health disorder of feelings of worry, or fear that interfere with daily activities), diabetes mellitus (blood sugar disorder), cognitive decline (reduction in cognitive ability such as memory, awareness, judgment and/or mental acuity), and Schizoaffective disorder, bipolar type (includes features of both schizophrenia, affects a person's thinking, sense of self, and perceptions, and a mood disorder such as bipolar disorder which includes mania and depression). He resided on the locked behavior unit. On [DATE] at 11:54 a.m., a review of Resident D's care plans were completed. They were created on [DATE], with no revisions, even with 2 psych hospital stays, 2/24-[DATE] and 7/20-[DATE], and 5 incidents with other residents. Resident C sustained a fractured wrist after he was pushed by Resident D. The care plan problems were: 1. Resident D had a diagnosis of homicidal behavior. 2. The resident uses anti-anxiety medication related to anxiety disorder. 3. The resident uses anti-psychotic medications related to schizoaffective disorder, bipolar type. Behavior management, Potential for injury to self or others. 4. Resident D exhibits restlessness, nervousness and/or other anxiety symptoms related to a diagnosis of anxiety. 5. Resident D had impaired cognitive function/impaired thought process related to diagnosis of Alzheimer's and is at risk for decline. 6. Impaired thought processes/altered mental status related to diagnoses of schizoaffective disorder, bipolar type and Psychotic disorder with delusions due to known physiological condition. A care plan was revise dated [DATE], it indicated the problem was Resident D had (Auditory, Visual) hallucinations (perception of something not present), delusional episodes, talking to himself in hallway and in his room, he had a history of threatening behaviors towards others, history of verbal aggression towards others, abusive language, history of throwing items, making statements about females and wanting a girlfriend. He was manipulative towards others, lunging at staff making threats, and making threatening gestures. The goal and interventions had not been updated since the care plan was created on [DATE]. Resident D's reportable incidents to the Indiana Department of Health for the last 8 months were as follows: a. On [DATE], it was reported that Resident D wanted to borrow Resident 16's cell phone. She denied him and he called her a b***h. b. On [DATE], it was reported that Resident D made contact with Resident 17. Resident 17 was hallucinating and was sent to the hospital. c. On [DATE], it was reported that Resident 83 made racial comments to Resident D, and Resident D made contact with Resident 83. d. On [DATE], it was reported that Resident 17 made racial comments to Resident D, and Resident D pushed Resident 17. It was known that Resident 17 was in need of psych services. e. On [DATE], it was reported that Resident 83 made contact with Resident D for no reason. f. On [DATE], it was reported that Resident D pushed Resident C. Resident C fell and fractured his wrist. On [DATE] with no time noted, the SSD indicated she had a conversation with the Ombudsman 41. She recommended the SSD to schedule a discharge care plan meeting, issue 30-day notice and allow Resident D to make an appeal within 10 days. She stated if an appeal had not been made within 10 days, then the facility had the right to discharge Resident D to the [NAME] Mission. She recommended the SSD set the resident up with Midtown [NAME] (mental health center). SSD had told the Ombudsman 41 the resident had made sexual comments, verbal and physical aggression towards staff and peers, but was independent with all ADLs, scores high on BIMS (brief interview for mental status) and inquired about discharge to the [NAME] Mission. On [DATE] with no time noted, SSD indicated she contact the office of the Ombudsman but was unable to get through, left a voicemail and emailed Ombudsman 43. The SSD received a phone number for [NAME] Mission. On [DATE] with no time noted, SSD indicated she was asked to contact Midtown once a discharge date was established and she would set up an initial appointment. Midtown provided their transportation number through [NAME] to contact. Resident would be seen once every 3 months by a psychiatrist, and a therapist twice a month. On [DATE] with no time noted, SSD received a call from Ombudsman 42 who stated she is filling in. SSD provided information to Ombudsman 42 on Resident D. She explained safety concerns with the resident returning to the facility. She stated that the facility should decide based on the safety of the patients in the facility but indicated to understand that the psych hospital can call the board of health to file a complaint and there could be repercussions. Ombudsman 42 recommended that SSD try to work with psych hospital to find alternative placement that would agree to accept him, especially all male facility. On [DATE] with no time noted, SSD referred Resident D to several facilities, most have denied him. On [DATE] with no time noted, Resident D scored 13/15 on BIMS. SSD contacted Ombudsman 42 to discuss the facility's right to discharge Resident D to [NAME] Mission due to concerns with him. She stated the facility had the right to discharge him to the [NAME] Mission. SSD informed Ombudsman 42 that Resident D was independent with all ADLs, recommended for medication management, and informed Ombudsman 42 that SSD had already contacted Midtown [NAME] regarding scheduling an appointment. The SSD had contacted the transportation number that was provided to SSD from Midtown. SSD provided information of the discharge location to the transportation provider, and transportation stated they just needed a contact number at the [NAME] Mission to inform them of pick-up times for Resident D on appointment days. The transportation provider stated Midtown [NAME] will contact transportation to schedule transport with date and time, they stated SSD does not need to schedule this with them. On [DATE] with no time noted, a care plan meeting was held with SSD, ADON and Resident D. SSD discussed recently being readmitted to facility this morning from Assurance Psych. SSD asked Resident D if he recalls the reason for the psych stay, Resident D indicated he got into a fight. SSD agreed and discussed behaviors of becoming very loud with threatening behavior yelling and screaming out. We discussed his ADL (activity of daily living) status of being independent with all ADLS except medication management., discussed his potential 30-day notice to [NAME] Mission due to safety concerns of other residents. Resident D became very agitated and began yelling and screaming at SSD and ADON, stated he's not leaving, and he wants to stay at the facility. SSD had difficulty speaking to Resident D due to yelling, screaming out. SSD educated Resident D on current verbal behavior and disruption to other peers. Resident continued to yell and scream. SSD attempted to redirect him but was unsuccessful. He screamed at SSD and ADON to leave his room. [DATE] at 2:53 p.m., the SSD was notified by the DON of Resident D had become agitated with staff regarding the smoking time. He slammed his jacket on the chair in hallway. SSD spoke with Resident D this afternoon regarding his behaviors. He denied having these behaviors. SSD re-educated him on appropriate behaviors. He expressed understanding. No behaviors noted during this visit. On [DATE] at 12:54 p.m., a Social Services (SS) note indicated Resident D was visited by Greenhouse Psych therapist on this day with no concerns regarding behavior, psychosocial well-being, or mood. The Social Service Director (SSD) also visited with Resident D who was pleasant. No signs or symptoms of psychosocial well-being, mood concerns, or behaviors noted. On [DATE] with no time noted, the SSD was notified Resident D was upset with a female peer and told her she cannot have another boyfriend. SSD and ADON spoke with him. He admitted to having this behavior and state he was jealous. SSD educated Ray of previous conversation of him having behaviors and the potential for a 30-day discharge. He expressed understanding that this behavior could cost him a 30-day notice. He asked for a second chance. SSD stated she would speak with the Executive Director (ED). They will speak to him again next week. On [DATE] at 1:33 p.m., a SS note indicated the SSD visited with Resident D who was in good spirits. He showed no behaviors, no signs or symptoms of psychosocial well-being or mood concerns. On [DATE] at 2:34 p.m., a SS note indicated the SSD and ADON visited with Resident D. SSD discussed threatening behaviors towards staff with yelling and screaming out, his impulsive outbursts, and safety concerns. Resident D was educated on 30 Day Discharge Notice that was issued to him on this day. He was educated on the right to file an appeal, and provided details on how to do so, and educated Resident D that he would discharge to [NAME] Mission. Educated Resident D on being followed by Midtown [NAME] Health for medication management after his discharge. Resident D became agitated and began to raise his voice, he continued to ask for another chance. SSD educated Resident D again on his behaviors. Writer emailed a 30-Day Notice to Discharge Resident D to the Ombudsman. On [DATE] at 12:29 p.m., a SS note indicated the SSD contacted Oak St. Health and attempted to schedule an initial primary care physician (PCP) appointment. Oak St. Health stated someone from admissions will contact SSD next week to schedule initial appointment. Oak St. Health would provide transportation to and from his appointments. On [DATE] at 10:46 a.m., a nursing note indicated the Assistant Director of Nursing (ADON), currently the Interim DON, indicated Resident D scored at a high risk on an elopement assessment due to being independently mobile and having dementia. On [DATE] 12:21 a.m., the Nurse Practitioner (NP) 40 indicated in a late entry that she had a discharge visit with Resident D. She indicated he was being seen today for discharge planning to the [NAME] Mission per the facility. He had a past medical history of psychotic disorder, Alzheimer's disease, Schizoaffective disorder, Parkinson's disease, diabetes mellitus type 2, age-related cognitive decline, anxiety disorder, tremor, muscle weakness, difficulty in walking, and insomnia. He did not appear to be in any acute distress at this time or during this visit. He was resting quietly in a chair. He was oriented to person and place with periods of confusion. He was pleasant and cooperative. Medications were sent with Resident D upon his discharge. On [DATE] at 2:53 p.m., the Discharge Summary indicated the SSD had spoken with Resident D several times throughout this week regarding his upcoming discharge on [DATE]. She discussed scheduling an initial PCP appointment through Oak St. Health, informed Resident D of Oak St. Health providing transportation from the facility to their clinic for an initial appointment on [DATE], then will be transported to [NAME] Mission. Oak St. Health would refill his medications monthly. She provided Resident D with the transportation number to Southeast Trans for transportation. She contacted Midtown [NAME] Health to schedule initial appointment, they indicated they can transport him to and from appointments, Midtown to contact writer back with initial appointment date as writer left a voice mail at Midtown [NAME]. Resident D became agitated throughout these visits and asked on different occasions for another chance. SSD attempted to redirect Resident D by educating him but was unable to due to him yelling at writer. Staff members have visited with Resident D on this day regarding his discharge to the [NAME] Mission related to the 30-day discharge notice. Resident refused to leave facility. He was yelling and screaming, with threatening behaviors. He told the staff the only way I'm leaving was if the cops were called. Non-emergency police were contacted to assist with escorting Resident to an Oak St. Health vehicle. The police escorted Resident D outside and into van. SSD had made contact Oak St. Health regarding Resident D's initial appointment; they stated Resident D had arrived and would be checked in. He was discharged with medications, contact numbers, and discharge information. On [DATE] with no time noted, the SSD contacted [NAME] Midtown to follow up regarding scheduling an appointment for Resident D's transportation. Midtown indicated she recalled speaking with SSD in March and informed SSD that their policy had changed for scheduling appointments and scheduling transportation for clients. She stated they do not schedule appointments or transportation because it is all now walk-ins only on Monday - Friday, from 9:00 a.m. to 12:00 p.m. Midtown provided SSD a transportation number to contact to schedule for pick up to and from Midtown. Midtown indicated patient would now need to schedule their own appointments. On [DATE] at 5:56 p.m., the Staffing Coordinator/Unit Manager indicated Resident D returned to facility at 5:15 p.m. today. Resident returned with medications and his belongings. He was placed in a room on the locked behavior unit. Physician's orders were received to give him his 9:00 a.m. medication now per NP 40. He was alert and oriented x 3. He ambulated on own without an assistive device. His gait was steady. On [DATE] at 6:00 p.m., Resident D's Admission/readmission form indicated he was admitted from [NAME] Mission. He was oriented to person, place, time, and situation. He had a diagnosis of dementia and used 9 or more medication. His cognition was intact. On [DATE] with no time noted, the SSD indicated she spoke with the [NAME] Mission Director (WMD). He indicated the facility send Resident D back to the facility as no one contacted them to inform them of Resident D being dropped off. SSD informed WMD that she was unaware of needing to inform them of residents' arrival because they took walk-ins. The WMD indicated that was no longer the case. On [DATE] SSD was notified of Resident D smacking a Certified Nursing Aide (CNA) on the buttocks. SSD asked Resident D why he did it, educated him on appropriate behaviors and explained this behavior was inappropriate. Resident D apologized. On [DATE] with no time noted, SSD was notified of Resident D becoming agitated and verbally aggressive as he stated he was jealous of the other peers wanting a girlfriend. SSD was able to redirect him with conversation, walking on the unit and offered activities of interest. He appeared in a better mood with no further behaviors noted. On [DATE] with no time noted, the SSD, DON and the Rounding Psych physician and the Rounding Psych NP discussed Resident D and his behaviors. Possible in-patient referral was discussed. The Rounding Psych physician who also works at Assurance Psych denied him at Assurance stating medications will not help his behaviors, stat this was his personality and medication will not change or help him. He recommended the facility send Resident D to [NAME] ER and recommended the facility to not accept him back to the facility. On [DATE] with no time noted, the SSD attempted to contact [NAME] Midtown to discuss group home placement but was unable to get through and unable to leave a voice message. On [DATE] with no time noted, SSD emailed Ombudsman office and attempted to contact Ombudsman 44 and left a voice mail. On [DATE] with no time noted, SSD spoke with Ombudsman 44 and requested recommendations and thoughts regarding placement for Resident D. Ombudsman 44 indicated a place to try who accepted residents with behaviors. On [DATE] at 8:31 a.m., ED indicated she received a call from the WMD and he indicated they would not accept him. He said you must have our permission, we will not accept him. On [DATE] at 2:32 p.m., the SSD indicated she had provided all transfer documents to Resident D. He did not sign any transfer or discharge documents. On [DATE] at 2:35 p.m., the ED indicated Resident D did not have a behavioral contract with the facility. On [DATE] at 2:36 p.m., the SSD indicated she believed Resident D left with a 30-day supply of all April MAR medications because he was a Medicaid recipient. 1. Aripiprazole tab 20 mg (milligram), take 1 tablet by mouth once daily for schizophrenia. 2. Quetiapine fumarate (anti-psychotic) tab 50 mg, take 1 tablet by mouth every morning. 3. Quetiapine fumarate tab 300 mg, take 1 tablet by mouth every night at bedtime. 4. Buspirone Hcl (anti-anxiety) tab 5 mg, take 5 mg by mouth 3 times a day for anxiety. 5. Lactulose (laxative) 10 gr (grams)/15 mL, take 30 mL by mouth once daily for hyperammonemia (high ammonia). 6. Trazodone Hcl (antidepressant/sedative) tab 50 mg, take 1 tablet by mouth every night at bedtime for insomnia. 7. Carbidopa/Levodopa (dopamine promotor for Parkinson's disease) tab 25-100 mg, take 1 tablet by mouth once daily. 8. Amantadine Hcl (dopamine promotor) cap 100 mg, take 100 mg by mouth once daily at 9:00 a.m. for Parkinson's. 9. Amlodipine Besylate (calcium channel blocker for high blood pressure) tab 10 mg, take 1 tablet by mouth once daily for hypertension. 10. Donepezil Hcl tab 10 mg, take 1 tablet by mouth at bedtime for major depressive disorder. 11. Gabapentin cap 300 mg, take 1 capsule by mouth three times daily for bipolar disorder. 12. Hydrochlorothiazide tab 25 mg, take 1 tablet by mouth daily for hypertension. 13. Lamotrigine tab 200 mg, take 1 tablet by mouth once daily for bipolar disorder. 14. Vitamin D cap 1.25 mg (50,000 units), take q capsule by mouth every week for vitamin daily deficiency. 15. Acetaminophen tabs 325 mg, take 2 tablets by mouth every 6 hours as needed for pain. On [DATE] at 3:12 p.m., the ED indicated Resident D did not have a self-administration assessment, but the resident had no narcotics. On [DATE] at 3:13 p.m., the Activity Director (AD) indicated Activity Aide 36 had a good relationship with Resident D and was able to redirect him. Resident likes to do crafts, loves newspapers, and we talked to him. She indicated she did not know if the evening/night shift or weekends had special activities for him, but they did know where the activity room key was kept so they could have had access to supplies for his leisure. The facility also buys him cigarettes when he is out. Activity personnel are in the building 7 days a week until 7:00 p.m. On [DATE] at 3:14 p.m., the SSD indicated Resident D loved cleaning and organizing things in his room. The staff knows the resident very well. He likes to talk about cars. He like to compare prices. The AD indicated she would take a computer to him to look at ads. The SSD indicated she was looking into making a binder of activities of interest for him. On [DATE] at 3:19 p.m., the ED indicated the Staff Coordinator was trained to run the locked behavior health unit and for the most part there was a dedicated staff on the behavioral health unit. The ED provided the specific training the Staff Coordinator did to be over the locked behavior unit. She watched 6 YouTube videos, totally 62.5 minutes. Then, she educated the behavioral health staff, who also watched the 6 videos. The YouTube videos were provided online by BJC Behavioral Health. They were called, Do This Not That: Providing Care for Medical Patients with Psychiatric Issues. 1. The video to educate about anxiety issues was 9:09 minutes long. 2. The video to educate about anger and aggression issues was 11:57 minutes long. 3. The video to educate about delusions issues was 9:37 minutes long. 4. The video to educate about suicide risk issues was 11:52 minutes long. 5. The video to educate about depression issues was 10:15 minutes long. 6. The video to educate about hallucination issues was 9:47 minutes long. On [DATE] at 2:17 p.m., the SSD indicated she provided the Notice of Transfer or Discharge to Resident D on [DATE] at 4:30 p.m. It was at the end of the business day and did not count as day 1. It indicated the effective date for the discharge was [DATE]. Resident D was removed from the locked unit and escorted by the police out of the building on [DATE]. The SSD indicated she did not realize the date was different on the Notice of Transfer/Discharge. The reason indicated the safety of the individuals in the facility was endangered. Resident D was removed from the building after 28 days had expired on [DATE]. A Discharge Information document with Resident D name and dated [DATE] indicated Resident D would be discharged with 30 days' worth of medications. His prescriptions would be filled monthly by Oak St. Health. Part of his discharge information was a copy of his April MAR. On [DATE] at 2:20 p.m., the ED indicated Resident D did not sign any discharge documents. The ombudsman had indicated the resident would have 10 days to appeal. She believes he was not appealing by screaming and yelling when escorted out of the building by the police. On [DATE] at 2:22 p.m., the SSD indicated during a [DATE] meeting with the psychiatric physician 47 and the NP, it was disclosed Resident D was denied at admission to Assurance. Physician 47 indicated to send Resident D to [NAME] ER and not accept him back. On [DATE] at 2:26 p.m., the SSD indicated the ombudsman correspondence was with Ombudsman 42, 43, and 44. A review of documents provided by the SSD on [DATE] at 2:17 p.m., provided typed narratives of several conversations. On [DATE] at 3:11 p.m., the SSD indicated that the information regarding the contact with the ombudsman program was in the soft file narrative. On [DATE] at 9:41 a.m., the DON indicated she was the Assistant Director of Nursing (ADON) when Resident D left for [NAME] Mission on [DATE]. His ride was here and he did not want to go, His 30 days was over and he had to go. He sat up front in a lobby chair. The police indicated he had to leave the building or the police would arrest him. He was not aware he was asked to leave before the 30 days were over. He was yelling in the lobby about how he didn't want to go and he wanted to stay here. In the begin, he was offered to make an appeal of the 30 day notice, the SSD, ED, and ADON, were present. It probably would have been an appropriate idea to begin an appeal if he had said or was yelling he did not want to leave here. She indicated she didn't know of anyone was advocating for the resident's wants and needs. He had his medications with him in bubble pack cards. He did not have any narcotics with him. During an interview, on [DATE] at 10:11 a.m., Resident D indicated the SSD doesn't like him. He came in from outside and the SSD indicated to him he needed to go to the [NAME] Mission for no reason. He indicated he was given documents that were a 30 day notice and a right to appeal. He provided the documents to review. Resident D began shaking badly, this conversation was upsetting to him. He said he received the papers but did not understand what the notice of discharge or request for a hearing meant. He indicated he was send to [NAME] Mission and they (the staff at [NAME] Mission) indicated the facility had no right to send him there. He was in room at the facility and the SSD indicated it was time to go. He had been laying down. He indicated she used to say that she would send him to [NAME] Mission as a threat to get him to go the (psych) hospital. On the [NAME] Mission day, he was mad and he faced the wall. The police came and got him to go to the front door. The police said if he didn't go to the [NAME] Mission then he would go to jail in the police car. He had 3-4 big bags of clothes and medications. He indicated he did not know how to take medications or when. The people at [NAME] Mission told him they do not dispense medications. He did not take any medications during his stay at [NAME] Mission because he didn't know how to take it. The [NAME] Mission staff called the facility and put all his stuff in a van and brought him back to Envive. On arrival, the ED indicated he could stay at the facility. Resident D did not know why the ED let him come back. He came back with his medications. At the [NAME] Mission, his medications were locked in a locker, he had the key. One resident at [NAME] Mission tried to start something with him, he just turned and walked away. His medication remained locked in his locked locker the whole time he was at [NAME] Mission because didn't know how to take the medications, so he left them alone. Resident D indicate with his sometime severe shaking he was unable to read. He indicated he did not try to read the medication packaging. He didn't know how to take the medication, he did not know what kind of medications he takes now. He indicated sometimes he thought about killing people. He had never killed anyone or tried to kill anyone. He only thought about killing his brother and sister because they took his money and threw him out. He indicated he was mad at the SSD but had not thought about killing her. Sometimes he felt like fighting, but not fighting to kill them. He indicated he did not know he could have called the health department to make a complaint. If he knew that, he would have never gone to [NAME] Mission. He was not aware of any elder agencies to help him. On [DATE] at 10:46 a.m., the SSD indicated she provided the 30 day notice to discharge to Resident D on [DATE] at 4:34 p.m She indicated she provided the notice and immediately put the progress note in his chart. On [DATE] at 10:47 a.m., the ED and SSD were trying to get him to leave the facility because of his behaviors. The psych physician indicate he had a personality disorder, not behaviors. His behaviors were at a very high level compared to the other residents. The facility was trying to care for his needs. We were able to care for his needs. But this was a personality disorder. He didn't need to be around other people. On [DATE] at 10:53 a.m., the SSD indicated the psych physician indicated to the facility to send Resident D to [NAME] ER and not accept him back. They did not follow these instructions. On [DATE] at 11:00 a.m., the SSD provided a list of referred facilities to whom she had applied to send Resident D. Many of these buildings did not have a locked unit. Her documentation indicated she referred him to 37 buildings, 3 of them twice. On [DATE] at 11:16 a.m., the SSD indicated the Director of the [NAME] Mission called and talked to SSD and ED. He was very upset about Resident D arriving at [NAME] Mission. He indicated the facility had to have permission. He called on [DATE] and insisted Resident D come back to the facility. On [DATE] at 12:03 p.m., the DON indicated the list of medications were on the April MAR provided in Resident D's discharge documents, but the quantity of medications we not part of the discharge summary. She indicated the facility did not count they medications given to Resident D upon his discharge. On [DATE] at 12:05 p.m., the VPCS indicated the facility did not need to count the non-narcotic medications. Those medications belonged to Resident D. If we would have destroyed them, we would have completed a disposition of the medications. On [DATE] at 12:29 p.m., the [NAME] President of Clinical Services (VPCS) indicated the SSD believed because Resident D was a Medicaid recipient he left here with a 30 day supply of all his medications. The VPCS indicated the facility did not count how many medications Resident D left with on [DATE] and did not count how many medications he returned with on [DATE]. She indicated we do not know how many pills went out or came [NAME] in. There are no regulations requiring we do so. On [DATE] at 12:32 p.m., the DON indicated when the medications were returned to the building after being at the [NAME] Mission they were put back in use for Resident D. On [DATE] at 2:44 p.m., the Ombudsman Leader (OL) indicated Ombudsman 41 was not employed by the Ombudsman program on [DATE] and believed the SSD entry for that date was invalid. The OL indicated she had been in the facility several times for other residents but information or questions regarding Resident D's discharge never came up. She indicated they never received a Notification of Discharge document from the facility for Resident D. Whenever they get a notice of discharge, they will go to the facility to advocate for the resident. In our training, we learn to not send people to specific places, and we do not approve transfer discharges. No ombudsman spoke with Resident D. If the Ombudsman would have known they planned to discharge Resident D to [NAME] Mission they would not have agreed to this placement. The SSD never asked us to see Resident D. She only asked questions about how to help the facility discharge residents, nothing about how to advocate for the residents. On [DATE] at 4:03 p.m., Ombudsman 42 indicated she talked with the SSD on [DATE]. The SSD provided no name and gave no specific information, she just indicated they had a resident who had aggressive behaviors, especially with women. The SSD indicated they wanted to discharge him to [NAME] Mission. Ombudsman 42 indicated she did not think that was appropriate to send him there, and the SSD needed to talk to them first because he was aggressive and had behaviors. Ombudsman 42 indicated it was apparent that the SSD did not like that information. Ombudsman 42 indicated she did not advise or tell them to send him to [NAME] Mission, she told them to call [NAME] Mission. She warned the SSD of the possibility of consequences if she refused to take him back, someone could call the Board of Health and file a complaint because that was considered dumping (residents suffering from mental illness are often released even thought they are unable to care form themselves). On [DATE], the Admissions Agreement was provided by the facility. A document within the admission Agreement, titled, Indiana Resident Rights and Facility Responsibilities, was reviewed. It indicated, .The resident has the right to be cared for in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality .A copy of the resident's rights must be available in a publicly accessible area. The copy must be at least 12-point type .The transfer and discharge rights of residents of a facility are as follows .before an interfacility transfer or discharge occurs, the facility must .place a copy of the notice in the resident's clinical record and transmit a copy to the following .the local long term care ombudsman program for involuntary relocations or discharges only .the notice of transfer or discharge .must be made by the facility at least t[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor for new or worsening wounds which resulted in actual harm when a change of condition in his skin integrity led to his hospitalization and a diagnosis of a necrotic decubitus ulcer and coccygeal osteomyelitis; and the facility failed to ensure interventions to prevent the wound from worsening were in place per his plan of care and infection control techniques were taken during wound treatments for 1 of 1 resident reviewed for wounds (Resident B). Findings include: On 9/12/22 at 11:36 a.m., Resident B was observed. He was lying in bed, flat on his back. Although his eyes were open, he did not respond appropriately to questions and closed his eyes and appeared to sleep. His bed was a low air loss mattress bed and was observed to be operating at the appropriate setting. On 9/13/22 at 10:56 a.m., Resident B was observed. He was lying flat on his back. On 9/13/22 at 11:33 a.m., Resident B remained on his back. On 9/13/22 at 11:51 a.m., Resident B was observed and remained lying flat on his back. On 9/14/22 at 9:57 a.m., Resident B was observed. He was lying in bed flat on his back. On 9/14/22 at 2:10 p.m., Resident B remained flat on his back. On 9/15/22 at 10:00 a.m., Resident B was observed. He was lying flat on his back. On 9/15/22 from 11:45 a.m., Resident B was observed. He was lying flat on his back. On 9/15/22 from 1:05 p.m., until 2:35 p.m., a continuous observation was conducted for Resident B. Although he had been assisted to try and eat lunch, Resident B was never turned or repositioned to offload the pressure from his bottom. On 9/16/22 at 12:13 a.m., Resident B was observed. He remained in bed, flat on his back. During an interview on 9/16/22 at 12:33 a.m., LPN 23 indicated Resident B should be turned or repositioned to offload the sore on him bottom at least every two hours. On 9/19/22 at 3:05 p.m., Resident B's medical record was reviewed. His record indicated he had been a long-term care resident for many years, and previously resided on the Behavioral Health Unit. He had chronic disease diagnoses which included, but were not limited to schizoaffective disorder, type II diabetes, and chronic obstructive pulmonary disease (COPD). He had an active order for weekly skin assessments to be completed every Wednesday on day shift. On 9/16/22 at 10:28 a.m., the Director of Nursing (DON) provided copies of Resident B's weekly skin assessments and were reviewed at this time. On 3/30/22, no skin alterations were noted on the weekly skin check log. However, a Nurse Practitioner (NP) progress note, dated 3/31/22 at 10:33 a.m., indicated Resident B was being seen per nursing request for rash on buttocks. Nursing was unclear of onset of rash, and Resident B reported tenderness, local pain and itching, down there. The NP diagnosed Resident B with genital herpes and prescribed Acyclovire (an oral antiviral medication). The skin assessment logs indicated from 3/16/22 to 4/20/22 indicated LPN 23 had conducted the assessments and no new alterations in his skin integrity were noted. The record lacked documentation of a change in condition related to the development of a new wound/skin area. The record lacked documentation of continued monitoring of the outbreak area. The record lacked documentation that the diagnosis was added to his comprehensive plan of care. On 9/19/22 at 9:30 a.m., the DON provided copies of Resident B's March and April Certified Nursing Assistant (CNA) Point of Care (POC) documentation for March indicated: Resident B was at risk for behaviors and monitored each shift with no refusal of care noted. Resident B was at risk for alterations in skin integrity but only monitored as needed. March 1st-24th were all blank, NA (not applicable), or 5 (none observed). March 25, 26 and 27th were left blank. On March 30th, a new area of discoloration was noted but also coded no, it was not a new area. March 31st, was coded NA (not applicable). It appeared no bed baths or showers had been provided as each observation was blank or coded NA. Shower sheets were requested for March but were not able to be provided by survey exit. Point of care Documentation for the month of April indicated: Resident B was at risk for behaviors and monitored each shift with no refusal of care noted. Resident B was at risk for alterations in skin integrity but still only monitored as needed. On April 24th, 25th and 26th, no new areas were noted. On the 27th an open area was noted but not coded a new. A nursing progress note, dated 4/24/22 at 5:52 a.m., indicated Resident B had an open wound on his coccyx. The nurse assessed the area and applied a dressing. The Resident was repositioned on his left side and the nurse educated the resident about the importance of being turned every two hours. An NP progress note, dated 4/25/22 at 1:46 p.m., indicated Resident B was being seen for a new open area on his intergluteal cleft. Alleyn ([ALLEVYN]] is a range of moist wound environment dressings designed specifically for the management of chronic and exuding fluid from the wounds) currently covering open area. A small amount of serosanguinous dressing was noted on the dressing. No slough was noted within wound. An order was given for silver alginate and to cover with Alleyn. The NP note did not include measurements. A Pressure Ulcer Skin Log, dated 4/27/22, indicated Resident B had three areas that were acquired on 4/24/22. Wound 1: Stage III (full thickness skin loss where fat is visible) pressure ulcer to the coccyx with moderate serosanguinous drainage that measured 3 cm (centimeters) long by 3 cm side and 0.5 cm deep. Wound 2: Unstageable (full thickness skin loss where the wound bed is not visible due to slough or eschar) to the left buttock, purple in color which measured 11 cm long by 6.8 cm wide. Wound 3: Unstageable to the left glute, red/purple in color which measured 8 cm long by 6 cm wide. A nursing progress note, dated 5/1/22 at 6:15 a.m., indicated Resident B was noted to have difficulty swallowing pills and was shaking uncontrollably with signs/symptoms of shortness of breath. The On-Call doctor was notified and gave no new orders, just continue to monitor. His O2 (oxygen) was not in place and his 02 saturation (sats) was 87%. When his 02 was placed his sats increased to 94%. A Pressure Ulcer Skin Log, dated 5/4/22, indicated Resident B's areas were improved. Wound 1: Unstageable to the left glute, purple/red in color and measured 7.5 cm long by 5.5 cm wide, being treated with skin prep. Wound 2: Unstageable to the sacrum, red in color with slough and serosanguineous drainage that now measured 13 cm long by 9 cm wide. A NP progress note, dated 5/4/22 at 2:28 a.m., indicated Resident B was being seen after nursing staff reported he had a decreased level of orientation for the last day, and she ordered labs for a CBC (complete blood count) and Urinalysis. A nursing progress note, dated 5/6/22 at 11:11 a.m., indicated Resident B was sent to the ER (emergency room) for further evaluation due to continued decreased levels of conscious. On 5/16/22 Resident B remained at the hospital and required a surgical debridement of the wound and a bone biopsy was conducted which revealed necrosis of the bone. A hospital Discharge summary dated [DATE] indicated, .Collateral was obtained via his nurse at his ECF [extended care facility]. His nurse stated that normally patient is AAx4 [alert and oriented to person, time, place and situation] at baseline but this morning he woke up and remained somnolent and would not open his eyes or swallow his medicines. He stated that he was overall sluggish and had to manually remove the medication from his mouth after he administered them. When asking patient regarding his symptoms he did endorse feeling confused The primary diagnosis was a necrotic decubitus ulcer and coccygeal osteomyelitis (infection of the bone). An MRI completed on 5/8/22 revealed findings consistent with osteomyelitis of coccygeal segments with subjacent cellulitis. Resident B's current CNA assignment sheet was reviewed and indicated, up for all meals, however throughout the surveyor timeframe, Resident B was never observed out of bed. The record lacked documentation of Resident B's refusals to get out of bed. The pressure ulcer wound treatments were observed twice. 1. A wound treatment observation occurred on 9/14/22 from 3:15 p.m., until 4:00 p.m. The following was observed: Licensed Practical Nurse (LPN 23) indicated she would be changing the wound vacuum (vac) dressing to Resident B's coccyx wound. Certified Nursing Assistant (CNA) 23, CNA 51, and CNA 22 were present for the treatment of wounds. CNAs 23 and CNA 51 entered room after using hand sanitizer in the hall and applied a clean pair of gloves. CNA 23 indicated it usually took two people to hold and position the resident during the treatment. The CNAs stood on the right side of the resident and held him over to his left side. LPN 23 put on a clean pair of gloves at the door, then opened sani-wipes and wiped off the overbed table surface, placed a plastic barrier on the table and set up station with supplies to provide wound care. LPN 23 removed the old dressing dated with yesterday's date from the resident's ischium. There was a minimal amount of yellow fluid on the old dressing. LPN 23 did not have the ordered dressing present to apply to the wound. LPN 23 received the xeroform dressing and applied it to the wound to the intact skin around the peri-wound. She applied a dressing over the xeroform and secured the dressing with a white adhesive tape over the xeroform. CNA 23 was waving away gnats during the treatment. LPN 23 indicated that resident had a wound on his sacrum and was going to change the wound vac dressing. LPN 23 exited the room and came back into the room with linens. She placed a new pair of gloves on and did not perform hand hygiene prior to putting on gloves. LPN 23 cleaned a pair of scissors with a disinfectant. LPN 23 called Resident B by name, adjusted his nasal cannula tubing and lowered the head of his bed. LPN 23 measured from the peri-wound to the opposite peri-wound instead of the wound edges. LPN 23 removed the wound vac dressing. She measured the wound that was a stage 4 pressure ulcer (full thickness skin and tissue loss with muscle, bone, and/or tendon visible). She used a saline syringe and pushed saline into the wound on his sacrum to clean the wound. LPN 23 adjusted the resident's indwelling catheter. She used hand sanitizer and then applied a new pair of gloves. She used a saline syringe and pushed the saline into the wound on his sacrum. She opened the wound vac dressing. LPN 23 indicated that the depth of the sacral wound was 2.2 centimeters and used a cotton tipped applicator to obtain the depth. There was undermining around the entire the wound. The VP of clinical operations came into the room to assist LPN 23. LPN 23 was cutting a clear adhesive dressing to the peri-wound after applying skin prep to the peri-wound. LPN 23 was using the clear adhesive dressing and placing on the dressing to border of the wound (windowpane) instead of using the clear dressing sheet and covering the entire wound. LPN 23 cut the foam dressing and placed the foam dressing against her uniform. On 9/14/22 at 3:56 p.m., the [NAME] President (VP) of Clinical Operations was summoned to the room. She attempted to identify tunneling of the wound with a tongue depressor. The VP of Clinical Operations placed gloved fingers into the wound. She cut the foam dressing with scissors that were laying on the bed on and placed the foam dressing into the wound. The VP of Clinical Operations stayed with LPN 23 and finished the dressing change. As Resident B was lying on his side, there were abnormal areas observed on the back of his left calf. LPN 23 indicated that the areas were bruising and shearing. One area was open and had a black edge at the top of the wound. These areas were identified as deep tissue injuries by the VP of Clinical Operations. When asked when the last time Resident B had been turned or repositioned, CNA 51 started to give an answer, but was interrupted by the LPN 23 who indicated, it's 4:00 p.m. now, so he would have been turned at 2:00 p.m. 2. A second wound treatment observation occurred on 9/16/22. The following was observed: At 1:18 p.m., Resident B's active sacral pressure ulcer change order was reviewed. It indicated to cleanse with normal saline (NS) and apply the wound vac on every dayshift on Mondays, Wednesdays, and Fridays for wound care related to a stage 4 sacral pressure ulcer. At 1:38 p.m., Certified Nursing Assistant (CNA) 22 entered Resident B's room to assist the Director of Nursing (DON) with positioning the resident during the sacral wound dressing change. She did not wash her hands before putting on disposable gloves that she had in her pocket. At 1:38 p.m., the DON did not wash her hands before she put on gloves. She used a Super Sani cloth to wipe the resident's over-the-bed table and laid a white trash bag on it. The DON's table set up included wound vac supplies, hand sanitizer, an Optifoam gentle dressing, and a pink bin of dressing supplies. The DON removed her gloves and did not wash her hands but used hand sanitizer gel on her hands. The resident's door was left wide open and the resident's privacy curtain was left partially open. When CNA 22 removed Resident B's hip pillow, the resident's body did not shift to center. The DON and CNA 22 moved the resident onto his left side. Bodily fluids were observed on the resident's calf pillow that was used to relieve pressure on his heels. A weeping wound was observed on his left posterior-lateral calf. The bodily fluids were a tannish color, some fluids were dried on the pillowcase in several places, some were still wet. The wound was not dressed, and it was slightly larger than the size of a quarter. At 1:43 p.m., LPN 23 did not knock and wait for permission to enter the resident's room, she just called out knock knock. She requested to assist with holding the resident in position for the sacral dressing change. She did not wash her hands or use hand sanitizer gel. She put on gloves and held the resident's legs. The DON removed the outer portion of the previous sacral dressing and indicated it did not have the date, time, or initials for the staff person who placed it. It should have been labeled correctly. She removed her gloves, sanitized her hands, and put on new gloves. She laid a white towel on the resident's bed as a clean area. She removed the soiled black sponge from the resident's deep wound. She removed her gloves, sanitized her hands, and put on new gloves. The DON indicated she would clean the resident's wound with normal saline (NS). She was observed digging in the pink bin of dressing supplies with her gloved hands. She retrieved a 10 mL syringe of NS and opened it. Without changing gloves, she squirted the NS into the surface of the center of the wound. She indicated there was undermining of the wound from 3:00 to 6:00. She did not clean the undermined areas. With the same soiled gloves, she put a gauze square over the end of her index finger and wiped the center of the resident's wound, she did not wipe the undermined area. She the indicated the wound measured 3 cm (centimeter) x 6 cm and she would measure the depth of wound after she changed her contaminated gloves. She removed the gloves and sanitized her hands. After putting on new gloves she opened the sterile packaging for the wound vac dressing and suction system. She reached back into the bin of dressing supplies and pulled out a pair of scissors. She did not clean them before cutting the plastic adhesive part of the wound vac system into strips. Then, she cut the black sponge into 2 round circles and a long black strip. She placed the cut wound supplies inside the sterile packaging to keep them clean. The DON indicated the resident's wound was 70% granulation tissues and 30% slough. She indicated she forgot to measure the depth. At 1:53 p.m., the DON began placing adhesive plastic strips on the resident skin around the sacral wound. The first strip was from 9:00 to 12:00, the second strip, slightly over the wound was from 12:00 to 6:00 o'clock position. She placed the round black sponge in the wound. She placed another long plastic strip and adhesive plastic from the top of the wound to the left lateral hip. Then placed the long black sponge over it. She began placing cut adhesive plastic strips over the black sponges but was not able to make a seal. LPN 23 lifted her hand off of the resident's unwashed legs and pressed her unwashed gloved hand on the long plastic covered sponge before it was sealed. She pressed down with her hand trying to affect a seal. The DON was cutting more adhesive plastic strips with the unwashed scissors and continued to place them, trying the get a seal on the wound vac. The DON placed a suction device with tubing attached to it at the end of the long plastic covered black sponge. She attached additional tubing and then attached it to the wound vac machine. She checked the wound vac machine again. She placed an additional plastic adhesive strip over the wound. She pressed down on the plastic covered sponges many times trying to create a seal. She continued to push on the wound and the long plastic covered foam strip in several places for 3 minutes, from 2:05 to 2:08 p.m. She was unable to create a seal and was out of the plastic strips. At 2:09 p.m., LPN 23 opened the resident's curtain, removed her gloves, washed her hands, and left to get more adhesive plastic for the wound. She did not close the door when she left. The Nurse Practitioner (NP) did not knock and entered the room, she was in a position to see the resident exposed in his bed. She wanted the keys to the QMA's cart. As soon as the NP left, an x-ray technician did not knock and came into the room, she was in a position to see the resident exposed in his bed. She wanted to know if we were almost finished with him. At 2:12 p.m., the DON indicated the wound on Resident B's left lower leg area was open with a stage 3 pressure wound. This open area was not over a bony prominence. The three raised, irregular, deep purple areas around the wound, she indicated were pressure ulcers at stage 2. These areas were not over a bony prominence. CNA 22, with her unwashed gloves hands that had been holding the resident on his side, pressed on the purple areas to see if they wound blanch. They did not. CNA 22 removed her gloves, sanitized her hands, and put on new gloves. At 2:15 p.m., the [NAME] President of Clinical Services (VPCS) came in the room to see if the staff needed assistance, she was in a position to see the resident exposed in his bed. At 2:17 p.m., the DON indicated there was an issue with privacy during Resident B's dressing change. The door and privacy curtains should have remained closed. At 2:18 p.m., after asking about hand washing during dressing changes, the DON left to wash her hands. She was observed to wash her hands correctly, but she rubbed the paper towels on water running from her hands to her elbows, then finished drying her hands with contaminated paper towels. At 2:21 p.m., LPN 23 provided another packaged wound vac system. The DON opened it, cut more adhesive plastic strips with the contaminated scissors, and used them on the resident's new wound vac dressing to complete the seal. During an interview on 9/16/22 at 9:20 a.m., the Former DON (who was DON at the time Resident B developed the wound) indicated at the time of the development of the wound, weekly skin assessments were being conducted by the nurse on the floor and documented on paper. During an interview on 9/16/22 at 10:30 a.m., with the DON and Administrator present, the DON indicated weekly skin assessments should have been conducted by the floor nurse on duty. Any new break in skin integrity were reported to the DON for follow up. A turning and repositioning program was standard practice. In the weeks leading up to the development of the area he was wanting to stay in bed more, and he did refuse a lot of care. Care plans were put into place for continuity of care so that all the nursing staff could have a complete picture of the resident and their specific needs. During an interview on 9/16/22 at 10:36 a.m., with the Administrator present, LPN 23 indicated she typically did not work on the floor. Every now and then she would be called to help the nurse on the floor with insulin if needed or would be pulled to the floor for call-ins. It was the floor nurses' responsibility to complete the weekly skin assessments. She had not assessed Resident B on a weekly basis, and only saw the area on his bottom after it had opened up, and at that time there was a dressing in place. So, she never visualized the wound until the resident returned from the hospital During an interview on 9/16/22 at 11:07 a.m., the DON indicated it was the nurse on duty's responsibility to conduct the weekly skin assessments and it was important for the direct care nurse to complete skin checks to maintain continuity of care. During a follow up interview on 9/16/22 at 11:22 a.m., LPN 23 indicated she had reviewed the weekly skin check log with her signature and indicated, oh, well if I signed it I did it. LPN 23 indicated if she was called down for a skin assessment, it was usually just a quick look over as the CNA would have been cleaning him up. During an interview on 9/19/22 at 8:40 a.m., the Former DON indicated, after a discussion with the current DON, Administrator, and VPCO, it was assumed that Resident B's osteomyelitis infection must have come from the genital herpes outbreak. Unfortunately, it looked like the new diagnosis had not been added to his medical record which meant it was missed for care planning. A current policy, titled, Handwashing/Hand Hygiene, dated 9/2022, was provided by the VPCS, on 9/19/22 at 10:53 a.m. A review of the policy indicated, .Handwashing is the single most important factor in preventing transmission of infections .All healthcare workers shall utilize hand hygiene frequently and appropriately A current policy, titled, Dressing Change, dated 9/2022, was provided by the VPCS, on 9/19/22 at 3:45 p.m. A review of the policy indicated, .to ensure measure that will promote and maintain good skin integrity while maintaining standard measures that will minimize/control contamination . create a clean field .Wash hands with soap and water. Open dressing pack. Put on first pair of disposable gloves. Remove soiled dressing and discard in plastic bag or trash can. Dispose of gloves in plastic bag or trash can. Wash hands with soap and water. Put on second pair of disposable gloves. Follow doctor's recommendations for treatment. Apply dressing and secure with tape when done with treatment if necessary. If using scissors make sure, it is clean with antiseptic .Removes gloves and discard. Wash hands with soap and water On 9/12/22, the Admissions Agreement was provided by the facility. A document titled, Federal Resident Rights and Facility Responsibilities, was reviewed. It indicated, .The resident has a right to personal privacy .includes accommodations, medical treatment This Federal tag related to Complaint IN00389598. 3.1-37

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident C was interviewed on 9/13/22 at 11:35 a.m. He wanted to speak in private about a situation that occurred in the facility. He indicated that Resident D had gotten in his face. He had asked Resident D to get out of his personal space when Resident D pushed him down and broke his wrist. The police came and told Resident C that they could not arrest Resident D. He indicated that it happened in the hallway, just outside his room. The nursing staff arrived and told him to stay on the ground. The ambulance was notified, and he was taken to the emergency room for evaluation and treatment of his left wrist. Resident C pointed to a splint on his arm and indicated that he must wear it to help the fracture heal. He indicated that incident had had no effect on him. Since the incident, he did not do anything except play his video game system and smoke. The staff gave him nerve pills. On 9/13/22 at 3:00 p.m., Resident C's record review was completed. Resident C had the following diagnoses but not limited to schizophrenia, bipolar disorder, anxiety disorder, hypertension, and GERD (gastroesophageal reflux disease). A progress note, dated 7/16/22, indicated that Resident C and Resident D had an altercation on 7/16/22 resulting in Resident C being pushed down. Resident C had orders to send him to the emergency room for left arm evaluation. A note, dated 7/16/22 at 9:41 p.m., indicated Resident C returned from the emergency room with a new diagnosis of fracture of left ulnar, distal radius, and a splint to his left arm. A radiology report was reviewed from the emergency room. It indicated that there was a comminuted fracture of the distal radial surface and nondisplaced ulnar styloid fracture on 7/16/22 at 11:33 a.m. Resident C had orders, dated 7/21/22, for a left arm immobilizer to be on except for skin checks, OT (Occupational Therapy) services 5 days per week for 60 days for ADL (Activities of Daily Living) retraining, therapeutic exercise, therapeutic activity, patient/caregiver education, and group therapy due to decline in function following a fall with left wrist fracture. Resident had a care plan, dated 7/19/22. It indicated that resident had a wrist fracture with a goal of returning to his prior level of function after healing and rehabilitation. A policy title Behavior Assessment/Monitoring with a date of 8/2022 provided by the ED on 9/19/22 at 3:45 p.m. indicated, .The facility will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. Interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities 3.1-37(a) Based on observation, interview, and record review, the facility failed to ensure a resident on the behavior unit with Alzheimer's disease, psychotic disorder with delusions, and schizoaffective disorder was supervised and had interventions implemented to prevent resident to resident altercations which resulted in Resident D pushing Resident C, and Resident C breaking his arm for 1 of 2 residents reviewed for abuse (Residents D, C, 16, 17, and 83). Findings include: 1. On 9/15/22 at 11:50 a.m., Resident D's record was reviewed. Resident D was admitted on [DATE]. His diagnoses included, but were not limited to, Parkinson's disease (progressive deterioration of motor function), Alzheimer's disease(progressive mental deterioration), Homicidal Ideations (thinking about, considering, or planning a homicide), Psychotic disorder with delusions (a mental disorder with a disconnection from reality with a belief in altered reality), anxiety disorder (mental health disorder of feelings of worry, or fear that interfere with daily activities), diabetes mellitus (blood sugar disorder), cognitive decline (reduction in cognitive ability such as memory, awareness, judgment and/or mental acuity), and Schizoaffective disorder, bipolar type (includes features of both schizophrenia, affects a person's thinking, sense of self, and perceptions, and a mood disorder such as bipolar disorder which includes mania and depression). He resided on the locked behavior unit. On 9/15/22 at 11:54 a.m., a review of Resident D's care plans was completed. They were created on 5/4/22. The care plans lacked documentation of no revisions after the resident's 2 psychiatric hospital stays, 2/24 to 3/11/22 and 7/20 to 7/29/22, and 5 incidents with other residents. The care plan problems were: 1. Resident D had a diagnosis of homicidal behavior. 2. The resident uses anti-anxiety medication related to anxiety disorder. 3. The resident uses anti-psychotic medications related to schizoaffective disorder, bipolar type. Behavior management, Potential for injury to self or others. 4. Resident D exhibits restlessness, nervousness and/or other anxiety symptoms related to a diagnosis of anxiety. 5. Resident D had impaired cognitive function/impaired thought process related to diagnosis of Alzheimer's and is at risk for decline. 6. Impaired thought processes/altered mental status related to diagnoses of schizoaffective disorder, bipolar type and Psychotic disorder with delusions due to known physiological condition. A care plan, revised on 9/22/22, indicated the problem was Resident D had (Auditory, Visual) hallucinations (perception of something not present), delusional episodes, talking to himself in hallway and in his room, he had a history of threatening behaviors towards others, history of verbal aggression towards others, abusive language, history of throwing items, making statements about females and wanting a girlfriend. He was manipulative towards others, lunging at staff making threats, and making threatening gestures. The goal and interventions had not been updated since the care plan was created on 5/4/22. Resident D's reportable incidents to the Indiana Department of Health for the last 8 months were as follows: a. On 2/17/22, it was reported that Resident D wanted to borrow Resident 16's cell phone. She denied him and he called her a b***h. b. On 5/10/22, it was reported that Resident D made contact with Resident 17. Resident 17 was hallucinating and was sent to the hospital. c. On 5/17/22, it was reported that Resident 83 made racial comments to Resident D, and Resident D made contact with Resident 83. d. On 6/2/22, it was reported that Resident 17 made racial comments to Resident D, and Resident D pushed Resident 17. It was known that Resident 17 was in need of psych services. e. On 6/22/22, it was reported that Resident 83 made contact with Resident D for no reason. f. On 7/16/22, it was reported that Resident D pushed Resident C. Resident C fell and fractured his wrist. On 9/15/22 at 11:50 a.m., Resident D's soft file was provided by the SSD. These were dated paragraphs of information regarding Resident D and his progress to discharge. No times were noted. - On 2/23/22 with no time noted, the Social Services Director (SSD) indicated the resident had made sexual comments, verbal and physical aggression towards staff and peers, but was independent with all ADLs, scored high on BIMS (brief interview for mental status) and inquired about discharge to the local homeless shelter. -On 3/11/22 with no time noted, a care plan meeting was held with SSD, Assistant Director of Nursing (ADON) and Resident D. SSD discussed recently being readmitted to facility this morning from an inpatient psychiatric (psych) stay. SSD asked Resident D if he recalled the reason for the psych stay, Resident D indicated he got into a fight. SSD agreed and discussed behaviors of becoming very loud with threatening behavior yelling and screaming out. We discussed his ADL (activity of daily living) status of being independent with all ADLS except medication management., discussed his potential 30-day notice to Local homeless shelter due to safety concerns of other residents. Resident D became very agitated and began yelling and screaming at SSD and ADON, stated he's not leaving, and he wanted to stay at the facility. SSD had difficulty speaking to Resident D due to yelling, screaming out. SSD educated Resident D on current verbal behavior and disruption to other peers. Resident continued to yell and scream. SSD attempted to redirect him but was unsuccessful. He screamed at SSD and ADON to leave his room. - On 3/16/22 at 2:53 p.m., the SSD was notified by the DON of Resident D had become agitated with staff regarding the smoking time. He slammed his jacket on the chair in hallway. SSD spoke with Resident D this afternoon regarding his behaviors. He denied having these behaviors. SSD re-educated him on appropriate behaviors. He expressed understanding. No behaviors noted during this visit. - On 3/18/22 at 12:54 p.m., a Social Services (SS) note indicated Resident D was visited by Psych therapist on this day with no concerns regarding behavior, psychosocial well-being, or mood. The Social Service Director (SSD) also visited with Resident D who was pleasant. No signs or symptoms of psychosocial well-being, mood concerns, or behaviors noted. - On 3/21/22 with no time noted, the SSD was notified Resident D was upset with a female peer and told her she cannot have another boyfriend. SSD and ADON spoke with him. He admitted to having this behavior and state he was jealous. SSD educated Resident D of previous conversation of him having behaviors and the potential for a 30-day discharge. He expressed understanding that this behavior could cost him a 30-day notice. He asked for a second chance. SSD stated she would speak with the Executive Director (ED). They would speak to him again next week. - On 3/23/22 at 1:33 p.m., an SSD note indicated the SSD visited with Resident D who was in good spirits. He showed no behaviors, no signs or symptoms of psychosocial well-being or mood concerns. - On 3/24/2022 at 2:34 p.m., an SSD note indicated the SSD and ADON visited with Resident D. SSD discussed threatening behaviors towards staff with yelling and screaming out, his impulsive outbursts, and safety concerns. Resident D was educated on 30 Day Discharge Notice that was issued to him on this day. Resident D became agitated and began to raise his voice, he continued to ask for another chance. SSD educated Resident D again on his behaviors. -On 4/8/22 at 10:46 a.m., a nursing note indicated the Assistant Director of Nursing (ADON), currently the Interim DON, indicated Resident D scored at a high risk on an elopement assessment due to being independently mobile and having dementia. -On 4/22/22 12:21 a.m., the Nurse Practitioner (NP) 40 indicated in a late entry that she had a discharge visit with Resident D. She indicated he was being seen today for discharge planning to the local homeless shelter per the facility. He had a past medical history of psychotic disorder, Alzheimer's disease, Schizoaffective disorder, Parkinson's disease, diabetes mellitus type 2, age-related cognitive decline, anxiety disorder, tremor, muscle weakness, difficulty in walking, and insomnia. He did not appear to be in any acute distress at this time or during this visit. He was resting quietly in a chair. He was oriented to person and place with periods of confusion. He was pleasant and cooperative. Medications were sent with Resident D upon his discharge. - On 4/22/22 at 2:53 p.m., the Discharge Summary indicated the SSD had spoken with Resident D several times throughout this week regarding his upcoming discharge on [DATE]. She informed Resident D of the clinic providing transportation from the facility to their clinic for an initial appointment on 4/22/22, then would be transported to the local homeless shelter. Resident D became agitated throughout these visits and asked on different occasions for another chance. SSD attempted to redirect Resident D by educating him but was unable to due to him yelling at writer. Staff members visited with Resident D on this day regarding his discharge to the local homeless shelter related to the 30-day discharge notice. Resident refused to leave facility. He was yelling and screaming, with threatening behaviors. He told the staff the only way he was leaving was if the cops were called. Non-emergency police were contacted to assist with escorting Resident D to an outpatient clinic's vehicle. The police escorted Resident D outside and into van. He was discharged with medications, contact numbers, and discharge information. - On 4/25/22 at 5:56 p.m., the Staffing Coordinator/Unit Manager indicated Resident D returned to facility at 5:15 p.m. today. Resident returned with medications and his belongings. He was placed in a room on the locked behavior unit. Physician's orders were received to give him his 9:00 a.m. medication now per NP 40. He was alert and oriented times 3. He ambulated on own without an assistive device. His gait was steady. - On 5/26/22 SSD was notified of Resident D smacking a Certified Nursing Aide (CNA) on the buttocks. SSD asked Resident D why he did it, educated him on appropriate behaviors and explained this behavior was inappropriate. Resident D apologized. - On 6/1/22 with no time noted, SSD was notified of Resident D becoming agitated and verbally aggressive as he stated he was jealous of the other peers wanting a girlfriend. SSD was able to redirect him with conversation, walking on the unit and offered activities of interest. He appeared in a better mood with no further behaviors noted. - On 7/20/22 with no time noted, the SSD, DON and the Rounding Psych physician denied him for inpatient psych stating medications would not help his behaviors. This was his personality and medication would not change or help him. - On 9/19/22 at 2:35 p.m., the ED indicated Resident D did not have a behavioral contract with the facility. On 9/19/22 at 2:36 p.m., the April MAR medications indicated Resident D took the following medications: 1. Aripiprazole tab 20 mg (milligram), take 1 tablet by mouth once daily for schizophrenia. 2. Quetiapine fumarate (anti-psychotic) tab 50 mg, take 1 tablet by mouth every morning. 3. Quetiapine fumarate tab 300 mg, take 1 tablet by mouth every night at bedtime. 4. Buspirone Hcl (anti-anxiety) tab 5 mg, take 5 mg by mouth 3 times a day for anxiety. 5. Lactulose (laxative) 10 gr (grams)/15 mL, take 30 mL by mouth once daily for hyperammonemia (high ammonia). 6. Trazodone Hcl (antidepressant/sedative) tab 50 mg, take 1 tablet by mouth every night at bedtime for insomnia. 7. Carbidopa/Levodopa (dopamine promotor for Parkinson's disease) tab 25-100 mg, take 1 tablet by mouth once daily. 8. Amantadine Hcl (dopamine promotor) cap 100 mg, take 100 mg by mouth once daily at 9:00 a.m. for Parkinson's. 9. Amlodipine Besylate (calcium channel blocker for high blood pressure) tab 10 mg, take 1 tablet by mouth once daily for hypertension. 10. Donepezil Hcl tab 10 mg, take 1 tablet by mouth at bedtime for major depressive disorder. 11. Gabapentin cap 300 mg, take 1 capsule by mouth three times daily for bipolar disorder. 12. Hydrochlorothiazide tab 25 mg, take 1 tablet by mouth daily for hypertension. 13. Lamotrigine tab 200 mg, take 1 tablet by mouth once daily for bipolar disorder. 14. Vitamin D cap 1.25 mg (50,000 units), take q capsule by mouth every week for vitamin daily deficiency. 15. Acetaminophen tabs 325 mg, take 2 tablets by mouth every 6 hours as needed for pain. On 9/19/22 at 3:13 p.m., the Activity Director (AD) indicated Activity Aide 36 had a good relationship with Resident D and was able to redirect him. Resident D liked to do crafts, loved newspapers, and activity staff talked to him. She indicated she did not know if the evening/night shift or weekends had special activities for him, but they did know where the activity room key was kept so they could have had access to supplies for his leisure. The facility also bought him cigarettes when he was out. Activity personnel were in the building 7 days a week until 7:00 p.m. On 9/19/22 at 3:14 p.m., the SSD indicated Resident D loved cleaning and organizing things in his room. The staff knew the resident very well. He liked to talk about cars. He liked to compare prices. The AD indicated she would take a computer to him to look at ads. The SSD indicated she was looking into making a binder of activities of interest for him. On 9/19/22 at 3:19 p.m., the ED indicated the Staff Coordinator was trained to run the locked behavior health unit and for the most part there was a dedicated staff on the behavioral health unit. The ED provided the specific training the Staff Coordinator did to be over the locked behavior unit. She watched 6 YouTube videos, totally 62.5 minutes. Then, she educated the behavioral health staff, who also watched the 6 videos. The YouTube videos were provided online by BJC Behavioral Health. They were called, Do This Not That: Providing Care for Medical Patients with Psychiatric Issues. 1. The video to educate about anxiety issues was 9:09 minutes long. 2. The video to educate about anger and aggression issues was 11:57 minutes long. 3. The video to educate about delusions issues was 9:37 minutes long. 4. The video to educate about suicide risk issues was 11:52 minutes long. 5. The video to educate about depression issues was 10:15 minutes long. 6. The video to educate about hallucination issues was 9:47 minutes long. During an interview, on 9/20/22 at 10:11 a.m., Resident D indicated the SSD did not like him. He came in from outside and the SSD indicated to him he needed to go to the local homeless shelter for no reason. He indicated he was given documents that were a 30 day notice and a right to appeal. He provided the documents to review. Resident D began shaking badly and indicated this conversation was upsetting to him. He said he received the papers but did not understand what the notice of discharge or request for a hearing meant. On the day of his discharge, he was in his room at the facility and the SSD indicated it was time to go. He had just been laying down. He indicated he was sent to the local homeless shelter and the staff at local homeless shelter indicated the facility had no right to send him there. He indicated the SSD used to say that she would send him to the local homeless shelter as a threat to get him to go the psych hospital. On the local homeless shelter day, he was mad and he faced the wall. The police came and got him to go to the front door. The police said if he didn't go to the local homeless shelter then he would go to jail in the police car. He had 3 or 4 big bags of clothes and medications. He indicated he did not know how to take medications or when. The people at local homeless shelter told him they do not dispense medications. One resident at local homeless shelter tried to start something with him, he just turned and walked away. Resident D indicated with his occasional severe shaking he was unable to read. He indicated he did not try to read the medication packaging. He did not know how to take the medication, he did not know what kind of medications he takes now, so he left them alone. He indicated sometimes he thought about killing people. He had never killed anyone or tried to kill anyone. He only thought about killing his brother and sister because they took his money and threw him out. He indicated he was mad at the SSD but had not thought about killing her. Sometimes he felt like fighting, but not fighting to kill them. During an interview on 9/20/22 at 10:47 a.m., the ED and SSD indicated they were trying to discharge Resident D from the facility because of his behaviors. The psych physician indicated he had a personality disorder, not behaviors. His behaviors were at a very high level compared to the other residents. The facility was trying to care for his needs. They were able to care for his needs. But this was a personality disorder. He did not need to be around other people. On 9/20/22 at 10:53 a.m., the SSD indicated the psych physician indicated to the facility to send Resident D to the local mental health outpatient center emergency room and not accept him back. They did not follow these instructions.