Every finding on record at Ambassador Healthcare

Based on interview, observation and record review, the facility failed to ensure residents maintained dignity by assisting residents with toileting needs in a timely manner, resulting in incontinence for 1 of 4 residents reviewed for resident rights. (Resident 14) Findings Include: The clinical record for Resident 14 was reviewed on 5/7/26 at 12:05 p.m. The resident's diagnoses included, but were not limited to: morbid obesity (body mass index of 40 or higher), essential tremors (progressive neurological disorder that caused involuntary rhythmic shaking), mononeuropathy of bilateral upper limbs (damage to or compression of individual peripheral nerves in both arms or hands), and chronic pain syndrome. The care plan, dated 10/3/25 and revised 12/19/25, indicated Resident 14 had occasional episodes of bladder incontinence. An intervention was to provide moderate assistance with toilet transfers and hygiene. An interview was conducted with Resident 14 on 5/7/26 at 12:16 p.m. The resident indicated she could usually get herself onto the commode, but she needed assistance with wiping afterwards. She would wait twenty minutes for staff to come assist her with wiping after she pressed her call light. When staff finally came to assist, she was sitting in a dirty brief from having had a bowel movement and inability to wipe herself. An interview was conducted with CNA (Certified Nursing Assistant) 5 on 5/12/26 at 10:50 a.m., the CNA indicated she worked with Resident 14 roughly once a week. The resident needed extensive assistance with hygiene. Resident 14 did not need help transferring onto or off the commode, only with wiping afterwards and pulling her pants back up. The resident used her bathroom call light to ask for assistance. CNA 5 hadn't known Resident 14 to assist herself off the commode. She usually always used her call light. An interview was conducted with Resident 14 on 5/12/26 at 11:11 a.m., the resident indicated that morning she pressed her call light around 7:15 a.m., and she didn't get assistance until 8:00 a.m. The resident normally took herself to the bathroom, but today she needed assistance onto the toilet. CNA 7 was the one who assisted her onto the commode. When CNA 7 assisted her, CNA 7 informed Resident 14 she had to get breakfast trays out, and that was why it took her so long to answer her call light. Resident 14 understood that, but the facility still needed staff to assist residents with going to the restroom. An interview was conducted with CNA 7 on 5/12/26 at 11:29 a.m., the CNA indicated she assisted Resident 14 onto the commode after breakfast, around 8:00 a.m. CNA 7 did not know how long Resident 14's call light was on, before she answered it to assist her. CNA 7 was assisting another resident with eating, so when she finished, she went into Resident 14's room to help her. CNA 7 could hear Resident 14's call light going off while assisting the other resident, but she did not want to leave the other resident. The other CNA working the hall was assisting another resident at the time too. Resident 14 informed CNA 7 that her call light had been on for 45 minutes. An interview was conducted with RN (Registered Nurse) 8 on 5/12/26 at 11:29 a.m., the RN indicated she was in and out of rooms passing medications during that timeframe and did not see Resident 14's call light on. No one was sitting at the nurse's desk during that timeframe either, because everyone was very busy An interview was conducted with the DON (Director of Nursing) on 5/12/26 at 11:36 a.m., the DON indicated Resident 14 was a fairly reliable source of information but found a 45 minute wait time hard to believe. She could see 15 to 20 minutes, especially during mealtimes. Typically, a five-to-ten-minute wait time was fine. An interview was conducted with the DON on 5/13/26 at 10:55 a.m., the DON indicated she looked at the facility's cameras and found Resident 14's call light was on 24 minutes before CNA 7 went into the room to assist her. It was turned on at 7:38 a.m. and turned off at 8:02 a.m. An interview was conducted with Resident 14 on 5/13/26 at 11:18 a.m., the resident indicated she was agitated while waiting for someone to come and assist her to the restroom. It was hard to hold it in while waiting, and her stomach was cramping. The Residents Call System policy was provided by the ED (Executive Director) on 5/12/26 at 12:52 p.m. It indicated, Calls for assistance are answered as soon as possible, but no later than 5 minutes. Urgent requests for assistance are addressed immediately. During a confidential interview conducted during the survey, from 5/6/26 through 5/13/26, the confidential interview indicated the staff walked by or entered a residents room and stated they would get help, but it took hours to receive assistance from the toilet. By the time staff assisted the residents, they had already experienced bowel and bladder incontinence. A policy entitled, Resident Rights, was provided by the Administrator on 5/13/2026 at 9:52 AM. The policy indicated resident had the right to be treated with kindness, dignity, and respect. 410 IAC (Indiana Administrative Code) 3.1-3(a)410 IAC 3.1-38(a)(2)(C)

Based on observation, interview, and record review, the facility failed to honor a resident's bathing time preference for 1 of 1 resident reviewed for choices. (Resident 14)Findings include:The clinical record for Resident 14 was reviewed on 5/7/26 at 12:05 p.m. The resident's diagnoses included, but were not limited to: morbid obesity (body mass index of 40 or higher), essential tremors (progressive neurological disorder that caused involuntary rhythmic shaking), mononeuropathy of bilateral upper limbs (damage to or compression of individual peripheral nerves in both arms or hands), and chronic pain syndrome. The activities of daily living (ADL) care plan, revised on 12/19/25, indicated the resident required moderate assistance with self-care and mobility tasks related to weakness. An intervention was for staff to assist her with any areas of bathing she could not complete, initiated 10/3/25. The preferences and specifications care plan, revised 12/19/25, indicated the resident preferred to take a shower in the morning. An interview was conducted with Resident 14 on 5/7/26 at 12:11 p.m. The resident indicated she was fine with her scheduled shower days of Wednesday and Saturday, but she wanted to take them in the morning, not at night. She received more of them at night than she did in the morning. An interview was conducted with Certified Nursing Assistant (CNA) 5 on 5/12/26 at 10:50 a.m. The CAN indicated she worked at the facility with Resident 14 roughly once a week. Resident 14 required extensive assistance of one staff person for showers. She worked from 10:00 a.m. to 6:00 p.m. She had never given Resident 14 a shower, because she did not work during Resident 14's scheduled shower time. When she arrived at the facility, Resident 14 was always already up and dressed. Her showers weren't until the evening time. An observation of the shower schedule posted on the shower room door and interview was conducted with CNA 5 on 5/12/26 at 10:53 a.m. The schedule indicated Resident 14's shower was scheduled for second shift on Saturdays and Wednesdays. CNA 5 indicated second shift was 2:00 p.m. to 10:00 p.m., but Resident 14 received her showers after CNA 5 left at 6:00 p.m. An interview was conducted with Resident 14 on 5/12/26 at 11:11 a.m. The resident indicated when staff waited until 7:00 p.m. to offer her a shower, she ended up telling them she didn't want one anymore, because it was too late for her by then. An interview was conducted with the Director of Nursing (DON) on 5/12/26 at 11:36 a.m. The DON indicated the CNAs were giving showers based on residents' room numbers, instead of each resident's actual preference, but they were working on getting that process fixed. CNA 6 worked with Resident 14 more regularly and would have more insight into when Resident 14 received her showers. An interview was conducted with CNA 6 on 5/12/26 at 2:32 p.m. The CNA indicated she always assisted Resident 14 with her showers before she left at 6:00 p.m., but it was not necessarily in the morning. It was usually before 2:00 p.m. The Resident Self Determination and Participation policy was provided by the Executive Director (ED) on 5/12/26 at 12:52 p.m. It indicated, Each resident is allowed to choose activities, and schedule health care and healthcare providers, that are consistent with his or her interests, values, assessments and plans of care, including: a. daily routine, such as sleeping and waking, eating, exercise and bathing schedules. 410 IAC (Indiana Administrative Code) 16.2-3.1-3(u)(1)

Based on interview and record review, the facility failed to incorporate the recommendations from a resident's PASRR (Preadmission Screening and Resident Review) Level II determination and PASRR evaluation report for 1 of 1 resident reviewed for PASRR. (Resident 14)Findings include:The clinical record for Resident 14 was reviewed on 5/7/26 at 12:05 p.m. The resident's diagnoses included, but were not limited to: bipolar disorder (mental health condition that causes extreme, uncontrollable shifts in a person's mood), anxiety, and attention deficit disorder (neurodevelopmental disorder marked by persistent patterns of inattention, hyperactivity, and impulsivity). The physician's orders indicated Resident 14 was prescribed Aripiprazole (antipsychotic medication) Oral Tablet 5 MG tablet in the morning for bipolar disorder, effective 11/17/25, and Desvenlafaxine Succinate ER (antidepressant medication) Oral Tablet Extended Release 24 Hour 100 MG one tablet in the morning for bipolar disorder, effective 11/17/25. The PASRR Level II , dates 3/12/26, indicated she needed to be provided with mental health services that included individual therapy. The reasons for this support were she would benefit from mental health counseling to help cope with the symptoms of her bipolar disorder, and she needed medication monitoring with a psychiatrist/psychiatric nurse practitioner to make sure her medication was working well. There was no documentation in Resident 14's clinical record that indicated she received individual mental health therapy or medication monitoring with a psychiatrist/psychiatric nurse practitioner while in the facility. An interview was conducted with the Director of Nursing (DON) on 5/13/26 at 10:55 a.m., the DON indicated there was no verification that the recommendation for individual mental health therapy or medication monitoring with a psychiatrist/psychiatric nurse practitioner was addressed after the PASRR Level II dated 3/12/26. An interview was conducted with the Business Office Manager (BOM) on 5/13/26 at 11:13 a.m., the BOM indicated she scanned the PASRR Level IIs into residents' electronic health records, but she did not review them for recommendations. An interview was conducted with Resident 14 on 5/13/26 at 11:18 a.m., the resident indicated discussing her concerns in mental health counseling might help. The PASRR and Level of Care (LOC) admission policy was provided by the ED (Executive Director) on 5/13/26 at 11:53 a.m. It indicated, POST-admission REQUIREMENTS PASRR Compliance.Implement specialized services identified in Level II. DOCUMENTATION REQUIREMENTS The medical record must include: .Evidence of specialized services (if required) . RESPONSIBILITIES.Social Services: .Coordinate PASRR Level II process. Ensure follow-up on specialized services.

The facility failed to accurately and complete document eternal feeding and flush documentations for 1 of 3 residents reviewed for documentation accuracy. (Resident 98) The clinical record for Resident 98 was reviewed on 5/11/2026 at 11:09 a.m. The resident's diagnoses included, but were not limited to, amyotrophic lateral sclerosis (progressive neurological disorder) and ventilator dependence. An annual Minimum Data Set (MDS) assessment, dated 2/14/2026, indicated Resident 98 was cognitively impaired, had verbal outbursts that affected others, did not have weight loss, and was dependent on tube feeding. The assessment indicated Resident 98 had impaired mobility in all four extremities, was dependent on staff for all activities of daily living, and did not take nutrition by mouth.A care plan, dated 6/5/2024 and revised on 2/25/2026, indicated Resident 98 had specialized needs. The interventions included, but were not limited to, providing specialized dietary management including nothing by mouth and providing supplemental nutrition via enteral feedings.A nutritional care plan, dated 6/14/2024 and revised on 2/25/2026, indicated Resident 98 was at risk for an alteration in nutrition due to the need for enteral feedings. The interventions included, but were not limited to, administering artificial nutrition support as ordered and administering flushes as ordered.A physician's order, dated 4/7/2026, indicated Resident 98 was to receive Diabetisource, 1.2 enteral feeding, at 55 mL(milliliters)/hour continuously, with a 10 mL/hour continuous water flush. The order indicated the feeding was to run through the G/J-tube and was related to unspecified severe protein-calorie malnutrition. A physician's order, dated 4/20/2026, indicated Resident 98's G/J-tube was to be flushed four times a day with 75 mL of water.Review of the May 2026 Medication and Treatment Administration Record indicated blank documentation for water flushes from May 1 at 6:00 p.m. until May 11 at 6:00 a.m. The resident's enteral feeding documentation was blank from May 1 during 2:00 p.m. to 10:00 p.m. shift until May 11 during 6:00 a.m. to 2:00 p.m. shift.During an observation, on 5/6/2026 at 1:05 p.m., Resident 98's tube feeding was observed as administering as ordered.During an interview with the Director of Nursing (DON), on 5/11/2026 at 1:38 p.m., the DON indicated there had been a system documentation error. The workflow for documenting enteral feedings had been changed to an electronic form the facility did not use. Staff had been completing shift checks on paper report sheets; however, those sheets were not retained as part of the resident's medical record. During an interview with the Administrator, on 5/13/2026 at 11:30 a.m., the Administrator indicated residents dependent on enteral feedings had not had any unexplained weight loss from 5/1/2026 through 5/11/2026. A policy entitled, Charting and Documentation, was provided by the Executive Director on 5/11/2026 at 2:57 PM. The policy indicated medication administrations, treatments and services performed should be documented in the medical record for each resident. 410 IAC (Indiana Administrative Code) 16.2-3.1-50(a)(1)410 IAC 16.2-3.1-50(a)(2)

Based on interview and record review, the facility failed to implement an inventory sheet with resident belongings for newly admitted residents for 3 of 3 residents reviewed for missing items. (Resident B, Resident D and Resident C)Findings include:1. The clinical record for Resident B was reviewed on 8/11/25 at 11:00 a.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus and congestive heart failure. Resident B was admitted to the facility on [DATE]. During an interview on 8/12/25 at 1:30 p.m. with Resident B's family member, they indicated Resident B should have arrived at the facility, on 7/26/25, with a back brace and he did not. Resident B's family member indicated she contacted the hospital Resident B discharged from and they indicated he was discharged with the back brace on him for transport. The family member indicated the facility did not fill out an inventory sheet upon admission. No inventory sheet was documented in Resident B's Electronic Health Record (EHR). During an interview with Licensed Practical Nurse (LPN) 4 on 8/12/25 at 1:17 p.m., she indicated she did not fill out an inventory sheet when Resident B was admitted to the facility. LPN 4 indicated facility staff normally completed them on all new admissions. During an interview with the Director of Nursing (DON) on 8/12/25 at 2:06 p.m., she indicated facility staff were responsible for making sure inventory sheets for residents were completed. 2. During an interview with Resident D on 8/12/25 at 11:10 a.m., she indicated she was admitted to the facility, on 8/8/25, and the facility did not fill out an inventory sheet with her belongings. The resident indicated she did not know if she had any personal belongings missing because she did not know what all was brought with her when she came. During an interview with LPN 2 on 8/12/25 at 11:48 a.m., they indicated the facility did not have resident records in a hard chart or on paper it was all documented on the EHR in the computer. The clinical record for Resident D was reviewed on 8/12/25 at 1:55 p.m. The diagnoses included, but were not limited to, lung cancer, emphysema, heart failure, osteoporosis, anxiety and depression. The resident's record did not indicate an inventory sheet was completed for the resident. A progress note for Resident D, dated 8/8/25 at 9:50 a.m., indicated the resident was admitted to the facility. The resident was alert and oriented to person, place, time and situation. The resident was able to answer questions appropriately. 3. During an interview with Resident C on 8/12/25 at 11:50 a.m., he indicated the facility did not complete an inventory sheet of his belongings when he was admitted to the facility. Resident C indicated he did not have any belongings missing that he was aware of. The clinical record for Resident C was reviewed on 8/12/25 at 2:20 p.m. The diagnoses included, but were not limited to, hypertension, diabetes, atrial fibrillation, malnutrition and hyperlipidemia. The resident's record indicated an inventory sheet was not completed for the resident's belongings. The quarterly Minimum Data Set (MDS) assessment for Resident C, dated 7/3/25, indicated the resident was cognitively intact for daily decision making. The resident was reasonable and consistent. The resident was admitted to the facility on [DATE]. This citation relates to Complaint 2578556. 3.1-50(a)(1)

Based on interview and record review, the facility failed to include the resident's family in a physician follow-up visit with the neurosurgeon's office, at their request, after the resident's back surgery for 1 of 3 residents reviewed for physician appointments. (Resident B)The findings include:During an interview with Resident B's family member on 8/11/25 at 1:30 p.m., she indicated the family and Resident B had a virtual doctor's appointment with neurosurgery scheduled for 7/28/25 at 9:15 a.m. Resident B's family member indicated Licensed Practical Nurse (LPN) 3 had come into Resident B's room the morning of the appointment and mentioned something about a tablet to use for the appointment and Resident B's family member indicated she was not sure how to use the tablet. So, she wanted LPN 3 to have the doctor's office call her phone because the family, as well as the resident, wanted to speak to the surgeon about Resident B's fall the day before and not having the required back brace at the facility. The family member indicated the resident was capable of participating in the virtual meeting and had questions and so did the family. The family member indicated LPN 3 took the phone call without including the family as requested. An Inpatient Discharge Instructions form was provided by the Executive Director on 8/12/25 at 10:30 a.m. It indicated Resident B was to receive a virtual home visit follow up appointment with neurosurgery on 7/28/25 at 9:15 a.m.During an interview with LPN 3 on 8/12/25 at 11:12 a.m., she indicated Resident B's wife was who set up the virtual appointment at the hospital and was unsure what phone number she gave them. LPN 3 indicated that any appointments for residents are recorded on their unit calendar. The unit calendar, for 7/28/25, indicated Resident B had a neurosurgeon virtual visit and the phone number of the neurosurgeon's office at 9:15 a.m. LPN 3 indicated she did not know how to use the tablet for virtual doctor's visits. When the neurosurgeon's office called the facility she took the call, provided information, and received new orders but did not think the family needed to be in on the phone call.During an interview with the Director of Nursing (DON) on 8/12/25 at 2:06 p.m., she indicated physician's office usually will call the facility and set up a virtual office visit. The physician's office will provide us with an email/code for our tablet so everyone can be involved.During an interview with the Executive Director (ED) on 8/12/25 at 2:00 p.m., he indicated the facility did not have a policy regarding virtual doctor's appointments. This citation relates to Intake 2578556. 3.1-3(n)(3)

Based on interview and record review, the facility failed to ensure follow up was conducted on care concerns for a resident and the resident's family who had expressed multiple care concerns via email and follow the facility's policy pertaining to grievances for 1 of 3 residents reviewed for quality of care. (Resident B)Findings include: The clinical record for Resident B was reviewed on 8/11/25 at 11:00 a.m. The diagnoses included, but were not limited to, Parkinson's disease and rib fracture.During an interview with Resident B's family member on 8/11/25 at 1:30 p.m., they indicated they emailed the Admission's Director a list of concerns that Resident B's family had throughout their stay at the facility. During an interview with the Director of Nursing (DON) on 8/12/25 at 2:06 p.m., she indicated social services were responsible for filing a grievance.During an interview with the Social Service Director (SSD) on 8/12/25 at 2:25 p.m., she indicated she was aware that Resident B's family had concerns and believed the Admission's Director was handling them. The SSD indicated whoever took the grievance was usually the person who fills them out and were then turned into her to file.During an interview with the Admission's Director on 8/12/25 at 2:34 p.m., she indicated she did not fill out a grievance after receiving Resident B's family member's email of concerns. The Admission's Director indicated she forwarded the email to the SSD, DON, Executive Director (ED), and physical therapy. The Admission's Director indicated she thought letting everyone know by email would update them on the concerns Resident B's family had. The Admissions Director provided an email with Resident B's family concerns.The email, dated 8/4/25, sent by Resident B's family, indicated the following care concerns: a missing back brace, thrown away items, delay in follow-up after a fall, cleanliness of resident's room, and care assistance.A Filing Grievances/Complaints Policy was provided by the ED on 8/12/25 at 3:00 p.m. It indicated, .7. Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and/or complaint .This citation relates to Complaint 2578556.3.1-7(a)(2)

Based on interview and record review, the facility failed to follow a neurosurgeon's discharge instructions to call 911 or go to the hospital if the resident experienced a fall and ensure a resident and the resident's family were included in a virtual physician follow-up appointment with the neurosurgeon's office after the resident's back surgery for 1 of 3 residents reviewed for physician appointments and quality of care. (Resident B) Findings include: A. The clinical record for Resident B was reviewed on 8/11/25 at 11:00 a.m. The diagnoses included, but were not limited to, obstructive sleep apnea and fracture of T11-T12 vertebra.A Resident Fall Investigation Checklist was provided by the Executive Director (ED) on 8/12/25 at 10:00 a.m. It indicated Resident B had an unwitnessed fall in his room on 7/27/25 at 8:45 a.m.During an interview with Resident B's family member on 8/11/25 at 1:30 p.m., they indicated they called the facility back after Resident B's fall and requested he have an x-ray since he recently had major back surgery. Resident B's family member indicated the facility staff told her they had onsite x-ray, and they would do it. The family member indicated the x-ray was not done until the next day on 7/28/25.A nurse's note, dated 7/27/25 at 3:20 p.m., indicated Resident B's family requested a spinal x-ray due to his fall and an order was placed at that time.Resident B's discharge summary from the hospital, dated 7/26/25, indicated discharge orders/instructions, included but were not limited to, go to the emergency department or call 911 if you have a fall.B. During an interview with Resident B's family member on 8/11/25 at 1:30 p.m., she indicated the family and Resident B had a virtual doctor's appointment with neurosurgery scheduled for 7/28/25 at 9:15 a.m. Resident B's family member indicated Licensed Practical Nurse (LPN) 3 had come into Resident B's room the morning of the appointment and mentioned something about a tablet to use for the appointment and Resident B's family member indicated she was not sure how to use the tablet. So, she wanted LPN 3 to have the doctor's office call her phone because the family, as well as the resident, wanted to speak to the surgeon about Resident B's fall the day before and not having the required back brace at the facility. The family member indicated the resident was capable of participating in the virtual meeting and had questions and so did the family. The family member indicated LPN 3 took the phone call without including the family as requested. An Inpatient Discharge Instructions form was provided by the Executive Director on 8/12/25 at 10:30 a.m. It indicated Resident B was to receive a virtual home visit follow up appointment with neurosurgery on 7/28/25 at 9:15 a.m.During an interview with LPN 3 on 8/12/25 at 11:12 a.m., she indicated Resident B's wife was who set up the virtual appointment at the hospital and was unsure what phone number she gave them. LPN 3 indicated that any appointments for residents are recorded on their unit calendar. The unit calendar, for 7/28/25, indicated Resident B had a neurosurgeon virtual visit and the phone number of the neurosurgeon's office at 9:15 a.m. LPN 3 indicated she did not know how to use the tablet for virtual doctor's visits. When the neurosurgeon's office called the facility she took the call, provided information, and received new orders but did not think the family needed to be in on the phone call.During an interview with the Director of Nursing (DON) on 8/12/25 at 2:06 p.m., she indicated physician's office usually will call the facility and set up a virtual office visit. The physician's office will provide us with an email/code for our tablet so everyone can be involved.During an interview with the Executive Director (ED) on 8/12/25 at 2:00 p.m., he indicated the facility did not have a policy regarding virtual doctor's appointments. This citation relates to Complaint 2578556. 3.1-37(a)

Based on interview and record review, the facility failed to ensure a resident's equipment of an enabler bar was functioning properly, failed to complete a thorough assessment after the resident's fall, and failed to implement fall interventions for a resident at high risk for falls for 1 of 3 residents reviewed for falls. (Resident B)Findings include: The clinical record for Resident B was reviewed on 8/11/25 at 11:00 a.m. The diagnoses included, but were not limited to, Parkinson's disease and fracture of T11-T12 vertebra.An Admit/Readmit Screener, dated 7/26/25, indicated Resident B had recent falls and was at risk for falls. Bilateral side rails for the bed were indicated for safety. A Resident Fall Investigation Checklist was provided by the Executive Director on 8/12/25 at 10:00 a.m. It indicated Resident B had a fall in his room on 7/27/25 at 8:45 a.m. The checklist indicated side rails need to be positioned and bedside rail on left side was stuck down. During an interview with Resident B's family member on 8/11/25 at 1:30 p.m., they indicated Resident B was admitted , on 7/26/25, and had a TV remote with no batteries. Resident B's family member indicated the morning Resident B fell, on 7/27/25, he had been asking about his TV and thought he was getting out of bed to turn on the TV when he fell. Resident B's family member indicated the TV remote kept coming up missing during his stay at the facility and he really enjoyed watching TV. During an interview with Licensed Practical Nurse (LPN) 4 on 8/12/25 at 1:17 p.m., she indicated Resident B's enabler bar on his bed was stuck down. The bar had a little black knob on it, but it wouldn't work. LPN 4 indicated she did not have the tools to fix the bed. LPN 4 indicated the Admissions Coordinator, Certified Nurse Aides (CNAs), and maintenance were responsible to ensure rooms were appropriately set up with working equipment and supplies for newly admitted residents. The Resident Fall Investigation Checklist indicated post fall assessments would be completed every shift for 72 hours post fall. No post fall assessments were documented in the electronic health record (EHR) for 7/27/25. The plan of care for Resident B indicated he was at risk for falls. The care plan indicated no fall interventions were implemented until 7/28/25.During an interview with the Director of Nursing (DON) on 8/12/25 at 2:06 p.m., she indicated she did not know why any post fall assessments were not completed for 7/27/25.A policy entitled Falls - Clinical Protocol was provided by the Executive Director on 8/11/25 at 11:00 a.m. The policy indicated the following, .Assessment and Recognition . 2. In addition, the nurse shall assess and document/report the following . a. Vital signs . b. Recent injury, especially fracture or head injury . c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc . d. Change in cognition or level of consciousness . e. Neurological status . f. Pain . h. Precipitating factors, details on how fall occurred . 3. The staff and practitioner will review each resident's risk factors for falling and document in the medical record . 5. The stall will evaluate and document falls that occur while the individual is in the facility . Monitoring and Follow-Up . 1. The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved . 2. The staff and physician will monitor and document the individual's response to interventions in-tended to reduce falling or the consequences of falling This citation relates to Complaint 2578556. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to provide a homelike environment by not providing television (TV) remotes for newly admitted residents to watch TV per their preference for 2 of 3 residents reviewed for accommodation of needs. (Resident B and Resident D) Findings include: 1. During an interview with Resident B's family member on 8/11/25 at 1:30 p.m., they indicated Resident B was admitted , on 7/26/25, and had a TV remote with no batteries. Resident B's family member indicated the morning Resident B fell, on 7/27/25, he had been asking about his TV and thought he was getting out of bed to turn on the TV when he fell. Resident B's family member indicated the TV remote kept coming up missing during his stay at the facility and he really enjoyed watching TV. The clinical record for Resident B was reviewed on 8/11/25 at 11:00 a.m. The diagnoses included, but were not limited to, dementia and atrial fibrillation. During an interview with Licensed Practical Nurse (LPN) 4 on 8/12/25 at 1:17 p.m., they indicated the Admissions Coordinator, Certified Nurse Aides (CNAs), and maintenance were responsible to ensure rooms were appropriately set up with working equipment and supplies. 2. During an observation and interview with Resident D on 8/11/25 at 11:39 a.m., the resident was sitting in her room and indicated she was admitted to the facility on [DATE]. Resident D indicated she had been without a remote control to her TV since being admitted to the facility. At that time, the resident did not have a TV remote visible in her room. During an interview with Resident D on 8/12/25 at 11:10 a.m., she indicated she went three days without a remote since her admission to the facility. The resident indicated she was unable to walk or stand so she could not turn on her TV without a remote. Resident D indicated she stared at the walls all weekend. The resident indicated she reported to the nursing staff that she needed a remote control for her TV, but they told her that she would have to wait until Monday when maintenance was working. The resident indicated watching TV was about all she could physically do. The clinical record for Resident D was reviewed on 8/12/25 at 1:55 p.m. The diagnoses included, but were not limited to, lung cancer, emphysema, heart failure, osteoporosis, anxiety and depression. A progress note for Resident D, dated 8/8/25 at 9:50 a.m., indicated the resident was admitted to the facility. The resident was alert and oriented to person, place, time and situation. The resident was able to answer questions appropriately. The plan of care for Resident D, dated 8/11/25, indicated the resident was alert and able to make leisure lifestyle choices and preferred self-directed activities in her room. The interventions included, but were not limited to, watching TV. This citation relates to Complaint 2578556. 3.1-19(f)(5)

Based on interview and record review, the facility failed to ensure an allegation of verbal abuse was reported to the Indiana Department of Health within two (2) hours of its receipt for 1 of 3 residents reviewed for abuse. (Resident D)Findings include:In an interview with Resident D on 7-17-25 at 11:20 a.m., she indicated a physical therapist (PT 3) had been rude to her in the recent past when PT 3 told her, Show me what you can do, indicating this occurred after she had kicked me off of physical therapy. She indicated she promptly shared this information with the Social Services Staff and the Executive Director. In an interview with the Executive Director (ED) on 7-17-25 at 1:15 p.m., the ED indicated he did not report this as an allegation of abuse to the state. He indicated as soon as the facility began their investigation, It was very clear it was not abuse, but merely the resident being told something that she did not want to hear by the PT, who tends to be rather direct. On 7-17-25 at 10:36 a.m., the ED provided a copy of a policy entitled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program. This policy indicated, Residents have the right to be free from abuse, neglect.but it is not limited to freedom from.verbal.abuse.Identify and investigate all possible incidents of abuse.Investigate and report any allegations within timeframes required by federal requirements. This citation relates to Complaint IN00462662. 3.1-28(c)

Based on interview and record review, the facility failed to ensure a resident was referred for home health nursing services upon discharge for 1 of 3 residents reviewed for discharge. (Resident B)Findings include:The clinical record for Resident B was reviewed on 7/17/25 at 11:10 a.m. His diagnoses included, but were not limited to, mechanical complication of internal left knee prothesis, infection and inflammatory reaction due to internal left knee prosthesis, hypertension, and type 2 diabetes mellitus. He was admitted to the facility on [DATE] and discharged on 6/18/25. The 6/7/25 admission MDS (Minimum Data Set) assessment indicated he was cognitively intact.An interview was conducted with Resident B on 7/18/25 at 3:03 p.m. He indicated he had an infection in his leg and was on IV (intravenous) antibiotics four times a day while at the facility. When he was discharged from the facility on 6/18/25, they should have ordered nursing services for him, not just therapy. He wasn't able to get the IV antibiotics anymore but was supposed to be on them for two more weeks. It was almost a week after discharge, before he got everything figured out, but by that time, he'd already been off the antibiotics for a week. He was discharged from the facility with home health, but when the home health company contacted him after discharge, they informed him they only had an order for therapy. There were no orders for nursing, including the care of his PICC (peripherally inserted central catheter.) The first time the home health nurse came to see him, she just looked at the PICC, to ensure there were no signs of infection, because she had no orders. By the time it was straightened out and he was seen by a nurse from home health, his PICC dressing was overdue for a dressing change, as it had been almost two weeks since it was changed. Eventually, his PCP (primary care physician) wrote an order for home health to pull the PICC. Resident B's ID (infectious disease) physician was on leave at the time, so they were unable to write an order. He stated, If the facility had sent over the proper orders, I would have had what I needed. Someone from the facility came to speak with him, on 6/18/25, about the Medicaid application process, and he left the facility five hours later. He left with a 30-day supply of some medicine, two administrations of antibiotics, and some discharge paperwork, but no orders.On 7/17/25 at 2:21 p.m., an interview was conducted with the local hospital's social worker, where Resident B's Infectious Disease physician's office was associated. She indicated they were concerned with him discharging from the facility with a PICC in place and no follow-up for antibiotic treatment. Their office was informed when Resident B called and tried to set up getting his antibiotics taken care of after leaving the facility. The 5/30/25 medical professional progress note indicated the reason for the visit was debility, hypertension, failed total knee arthroplasty, obesity, diabetes mellitus, type 2, and left knee wound dehiscence. He was admitted to a local hospital, on 5/19/25, with a left total knee prosthetic joint infection, left total knee open dislocation, and traumatic arthrotomy of the left knee. He was transferred from the hospital to the facility, on 5/29/25, for continued skilled nursing care and rehabilitation. He was currently receiving IV antibiotics via a PICC line, with treatment scheduled to continue until 6/30/25. His admission to the facility included management of ongoing medical conditions, administration of IV antibiotics, and participation in physical and occupational therapy to aid in recovery. The Assessment and Plan section of the note indicated for the infection associated with prosthesis for left knee joint was to continue IV Cefepime as ordered until 6/30/25 and follow up in one week. The facility physician's orders indicated to administer one IV application of Daptomycin-Sodium Chloride Intravenous Solution 700-0.9 mg/100ML-% at bedtime, effective 5/31/25 until 6/30/25; to administer one IV application of Cefepime HCl Intravenous Solution 1 GM/50ML (one gram/50 milliliters) every 8 hours, effective 5/30/25 until 6/30/25; to change the sterile PICC dressing once a week and as needed if soiled, every evening shift every Saturday, from 6/2/25 to 6/7/25, and starting 6/14/25; to flush the PICC with 3-5 cc (three to five cubic centimeters) of saline, administer antibiotic, then flush with heparin followed by saline, every shift, effective 5/30/25; and to change the IV tubing every 24 hours for PICC line/IV antibiotic, effective 5/29/25. The 6/2/25 hospital follow up note indicated he was two weeks status post left knee resection arthroplasty incision. He was currently receiving Cefepime and Daptomycin per ID recommendation. He was doing relatively well. They would see him back in one week for possible staple removal and to check progress. He was to continue with IV antibiotics per infectious disease recommendation.The 6/18/25 nurses note indicated, Resident discharged from facility to home with family. All discharge paperwork signed and sent with resident's family. Sent inhaler, atb [antibiotic], insulin with resident/resident's family. Home health script [prescription] sent with family. No issues, complaints or concerns voiced. All personal belongings sent as well.The 6/18/25 Discharge Order Form, scanned into the electronic health record, indicated he discharged with home health care for therapy, but not for nursing services. The discharge planner was the SSD (Social Services Director). The form was signed by the NP (nurse practitioner) on 6/18/25. There was an order attached, dated 6/18/25 and signed by the NP (nurse practitioner) on 6/18/25, for a home health care evaluation for physical therapy and occupational therapy only. There was a second order attached, dated 6/23/25 and signed the NP on 6/23/25, for a referral for home health nursing services to include bandage changes.An interview was conducted with the facility's SSD on 7/17/25 at 12:44 p.m. She indicated she spoke with Resident B the day he left. He discussed the Medicaid process with her, and informed her he was leaving that day, so the SSD did a discharge for him. She set him up with home health care. Normally, when she knew someone was about to be discharged , they'd have the home health care company come into the facility to evaluate the resident, so everyone was on the same page, but since he was leaving that day, she could only send a referral. She spoke with home health directly that day, made the referral, then was out of the picture. Several days later, Resident B called her back, saying he'd been calling other places, trying to get his antibiotic and PICC care handled. Apparently, there was confusion with the PICC and antibiotic treatment with the home health company, since he called her back a few days after he was discharged . Resident B was aggravated at the time, saying he called one person, who then told him to call someone else, so the SSD informed him she would look into it. The referral for home health nursing services did not come until 6/23/25, when he called back, because that was when she was made aware of his need for it. The SSD thought the home health company needed an actual referral for nursing care. Resident B left the faciity on 6/18/25 with everything he needed, except the referral for nursing care. An interview was conducted with Resident B's Home Health Patient Care Manager, on 7/17/25 at 1:40 p.m., via telephone in the presence of the SSD. She indicated home health nursing services began on 6/24/25, after receiving the 6/23/25 referral for such. Resident B had a PICC, but no order for the PICC, no orders for the antibiotics, and nothing set up through an IV company. The facility was supposed to set up services for him through an IV company that supplied IV supplies. They were unable to do anything with Resident B's PICC line, and his PCP (primary care provider) would not give orders, because she wasn't the infectious disease provider. They needed orders, and the facility should have coordinated that, as well as with the IV company, because home health did not do that part. The only referral sent on 6/18/25, was for therapy. Resident B contacted the home health company to ask when services for his PICC would start, but since they had no orders, they were unable to provide the care, and eventually his PCP ordered to remove his PICC on 6/25/25. They removed it on 6/26/25. Resident B ended up taking Doxycycline twice daily, effective 6/24/25, probably from a bottle he already had at home.An interview was conducted with RN (Registered Nurse) 2 on 7/18/25 at 11:08 a.m. She indicated Resident B was at the facility after surgery. He was treated for pain, infection, and came with a PICC. They tried to get him to stay at the facility the day he was discharged . She talked to him that day, and he was worried about the Medicaid process. He was adamant about leaving. Upon discharge, he needed home health care for his IV antibiotic, their biggest concern. He needed to continue on the antibiotic due to infection. RN 2 thought the SSD got home health set up for him prior to leaving. RN 2 did not know why the nursing referral was not made at discharge but probably should have been. She did not know how the nursing services were missed at discharge. They got the orders into the pharmacy, but she did not know where the rest of it went.The Discharge Summary and Plan policy was provided by the ED (Executive Director) on 7/18/25 at 9:08 a.m. It indicated, Discharge to the Community .3. The facility makes referrals to local agencies, the local ombudsman, and support services that can assist in accommodating the resident's post-discharge preferences, as appropriate. Referrals made for this purpose, and the response to these referrals, are documented in the medical record 6. For residents discharged to their home, the medical record contains documentation that written and verbal discharge instructions were given to the resident or representative, and that the instructions were conveyed in a language and manner understood by the resident or representative.This Citation relates to Complaint IN00462276 and Complaint IN00462795. 3.1-12(a)(18)

Based on observation, interview, and record review, the facility failed to implement fall interventions, as care planned; transfer a resident utilizing a gait belt, as required; ensure position change alarm use was monitored for efficacy on an on-going basis; and ensure position change alarm use was aimed at assisting staff to assess for patterns and routines of residents for 4 of 5 residents reviewed for accidents. (Residents 23, 31, 41, and 71) Findings include: 1. The clinical record for Resident 71 was reviewed on 4/24/25 at 11:55 a.m. Her diagnoses included, but were not limited to, rheumatoid arthritis, diabetes mellitus, and stage four pressure ulcer of sacral region. She was admitted to the facility on [DATE]. The 1/14/25 Annual MDS (Minimum Data Set) assessment indicated she was cognitively intact. She was totally dependent for toileting hygiene, bathing, lower body dressing, and putting on/taking off footwear. She required substantial/maximal assistance with eating, oral hygiene, upper body dressing, and personal hygiene. An observation and interview were conducted with Resident 71 in her room on 4/24/25 at 11:57 a.m. She was lying in bed at that time. A position change alarm was attached to the side of her bed. Resident 71 indicated she had an alarm on her bed that beeped, if she moved around. She didn't' like it. It beeped all the time and was really loud. The physician's orders indicated to check the function and placement of her bed and chair alarm every shift, effective 9/11/23. The 9/11/23 at risk for falls care plan indicated she would climb out of bed and onto the floor mat and unplug her bed alarm. Interventions were bed and chair alarms, initiated 9/11/23. The clinical record indicated Resident 71's last fall was on 10/31/24, when she slid out of her wheel chair onto the floor after being transferred into her wheel chair with a Hoyer lift. The fall prior to the 10/31/24 fall was on 9/17/23, when she was found face down on the floor by the side of her bed. There was no information in the clinical record to indicate Resident 71's bed alarm was monitored for efficacy on an on-going basis or that it was originally aimed at assisting staff to assess for her patterns and routines. Interviews were conducted with the DON (Director of Nursing) on 4/29/25 at 1:26 p.m. and 4/30/25 at 10:44 a.m. She indicated the facility was not monitoring for efficacy of residents' alarm use, including Resident 71's, on a routine basis, and they had no documentation or verification that any resident's alarm use was for the purpose of assisting staff to assess for residents' patterns and routines. She understood alarm use in the facility was a concern and it was next on her list to address. 2. The clinical record for Resident 31 was reviewed on 4/24/25 at 11:05 a.m. Her diagnoses included, but were not limited to, Alzheimer's disease, depression, insomnia, anxiety, paranoid personality disorder, and hypertension. The 3/29/25 Annual MDS assessment indicated she was moderately, cognitively impaired. She was totally dependent for bathing and putting on/taking off footwear. She required substantial/maximal assistance with toilet hygiene, lower body dressing, personal hygiene, and transfers. An observation of Resident 31 and interview with LPN (Licensed Practical Nurse) 17 were conducted on 4/24/25 at 11:10 a.m. Resident 31 was sitting outside in her wheel chair in the patio area. There was a chair alarm attached to the back of her wheel chair. LPN 17 indicated Resident 31 had a chair alarm. If she moved forward, like she was about to get up, it would go off. She stated, Oh yea, it's loud. The physician's orders indicated to verify function and location of the pull pin (attached to chair alarm) on her wheel chair every shift, effective 4/21/25. The at risk for falls care plan, last revised 4/16/20, indicated a bed alarm, initiated on 6/28/19, and pull pin placed on wheel chair, initiated on 4/21/25. The clinical record indicated Resident 31's last fall was on 4/21/25, when staff entered her room and she was observed lying on her right side on the floor in the middle of her room. Resident 31 attempted to ambulate to a bedside table to get some candy. Resident 31's pull pin alarm was placed at this time. There was no information in the clinical record to indicate Resident 31's chair alarm was monitored for efficacy on an on-going basis or that it was originally aimed at assisting staff to assess for her patterns and routines. Interviews were conducted with the DON on 4/29/25 at 1:26 p.m. and 4/30/25 at 10:44 a.m. She indicated the facility was not monitoring for efficacy of residents' alarm use, including Resident 31's, on a routine basis, and they had no documentation or verification that any resident's alarm use was for the purpose of assisting staff to assess for residents' patterns and routines. She understood alarm use in the facility was a concern and it was next on her list to address. The Bed/Chair Alarm policy was provided by the DON on 4/30/25 at 11:45 a.m. It indicated, 1. Purpose .To reduce fall risks through timely staff interventions. To ensure alarms are used appropriately and not as a restraint. To comply with regulatory and ethical standards 5. Staff Responsibilities Document alarm triggers and responses 6. Review effectiveness regularly (e.g., weekly or monthly). Remove alarms when they are no longer clinically justified. Document review findings in the care plan. 7. Alternatives and Least Restrictive Interventions. Use other fall prevention methods [NAME] possible: Increased supervision. Environmental adjustments. Scheduled toileting. 8. Regulatory and Ethical Considerations Follow CMS (Centers for Medicare & Medicaid Services) and state regulations. Avoid alarms as restraints unless absolutely necessary. Encourage resident independence and dignity. 45291 3. The clinical record for Resident 23 was reviewed on 4/29/2025 at 12:45 p.m. The medical diagnoses included stroke and heart failure. A Quarterly Minimum Data Set Assessment, dated 3/31/2025, indicated Resident 23 was cognitively impaired, did not reject care, utilized bed and chair alarms, and had a fall during the review period. A care plan, revised 11/12/2024, indicated Resident 23 was at risk for falls. The interventions included a bed alarm, but did not mention a wheelchair alarm. A physician order, dated 11/20/2024, indicated Resident 23 was to utilize a wheelchair alarm. A fall risk assessment, completed 4/29/2025, indicated Resident 23 was at high risk for falls. During an interview and observation, on 4/29/2025 at 12:39 p.m., Resident 23 was sitting in the common area by the nurse's station. She had a chair pad alarm in her wheelchair, but it was not connected to the alarm box. Registered Nurse (RN) 8 verified the alarm was not connected. RN 8 plugged in the pad alarm to the alarm box and then verified it was in operational order. 25054 4. During an observation and interview on 4/28/25 at 1:16 p.m., Certified Nurse Aide (CNA) 10 and CNA 15 transferred Resident 41 from his wheelchair to his bed. CNA 10 indicated the resident had good days and bad days with transferring and two staff members were always utilized. CNA 10 and CNA 15 lifted the resident up underneath his arms and by the back of his pants to transfer him to his bed. Resident 41 was able to bear some weight but was not able to pivot. When queried if there was a reason a gait belt was not used for Resident 41 during the transfer, CNA 15 indicated there was no reason and they forgot to use a gait belt. Review of the clinical record of Resident 41, on 4/28/25 at 2:20 p.m., indicated diagnoses that included, but were not limited to, traumatic subdural hemorrhage, dementia, unsteadiness on feet, muscle weakness, depression, low back pain, Alzheimer's disease, convulsions, spinal stenosis, arthritis, anxiety disorder and congestive heart failure. The Annual MDS assessment, dated 1/10/25, indicated the resident was severely impaired for daily decision making. The resident used a wheelchair for mobility. The resident required substantial/maximal assistance for standing and transferring from the chair to the bed. The resident did not ambulate. The resident had one fall since the last MDS assessment. The plan of care for Resident 41, dated 1/22/25, indicated the resident required extensive assistance with self-care tasks. The interventions included, but were not limited to, assistance with transfers. The fall risk assessment for Resident 41, dated 4/11/25, indicated the resident was at high risk for falls. The safe lifting and movement of residents' policy was provided by the DON on 4/29/25 at 10:45 a.m. The policy indicated in order to protect the safety and well-being of staff and residents, and to promote quality of care, the facility would use appropriate techniques and devices to lift and move residents. Staff responsible for direct resident care would be trained in the use of gait/transfer belts. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to maintain comfortable sound levels for 1 of 5 residents reviewed for accidents. (Resident 71) The clinical record for Resident 71 was reviewed on 4/24/25 at 11:55 a.m. Her diagnoses included, but were not limited to, rheumatoid arthritis, diabetes mellitus, and stage four pressure ulcer of sacral region. She was admitted to the facility on [DATE]. The 1/14/25 Annual MDS (Minimum Data Set) assessment indicated she was cognitively intact. She was totally dependent for toileting hygiene, bathing, lower body dressing, and putting on/taking off footwear. She required substantial/maximal assistance with eating, oral hygiene, upper body dressing, and personal hygiene. The physician's orders indicated to check the function and placement of her bed and chair alarm every shift, effective 9/11/23. The 9/11/23 at risk for falls care plan indicated she would climb out of bed and onto the floor mat and unplug her bed alarm. Interventions were bed and chair alarms, initiated on 9/11/23. An observation and interview were conducted with Resident 71 in her room on 4/24/25 at 11:57 a.m. She was lying in bed at this time. A position change alarm was attached to the side of her bed. Resident 71 indicated she had an alarm on her bed that beeped, if she moved around. She didn't' like it. It beeped all the time and was really loud. Interviews were conducted with the DON (Director of Nursing) on 4/29/25 at 1:26 p.m. and 4/30/25 at 10:44 a.m. She indicated the facility was not monitoring for efficacy of residents' alarm use, including Resident 71's, on a routine basis, and they had no documentation or verification that any resident's alarm use was for the purpose of assisting staff to assess for residents' patterns and routines. She understood the alarm use in the facility was a concern and it was next on her list to address. The Bed/Chair Alarm policy was provided by the DON on 4/30/25 at 11:45 a.m. It indicated, 1. Purpose .To reduce fall risks through timely staff interventions. To ensure alarms are used appropriately and not as a restraint. To comply with regulatory and ethical standards 4. Alarm Selection and Placement. Choose the least intrusive and most effective alarm 5. Staff Responsibilities Document alarm triggers and responses 6. Review effectiveness regularly (e.g., weekly or monthly). Remove alarms when they are no longer clinically justified. Document review findings in the care plan. 7. Alternatives and Least Restrictive Interventions. Use other fall prevention methods when possible: Increased supervision. Environmental adjustments. Scheduled toileting. 8. Regulatory and Ethical Considerations Follow CMS (Centers for Medicare & Medicaid Services) and state regulations. Avoid alarms as restraints unless absolutely necessary. Encourage resident independence and dignity. The Homelike Environment policy was provided by the Administrator on 4/30/25 at 9:40 a.m. It indicated, 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include .comfortable sound levels. 3. The facility staff and management minimizes, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting. These characteristics include: .chair and bed alarms. 3.1-19(f)(5)

Based on observation, interview, and record review, the facility failed to provide privacy during care for 2 of 2 random observations (Resident 50 and Resident 36). Findings include: 1. During a medication pass observation on 4/28/25 at 10:10 a.m., Registered Nurse (RN) 11 knocked on Resident 50's door and walked in without waiting for a response. Resident 50 was standing up in front of his wheelchair and Certified Nurse Aide (CNA) 10 was applying an incontinent brief on the resident. The resident had no clothes on, and the privacy curtain was not pulled. Resident 50 was visible to the hallway. Review of the clinical record of Resident 50, on 4/30/25 at 11:10 a.m., indicated the diagnoses included, but were not limited to, schizophrenia, diabetes, depression, and muscle weakness. The Quarterly Minimum Data Set (MDS) assessment, dated 3/3/25, indicated the resident was cognitively intact for daily decision making. The resident was frequently incontinent of bowel and bladder. 2. Review of the clinical record of Resident 36, on 4/28/25 at 10:35 a.m., indicated the diagnoses included, but were not limited to, diabetes, Alzheimer's disease, dementia, major depressive disorder, anxiety, weakness, heart disease and stage three pressure ulcer to the coccyx (wound with full thickness tissue loss). During an observation of a pressure ulcer treatment for Resident 36 on 4/28/25 at 1:44 p.m., CNA 10 held Resident 36 on her right side while RN 11 was providing a pressure ulcer treatment to Resident 36's coccyx. RN 8 walked into Resident 36's room without knocking and the resident's buttocks were visible to the hallway. Resident 36 did not have a privacy curtain in her room. RN 11 and CNA 10 indicated they were unsure why the resident did not have a privacy curtain in her room. During an interview with RN 8 on 4/28/25 at 2:28 p.m., they indicated Resident 36 did not have a privacy curtain in her room because it was a private room. RN 8 indicated she knocked on Resident 36's door lightly before she came in but should have waited for a response before entering the resident's room. The dignity policy was provided by the Director of Nursing (DON) on 4/29/25 at 10:45 a.m. The policy indicated the residents would be treated with dignity and respect at all times. Staff would promote, maintain and protect resident privacy, including bodily privacy during assistance with person care and treatment procedures. Staff were expected to knock and request permission before entering residents' rooms. 3.1-3(p)(2) 3.1-3(p)(4) 3.1-3(t)

Based on observation, interview, and record review, the facility failed to ensure call lights were within reach (Resident 67 and 71) and failed to ensure fluids were available at the bedside (Resident 22) for 3 of 3 residents reviewed for accommodations of needs. Findings include: 1. The clinical record for Resident 67 was reviewed on 4/28/2025 at 2:08 p.m. The medical diagnoses included anoxic brain injury and contractures. A Significant Change Minimum Data Set Assessment, dated 2/14/2025, indicated Resident 67 was able to participate in his cognition exam, was severely cognitively impaired, and was dependent on staff for activities of daily living. A care plan, last revised 1/8/2025, indicated to ensure Resident 67's call light was within reach. During an observation on 4/29/2025 at 12:01 p.m., Resident 67's call light was noted to be out of his range. When asked if he could use his call light, he indicated no. During an interview and observation, on 4/29/2025 at 12:10 p.m., Licensed Practical Nurse (LPN) 2 verified the call light was out of Resident 67's reach. She stated the call light should definitely be closer, and moved it down so Resident 67 would be able to press it. 30344 2. The clinical record for Resident 71 was reviewed on 4/24/25 at 11:55 a.m. Her diagnoses included, but were not limited to, rheumatoid arthritis, diabetes mellitus, and stage four pressure ulcer of sacral region. The 1/14/25 Annual MDS (Minimum Data Set) assessment indicated she was cognitively intact. She was totally dependent for toileting hygiene, bathing, lower body dressing, and putting on/taking off footwear. She required substantial/maximal assistance with eating, oral hygiene, upper body dressing, and personal hygiene. An observation and interview were conducted with Resident 71 in her room on 4/24/25 at 11:59 a.m. She was lying in bed with the covers over her. Her call light was clipped to her outer cover but was wedged between her left side enabler bar and mattress. Resident 71 attempted to reach for her call light but was unable to reach it. She indicated, I can't reach it. I need my call light. An observation and interview were conducted with Resident 71 in her room on 4/30/25 at 1:14 p.m. She was lying in bed with the covers over her. Her call light cord was wrapped and tied around her left side enabler bar. There was not enough cord length available for Resident 71 to reach her call button. Resident 71 kept pulling at the cord and requested it be pulled within her reach. LPN 13 entered the room to assist. LPN 13 untied the cord from the enabler bar and pulled the cord to release more of its' length. LPN 13 asked Resident 71 if she'd rather it be clipped onto her cover. Resident 71 answered in the affirmative, so LPN 13 detached it from the enabler bar, and clipped it onto her blanket, within Resident 71's reach. A policy, entitled Call System, Residents, was provided by the Administrator on 4/30/2025 at 9:40 a.m. The policy indicated residents are to be provided a means to call staff for assistance through a communication system that directly calls a staff member or central work location and, .if the resident has a disability that prevents him/her from making use of the call system, an alternative measure of communication that is usable for the resident is provided . 50436 3. During an observation on 4/23/25 at 1:53 p.m., Resident 22 was lying in bed. The resident had no water or any type of fluids in their room. During an observation on 4/28/25 at 10:19 a.m., Resident 22 was sleeping in bed. The resident had no water or any type of fluids in their room. During an observation on 4/28/25 at 1:55 p.m., Resident 22 was lying in bed. The resident had no water or any type of fluids in their room. During an observation on 4/29/25 at 9:38 a.m., Resident 22 had a clear, empty plastic glass sitting on their bedside table. The clinical record for Resident 22 was reviewed on 4/28/25 at 11:00 a.m. The diagnoses included, but were not limited to, anxiety and diabetes mellitus. A physician's order, dated 3/13/25, indicated Resident 22 was on a regular diet with regular texture and nectar (thickened) consistency for fluids. An interview was conducted with Certified Nurse Aide (CNA) 3 on 4/29/25 at 9:41 a.m. CNA 3 indicated Resident 22 was able to drink by herself and did not need assistance if the drink was placed in front of her. During an interview with the Director of Nursing (DON) on 4/29/25 at 10:49 a.m., she indicated residents who have nectar (thickened) liquids ordered were not allowed to have pitchers of water at the bedside, but they can have thickened fluids at the bedside. The Serving Drinking Water policy was provided by the DON on 4/28/25 at 2:30 p.m. It indicated, . the purpose of this procedure are to provide the resident with a fresh supply of drinking water and to provide adequate liquids for the resident . 3.1-3(v)(1)

Based on observation, interview, and record review, the facility failed to provide nail care and oral care for 3 of 3 residents reviewed for activities of daily living (ADLs). (Resident 9, Resident 66 and Resident 23) Findings include: 1. During an observation on 4/23/25 at 1:05 p.m., Resident 9 had a dark substance underneath her fingernails on both hands. During an observation on 4/28/25 at 9:46 a.m., Resident 9 had a dark substance underneath her fingernails on both hands. During an observation and interview on 4/28/25 at 12:44 p.m., Resident 9 had a dark substance underneath her fingernails on both hands. Resident 9 indicated her fingernails were horrible. During an observation and interview on 4/29/25 at 10:08 a.m., Certified Nurse Aide (CNA) 12 verified Resident 9 had a black substance under her fingernails. CNA 12 indicated that the aides were supposed to clean her fingernails on bed bath days. Resident 9 received her bed bath on evening shift. CNA 12 indicated she was unsure if Resident 9 was a diabetic, but she would not trim her nails at this time but would clean the resident's fingernails. The clinical record for Resident 9 was reviewed on 4/29/25 at 9:55 a.m. The diagnoses included, but were not limited to, dementia, chronic obstructive pulmonary disease, Alzheimer's disease, anxiety, pain, major depressive disorder, and psychosis. The plan of care for Resident 9, dated 7/26/24, indicated the resident required limited assistance with self-care related to poor motivation and dementia. The interventions included, but were not limited to, shower per staff assistance two times a week and to include nail care. The Quarterly Minimum Data Set (MDS) assessment for Resident 9, dated 4/4/25, indicated the resident required substantial/maximal assistance with personal hygiene. The fingernail care policy was provided by the Administrator on 4/30/25 at 9:40 a.m. The policy indicated the purpose was to clean the nail bed to prevent infection. 30344 2. The clinical record for Resident 66 was reviewed on 4/24/25 at 11:20 a.m. His diagnoses included, but were not limited to, chronic obstructive pulmonary disease, diabetes, Alzheimer's disease, and congestive heart failure. He was admitted to the facility on [DATE]. An observation of Resident 66 was conducted on 4/24/25 at 12:06 p.m. He was lying in bed and was not wearing any socks. Both of his feet were completely visible. On his left foot, the pinky toenail and toenail next to the big toe were extremely long. On the right foot, the big toe and middle toe were long and curled over the end of the toes. The 3/21/25 Admission MDS assessment indicated he was severely cognitively impaired, required substantial/maximal assistance with bathing, and was totally dependent for putting on/taking off footwear. The 4/28/25 ADL care plan indicated he required maximum assistance with showers twice weekly with hair and nail care included. He was totally dependent on staff with putting on/taking off footwear. The 3/12/25 Request For Service Consent form did not indicate whether Resident 66's representative accepted or refused podiatry services, as both options were left blank on the consent form. The physician's orders indicated he may be seen by the podiatrist, effective 3/13/25. An interview was conducted with LPN (Licensed Practical Nurse) 4 on 4/28/25 at 1:18 p.m. Resident 66 was not available for observation at this time. She indicated she noticed how long his toenails were and how they curled over. They had a podiatrist who came to the facility, but a lot of residents' families didn't approve for them to be seen. Nursing staff usually contacted social services, who would talk with the family about being seen by the podiatrist. She hadn't discussed Resident 66's toenails with social services and was unsure if anyone else had either. An interview was conducted with the Social Services Director (SSD) on 4/28/25 at 1:46 p.m. She indicated no one mentioned anything to her about Resident 66 needing to be seen by the podiatrist. An interview was conducted with the SSD on 4/29/25 at 11:27 a.m. She indicated she had a call out to Resident 66's family member to discuss podiatry services. If they declined, perhaps nursing could address his long toenails. 45291 3. The clinical record for Resident 23 was reviewed on 4/29/2025 at 12:45 p.m. The medical diagnoses included stroke and heart failure. A Quarterly Minimum Data Set Assessment, dated 3/31/2025, indicated Resident 23 was cognitively impaired and did not reject care. A care plan, revised 11/11/2024, indicated Resident 23 needed maximal assistance with oral care twice a day and as needed. During an observation on 4/23/2025 at 1:10 p.m., Resident 23 was observed to have a thick white build up on her teeth as well as a white film over her teeth and lips. During an interview and observation, on 4/29/2025 at 12:39 p.m., Resident 23 was sitting in the common area by the nurse's station. She was observed to have a blue substance over her lips, around her mouth, and coating her teeth. She was also noted to have dry skin built up on her lips and a thick white substance built up between her teeth. During an interview on 4/30/2025 at 11:30 a.m., the Director of Nursing (DON) indicated nursing staff should provide care to assure residents are clean from food debris after meals. A policy entitled Mouth Care was provided by the Administrator on 4/30/2025 at 9:40 a.m. The policy indicated the purpose of the policy was to keep the resident's mouth and lips moist and provide oral care. 3.1-38(a)(2)(A) 3.1-38(a)(3)(A) 3.1-38(a)(3)(C) 3.1-38(a)(3)(E)

Based on observation, interview, and record review, the facility failed to timely provide optometry services and timely address a resident's missing glasses for 2 of 3 residents reviewed for vision services. (Residents 38 and 91) Findings include: 1. The clinical record for Resident 38 was reviewed on 4/24/25 at 12:10 p.m. Her diagnoses included, but were not limited to, cataracts, history of cerebral infarction, and dementia. The 3/26/25 Quarterly MDS (Minimum Data Set) assessment indicated she was cognitively intact. An interview and observation were conducted with Resident 38 in her room on 4/24/25 at 12:13 p.m. She indicated she had a hard time seeing, needed glasses, and hadn't seen the optometrist lately. She was not wearing glasses at that time. The physician's orders indicated she may be seen by the optometrist, effective 3/22/19. The 3/30/20 facility optometry provider's Request for Services Consultation indicated to please have the optometrist examine Resident 38. The 6/30/23 eye exam indicated new glasses were not recommended at this time, and that she only wore them intermittently. The plan was to monitor and follow up with a comprehensive exam on 6/30/24, and to continue wearing spectacles. The action required by nursing home staff was to encourage part-time use of glasses for reading. There was no information in the clinical record to indicate a follow up comprehensive exam was ever completed after the 6/30/23 exam, as planned. An interview was conducted with the SSD (Social Services Director) on 4/28/25 at 1:28 p.m. She indicated she handled ancillary services for all residents in the facility, including optometry services. No vision services had been provided in the facility since 10/7/24, which was by a previous provider. Resident 38 was not seen at the 10/7/24 visit and hadn't been seen since her 6/30/23 exam. The facility recently obtained a new provider who was scheduled to come to the facility for the first time on 5/1/25. An interview was conducted with the SSD on 4/29/25 at 11:50 a.m. She indicated she was unable to locate any glasses for Resident 38 yesterday. She also spoke with nursing staff and was informed they hadn't seen any glasses for Resident 38 either. The SSD reviewed Resident 38's clinical record and indicated there was no vision or ancillary services care plan for Resident 38, but she would create one now. 2. The clinical record for Resident 91 was reviewed on 4/24/25 at 11:30 a.m. His diagnoses included, but were not limited to, dementia. He was admitted to the facility on [DATE]. The physician's orders indicated he may be seen by the optometrist, effective 12/17/24. The 12/19/24 care plan indicated he had glasses. Interventions were to clean his glasses daily; ensure his glasses were on daily and removed prior to going to bed; and notify nursing/social services promptly of any lost/broken glasses. The 12/26/24 Admission MDS assessment indicated he had adequate vision with corrective lenses used. The 3/28/25 Quarterly MDS assessment indicated he had adequate vision, but no corrective lenses were used. It indicated he was severely cognitively impaired. An observation of Resident 91 and interview with Family Member 5 was conducted in Resident 91's room on 4/24/25 at 11:39 a.m. Resident 91 was sitting up in his wheelchair next to Family Member 5, and he was not wearing any glasses. Family Member 5 indicated he needed glasses, because he does better with glasses, but she thought he may have thrown them away, as they were unable to be located at this time. Family Member 5 was unsure whether he'd seen the optometrist since he'd been at the facility or if his missing glasses had been addressed. An observation of Resident 91 and interview with Family Member 6 was conducted in Resident 91's room on 4/28/25 at 1:00 p.m. Resident 91 was sitting up in his wheelchair, and he was not wearing any glasses. Family Member 6 indicated she hadn't heard anything about him seeing the eye doctor or getting new glasses. An interview was conducted with the SSD on 4/28/25 at 1:28 p.m. She indicated she handled ancillary services for all residents in the facility, including optometry services. No vision services had been provided in the facility since 10/7/24, which was by a previous provider. The facility recently obtained a new provider, who was scheduled to come to the facility for the first time on 5/1/25. The SSD reviewed the optometry provider's 5/1/25 visit list and indicated Resident 91 was not on the list to be seen as a new patient, but she would add him to the list to be seen today. She was unaware he was currently missing his glasses. The Availability of Ancillary Services: Dental, Vision, Podiatry, Audiology policy was provided by the Administrator on 4/30/25 at 9:40 a.m. It indicated, Oral, visual, podiatry and audiology services will be provided to each resident. Policy Interpretation and Implementation: 1. Oral, visual, podiatry and audiology services are available to all residents requiring routine and emergent care. 2. Social Services will be responsible for making necessary dental, visual, audiology and podiatry arrangements and obtain consents for services. 3. All requests for routine services should be directed to social services to assure that appointments/referral can be made in a timely manner 6. Residents with lost or damaged glasses/contacts will be promptly referred to an optometrist. 3.1-39(a)(1)

Based on observation, interview, and record review, the facility failed to provide pressure wound interventions for a resident at high risk of developing pressure areas for 1 or 2 residents reviewed for pressure wounds. (Resident 67) Findings include: The clinical record for Resident 67 was reviewed on 4/28/2025 at 2:08 p.m. The medical diagnoses included anoxic brain injury and contractures. A Significant Change Minimum Data Set Assessment, dated 2/14/2025, indicated Resident 67 was able to participate in his cognition exam, was severely cognitively impaired, and at risk for developing pressure areas. A skin care plan, last revised 4/7/2025, indicated to provide Resident 67 with wound care as ordered. A physician order, dated 4/24/2025, indicated to apply a foam dressing to the top of Resident 67's right foot as a preventative measure. A wound practitioner note, dated 4/28/2025, indicated for Resident 67 to encourage the use of pressure reducing (prevalon) boots at all times. During an observation on 4/29/2025 at 12:01 p.m., Resident 67 was observed in bed. Resident 67's pressure reducing boot were sitting on the bedside table. During an interview and observation, on 4/29/2025 at 12:10 p.m., Licensed Practical Nurse (LPN) 2 verified pressure reducing boots were off. Observation of Resident 67's right foot indicated the preventative dressing was off. LPN 2 indicated she did not provide that dressing, she was not sure if he had an order for a dressing to the foot, but if he did then he should have one on. The order for the preventative dressing to Resident 67's right foot was verified in the electronic medical record. A policy entitled Prevention of Pressure Injuries was provided by the Administrator on 4/30/2025 at 9:50 a.m. The policy indicated selecting appropriate supportive devices, to apply to devices, and to review the interventions and strategies for effectiveness. 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to implement and provide interventions for a resident with bilateral hand contractures for 1 of 2 residents revived for range of motion (ROM). (Resident 98) Findings include: Review of the clinical record of Resident 98, on [DATE] at 10:12 a.m., indicated the diagnoses included, but were not limited to, anoxic brain damage, anxiety, and respiratory arrest. The admission assessment for Resident 98, dated [DATE], indicated both arms were contracted at varying degrees. The Admission Minimum Data Set (MDS) assessment for Resident 98, dated [DATE], indicated the resident was severely cognitively impaired for daily decision making. The resident had impairment on both sides of his upper extremities. The plan of care for Resident 98, revised date of [DATE], indicated the resident was at risk for skin breakdown due to bilateral upper extremity contractures. During an observation on [DATE] at 1:20 p.m., Resident 98 was lying in bed, the resident had bilateral hand contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to restricted joint mobility), and the resident did not have any splint/carrot in place. During an observation on [DATE] at 1:54 p.m., Resident 98 was lying in bed, the resident had bilateral hand contractures, and the resident did not have any splint/carrot in place. During an interview with Registered Nurse (RN) 9 on [DATE] at 1:55 p.m., she indicated she was the nurse caring for Resident 98. RN 9 indicated the resident had bilateral hand contractures since admission to the facility. RN 9 had not seen any splint/carrot utilized for the resident. The contracture prevention policy was provided by the Director of Nursing (DON) on [DATE] at 11:45 a.m. The policy indicated the purpose was to prevent the progression of contractures in residents and ensure timely appropriate management when they occur. Individual care plans would be developed for at risk residents, addressing ROM, splints or supportive devices. 3XXX,d+[DATE](a)(2)

Based on interview and record review, the facility failed to protect the residents ' right to be free from sexual abuse for 3 of 3 male residents by a staff member while providing incontinence care. The staff member was on his first night of orientation without the presence of the regular staff member which he was paired with for his orientation for the shift. This action resulted in mental anguish for all 3 residents. (Residents B, C, D and CNA 3) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on, 3-20-24 at approximately 2:00 a.m., when CNA 3 masturbated 1 of 3 residents. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 4-17-24 at 11:55 a.m. The Immediate Jeopardy was removed on 3-27-24, but noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: The facility filed a reportable incident on 3-20-24 with the Indiana Department of Health, Long Term Care Division, citing concerns related to CNA 3, touching a male resident inappropriately while providing personal care to him during the night shift of 3-19-24 into 3-20-24. The report indicated an investigation had begun and CNA 3 had been suspended, pending results of the investigation. In an interview with the Executive Director (ED) on 4-16-24 at 2:43 p.m., he indicated on the morning of 3-20-24, he was informed by the Director of Nursing (DON) she had received a report from CNA 5 of an allegation of sexual abuse from Resident C. CNA 5 indicated she had noticed Resident C was acting different than usual. I would say she had to pry it out of him what happened. He seemed reluctant to address it, like he had something bothering him. Resident C shared with CNA 5, that he was not sure he should mention it, but finally decided he should let the management of the facility be aware a male CNA had been providing care to him for incontinence and then told him he was getting hard. Said the male CNA made him uncomfortable and the male CNA ended up leaving him alone. Resident C indicated the same CNA did return to his room later in the shift and the resident told him he didn't need anything and the male CNA did not offer to provide care at that time and left the room. The ED estimated the time of the inappropriate touching was around 2:00 a.m. The ED identified the male CNA as CNA 3. The ED indicated in interview with Resident C later in on 3-20-24, he detailed CNA 3 had physically contacted his penis and used vigorous hand movement. He did not indicate a time frame for the interaction. He said when the physical contact became uncomfortable, he mentioned it to CNA 3 and CNA 3 stopped. The ED indicated Resident C did not report the incident until around 8:00 a.m. to a day-shift staff, CNA 5, who in turn immediately reported the allegation to the DON. We immediately began the investigation and called in the male CNA to speak to us. This was his first shift of orientation on the floor with us. He was paired with (name of CNA 4) that night. In interview, he indicated he and (name of CNA 4) did rounds together around 11pm and around 2am, he went in to care for (name of Resident C) by himself. The male CNA told us that he went in to do incontinence care on (name of Resident C), cleaned off 'some white gunk' and bowel movement from the resident's penis, and was in the room about 10 minutes. He said he was simply providing incontinence care, nothing more or less. The ED indicated in post-incident interviews of residents down that hall, there was a total of two male residents, Residents B and C, that reported physical contact and one male resident, Resident D, said he had made him feel uncomfortable, but said there was no physical contact by the aide. The ED indicated CNA 3 provided unsupervised care only to male residents. We asked him how he selected the residents to care for by himself and he said that he went over (name of CNA 4)'s assignment ticket and selected people that were one person assistance for check and change (also called incontinence care). The ED indicated CNA 3 shared he had not given it any thought that it happened to be all male residents that he provided unsupervised care to. The ED indicated a review of CNA 3's employee file, revealed he had current CNA certification in good standing on the Professional Licensing website and he had worked in a few nursing facilities in the area. I had the our HR (Human Resources) person re-check all the references and we had no one give us anything other than good references. The ED provided information which indicated CNA 3 had completed abuse prohibition training on 3-13-24, and was signed by CNA 3 and the Human Resources staff member. The ED indicated the facility did interview each of the residents which CNA 3 had provided care for that night by himself. Each of those residents were considered cognitively intact. When the discussion with the residents got around to discussing the physical contact (by CNA 3) included hand grip (around the penis) and vigorous hand movement of the penis, their answers were very similar. I would like to think the male CNA was simply providing thorough care, but it seemed unusual their statements would be so similar. The ED indicated CNA 3 did return to the facility around 9:30 a.m., on of 3-20-23, to provide a statement of his own, as requested by the facility management. When he was in my office, he did deny that he touched the residents inappropriately and said he was merely providing care to them. He seemed very matter of fact and did not seem flustered, didn't yell or anything. The ED indicated CNA 3 was terminated upon completion of that visit to the facility. The ED indicated interviews with the staff CNA 3 worked with that night did not result in any concerns. Of course, he had only been on the floor the one shift. Nothing out of the ordinary or suggest any weird vibes. The ED indicated psycho-social follow-up visits were conducted with the residents that were identified as having a recollection of him working with him that night. He indicated the facility did follow their usual abuse prohibition policy recommendations as far as pre-employment license/certification verification, reference checking and provision of education on abuse prohibition. To be honest, I am not sure what I could have done better or differently. I followed our normal policy as far as hiring with verification of his CNA license, checking references, providing on-boarding training prior to him going out on the floor. There were no red flags as far as his license or references. Not sure what else we could have done or done differently. In a telephone interview with CNA 3 on 4-17-24 at 2:28 p.m., he indicated he has been a CNA since 2022. He indicated he was paired with CNA 4 for his first orientation shift at the facility Since I am an experienced aide, we were able to divide up the assignment, with her telling me some of the patients she thought that I would be able to check and change with just one person assist. The only person that I can think of that was a little harder than I expected was (name of Resident B). He is kind of heavy-set and partially paralyzed and he was harder to roll by myself. He was wet, plus he had some BM (bowel movement) on him; had to clean him up twice the first time I was in the room with him because he had BM on him to begin and did it again while I was cleaning him up. I can't say that I really had any problems with helping any of the residents .I don't remember him (Resident B) saying anything to me about being upset or anything. When I was called to come back in to talk to the administrator, they told me there had been an allegation about a patient saying I touched them. I've never had an allegation like that made about me. A couple of years ago, there was a patient who said I slapped them and that was not true. I didn't do anything that could have been mistook for touching a patient wrong. Later, I was told by Ambassador that another patient or two had said I had touched them, too. In a telephone interview with CNA 4 on 4-16-24 at 10:00 p.m., she indicated she was paired with CNA 3 on the night shift of 3-19-24 at 10:00 p.m. until 6:00 a.m. on 3-20-24. She indicated CNA 3 shared he was experienced aide with three years of experience. She indicated, He and I would go into a room to do patient care and he would leave the room and not say anything to me and I would not know where he was. He would seem to just disappear. Several times that night, I would ask the other aide or the nurses if they had seen him and I even thought maybe he had left. The others told me they hadn't seen him .I haven't oriented very many people, but when I was on orientation, I was paired with one of the other aides for several shifts before I had an assignment on my own. This was his first night on the floor and he was not familiar with our patients. I just thought it was odd that he just kept disappearing. At shift change and in between patients, he talked some about his family and things he did and he certainly sounded pretty normal to me. I haven't really been interviewed by the DON or Administrator about any of this stuff. CNA 4 indicated she was absolutely shocked when she learned of the allegations against CNA 3. She indicated the facility provided an inservice training on reporting of actual or suspected abuse shortly after the incident. In an interview with the ED on 4-19-24 at 11:30 a.m. The ED clarified CNA 4, was not formally interviewed by the management team during the active investigation, nor did she come forward with any concerns related to concerns for the allegation of abuse. With what we have learned since then, her concerns were more related to where the other CNA was, certainly not any abuse concerns. Going forward, we will certainly try to make sure we get those interviews conducted more quickly whenever there is an abuse allegation. In interview on 4-19-24 at 12:05 p.m., with the ED, he added, At the time of the investigation, we acknowledged the abuse allegation had not been made known to CNA 4, but to CNA 5, later on the morning of 3-20-24. (Name of Resident C) even told us when we spoke with him that he had not mentioned anything to anyone else prior to speaking with CNA 5. At the time of the investigation, we focused more on the people who were made aware of the abuse. In an interview on 4-17-24 at 1:35 p.m., with the Human Resources (HR) staff, she indicated she has [AGE] years of experience in HR at the facility. She indicated, During his (CNA 3) on-boarding process and all the references were all excellent and there were absolutely no red flags .I was dumb-founded when I found out the allegations. We do not have a particular policy about what to expect during the [working on the] floor orientation. We base their orientation on what their past experience is and what they need help with. We try to personalize it to the needs of the new employee. In an interview with the ED on 4-19-24 at 9:35 a.m., he indicated the facility does have a specific policy regarding the on-boarding of new employees. The policy indicated all new employees must participate in an orientation program within the first five days of employment and includes training for both general orientation as well as for each department. In interview with the ED on 4-19-24 at 11:26 a.m., he indicated the departmental orientation follows the job description for each position as well as the task-specific checklist associated with each department and takes into consideration each employees work experience, level of education and needs for further training. He indicated the facility does follow all regulatory guidelines related to abuse, specific to verification of licensure or certification, background checks for criminal background and sexual abuse registry and provision abuse prohibition education. Additionally, the potential employee's experience is taken into consideration. The ED indicated each employee will review and sign acknowledgement of receipt of the specific job description and each specific job will have a sign-off for the majority of common tasks associated with that specific position. He indicated CNA 3 received a task-associated document to sign off on as he completed each CNA-related task, but the facility did not receive this from him prior to his termination. The ED indicated the facility does not have strict guidelines for the length of direct supervision or training, it is based on the specific needs of each new employee. The ED provided a copy of CNA 3's job description, signed and dated on 3-13-24 by CNA 3 and the Human Resources staff. Additionally, CNA 3 signed an acknowledgement of receipt of training/education for abuse prohibition, including mandatory reporting, sexual harassment awareness, resident rights, elder justice act and ethics in long-term care on 3-13-24. A. The clinical record of Resident B was reviewed on 4-17-24 at 8:48 a.m. His diagnoses included, but were not limited to, hemiplegia and hemiparesis following a cerebral infarction affecting left non-dominant side, diabetes, urge incontinence, depression and anxiety. His most recent Minimum Data Set assessment, dated 3-23-24, indicated he is cognitively intact. It indicated he is frequently incontinent of his bladder and requires substantial to maximal assistance of staff with toileting. In an interview with Resident B on 4-17-24 at 10:28 a.m., he recalled about one month ago, a new male aide Sometime around 11:30 p.m., or could have been later on the third shift, I'm not sure, he came in by himself to check and change me. That part was pretty normal, because that's just part of the normal routine. After he got done cleaning me up, he tried to masturbate me. To be honest, I wasn't sure what to think, I guess I was just kind of in shock somebody would do that. I can't tell you right now exactly what time he did that, but it kind of weirded me out. I know I ended up telling him to leave me alone and he did .I was not sure what to think, still don't. I thought about busting his head, but I knew that was wrong. It still upsets me, makes me mad that somebody would do that to somebody else. Resident B shared later that morning, he told the day-shift aide what had happened. Resident B indicated he could not recall the exact date or the name of the day-shift aide. B. The clinical record of Resident C was reviewed on 4-17-24 at 4:28 p.m. His diagnoses included, but were not limited to surgical amputation of the right leg below the knee, diabetes, nontraumatic intracerebral hemorrhage and end-stage kidney disease with hemodialysis. His most recent Minimum Data Set assessment, dated 1-16-24, indicated he is cognitively intact. It indicated he is frequently incontinent of his bladder and bowel and requires substantial to maximal assistance of staff with toileting. In interview with Resident C on 4-17-24 at 3:00 p.m., he indicated on the night-shift of 3-19-24 until the morning of 3-20-24, the nursing staff on duty had introduced a new male aide to him around 11:00 p.m., and said it was his first shift at the facility. A little while later, I was not asleep, he came back in, not sure what time it was, and he asked if I needed changed. I told him that I didn't think I did. My incontinence is more with my stool. I told him he could check me, after he asked me several times. He had me roll over on my side, like the nurses normally do. I helped pull my sweats down and pulled the brief down. Don't know if he even looked at my bottom to check. He immediately started touching my penis from one side of the bed and then walked around and continued masturbating me. He leaned down at one point to near my ear and said, 'You're as hard as a rock.' I was shocked, actually not sure if I had heard him right. You have to understand I haven't had an erection in a long time because of my health problems. I asked him what he said and he, about that time, he had his head down close to my penis. I told him to just finish cleaning me up and he left. I worried about it off and on that night as to if I should tell anybody about it. When my day shift aide, [name of CNA 5] came in, I did mention it to her. Resident C indicated not long after he reported the incident to CNA 5, he was interviewed by the facility management team and by the local law enforcement several days later. C. The clinical record of Resident D was reviewed on 4-17-24 at 4:44 p.m. His diagnoses included, but were not limited to, pathological hip fracture, right kidney cancer and secondary bone cancer. His most recent Minimum Data Set assessment, dated 3-17-24, indicated he is cognitively intact. It indicated he is occasionally incontinent of his bladder and always continent of bowel and requires partial to moderate assistance of staff with toileting. In an interview with Resident D on 4-17-24 at 10:38 a.m., he indicated he had an incident about a month ago in which a male attendant was taking care of him, assisting him to get up in the middle of the night to use the bathroom. I can't walk well, so I use the urinal. After doing my business, he was helping me clean up in my private parts. I didn't think that I had made any kind of a mess with just urinating. He seemed to spend more time than I would have anticipated for the job at hand. I think he used some kind of wipe. I finally told him, 'We're done here,' and he said okay and left. I wasn't sure what to think about, but it seemed unusual, at the very least, to me. Later in the morning, (name of Social Services Designee), came in and asked me if I had had any type of incidents with any staff members. I had kind of struggled with trying to decide if I should say something or not, and then told her about what had happened with the one guy. She told me she would check into it. I had only been here a few weeks at that time and wasn't sure who or what to do about it. I think he had been in earlier in the shift, but not sure. I can't say anything happening or unusual conduct with him prior. I did not see him any more after that .I can't say that he caused me any harm, but I will say that guy certainly came across as weird to me. On 4-16-24 at 2:20 p.m., the ED provided a copy of a policy entitled, Abuse Prohibition, Reporting and Investigation. This policy was identified as the current policy utilized by the facility and had a revision date of 9/2017. This policy indicated, This facility shall prohibit and prevent abuse, neglect, misappropriation of resident property, and exploitation .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Instances of abuse of a resident, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse .Sexual Abuse - Non-consensual sexual contact of any type with a resident .Any staff to resident sexual contact and/or sexual relationship is considered abuse. The relationship between a resident and their caregiver is a professional relationship. The facility strictly prohibits relationships between an employee and a resident of any type beyond professional caregiver-to-resident interaction. Should there ever be a time when a caregiver acts or speaks in a manner which would be considered trying to establish a relationship beyond that of a professional caregiver, the caregiver must report to the nurse or supervisor immediately .Residents shall be questioned about the nature of the incident and their statements placed in writing. Investigation shall be conducted to assure other residents have not been affected by the incident or inappropriate behavior and the results documented. Statements shall be taken including, but not limited to, facts and observations by involved employee(s); facts and observations by witnessing employee(s), facts and observations by witnessing non-employee(s); facts and observations by any others who might have pertinent information; facts and observations by the licensed nurse or individual to whom the initial report was made . On 4-19-24 at 11:10 a.m., the ED provided a copy of a policy entitled, Orientation Program for Newly Hired Employees, Transfers, Volunteers, with a revision date of January, 2008. This policy indicated, An orientation program shall be conducted for all newly hired employees .All newly hired personnel .must attend an orientation program within the first five (5) days of employment .Our orientation program includes, but is not limited to .An introduction to resident care procedures .A review of the facility's Nursing Assistant's Training Program .A review of our organized staff including an introduction to each department supervisor; An overview of each department's services; A review of the employee's job description; A review of the resident rights including abuse prohibition .In addition to our general orientation, each department will orient the newly hired employee .to his or her department's policies and procedures, as well as other data that will aid him/her in understanding the team concept, attitudes and approaches to resident care. Our orientation program is an in-depth review of our facility's policies and procedures. A checklist is used to record materials reviewed with each employee . The Immediate Jeopardy, that began on 3-20-24, was removed on 3-27-24 when the facility inserviced the facility staff on abuse policies, but the noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because a systemic plan of correction had not been developed and implemented to prevent recurrence. This Federal tag relates to Complaint IN00430919. 3.1-27(a)(1)

Based on observation, interview, and record review, the facility failed to ensure 1 resident was not neglected in that the facility failed to supervise a dependent resident who was left on the facility bus after returning from a dental appointment for approximately 5 1/2 hours before being taken into the facility. This affected 1 of 3 residents in a sample of 3 and an supplemental sample of 2. (Resident #A) An Immediate Jeopardy (IJ) was identified on 3/22/11. The IJ began on 3/2/11, when resident #A was left on the facility bus for approximately 5 1/2 hours after returning from a dental appointment. The facility failed to have a check system in place to ensure residents were returned safely to the facility after an appointment, and establish communication procedures among staff to determine a residents whereabouts. The Administrator, and Director of Nursing (DoN) were notified of the IJ on 3/22/11 at 5:00 P.M. The IJ was removed on 3/23/11, but the facility remains out of compliance at a level of isolated, no actual harm with the potential for more than minimal harm that is not immediate jeopardy, because all staff had not been inserviced, and the need to incorporate policies into one policy. Findings include: Resident #A was observed seated in his wheelchair in the hallway on 3/21/11 at 2:10 P.M. Resident #A had his right leg amputated above the knee, and all 4 fingers on his right hand. During interview at that time, Resident #A indicated he recalled being left on the facility bus. Resident #A indicated he had been to the dentist and picked up his bottom dentures. Resident #A indicated he fell asleep on the facility bus, and when he woke up his hands were cold. Resident #A's record was reviewed on 3/21/11 at 2:25 P.M. Resident #A's March, 2011 physician's recapitulation order indicated Resident A's [DIAGNOSES REDACTED]. Resident #A's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #A was able to make himself understood, and had the ability to understand others. He required extensive assist of 1 person for bed mobility, transfer, dressing, toilet use, and personal hygiene. Nurses notes for resident #A indicated the following: 3/2/11 at 9:20 P.M. - The resident has not returned from a dental appointment from earlier today on day shift. 3/2/11 at 9:45 P.M. - The resident was found sitting in the bus after his dentist appointment. The resident was brought back into the facility, put to bed, and covered. Skin assessment done and no open areas noted. Buttock area red. B/P 160/86, temperature 96.4, pulse 80, respirations 20, and oxygen saturation 95%. Respirations easy and non-labored. Resident is alert and responsive. No complaint voiced. No documentation was available in the nurses notes that Resident #A had left the facility, and with whom Resident #A had left the facility with. Review of the facility's investigation on 3/21/11 at 10:55 A.M., indicated the following: Brief description of Incident - The resident was found on the facility bus after his dentist appointment. The resident was brought into the facility. The resident was examined and found uninjured. B/P 160/86, tympanic temperature 96.4, pulse 80, respirations 20, and oxygen saturation 95% at room air. Type of injury - Head to toe assessment completed, no injuries found. Skin intact with no open areas noted. Buttock bilaterally slightly red but blanched. Immediate action taken - Administrator, DoN, physician, and resident's power of attorney (POA) notified. Complete assessment done with no concerns noted. Bus driver suspended pending investigation Investigation immediately started. Preventative measures taken - The resident has been assessed for psychosocial well being without any concerns noted at this time. Policy put in place with a check off system to ensure that residents are returned to facility. All licensed staff, maintenance, and laundry staff in-serviced on new procedure. Nurses will document on the 24 hour report for shift to shift report when residents are out of the building. The facility investigation indicated an RN realized Resident #A was not back for supper, and by looking at the calendar, thought resident #A was out with family. Written on the calendar was Resident #A's name, and the words family dentistry. At the top of the calendar written in faint writing were the words, arrange facility transportation. Resident #A's appointment card was attached to the desk calendar indicating his appointment was scheduled for 1:30 P.M. The RN indicated when it was close to the end of her shift she called resident #A's POA, and was informed resident #A was not with him. The RN then called a day shift LPN on his cell phone at 9:31 P.M., and was informed the facility had taken Resident #A to his appointment. At approximately 9:37 P.M., a LPN on evening shift handed an evening shift CNA a flashlight to check the facility bus. The CNA found Resident #A seated on the bus at approximately 9:38 P.M. Resident #A told the CNA to shut the door because he was letting the cold in. The bus driver who transported Resident #A to and from his dental appointment could not recall taking Resident #A back into the facility upon return. An LPN looked the temperature outside up on the Internet. On 3/2/11 at 5:00 P.M., the temperature was 49 degrees and sunny. On 3/2/11 at 9-9:30 P.M. the temperature was 39 degrees. An interview with the Administrator on 3/21/11 at 12:10 P.M., indicated Resident #A was the only resident on the facility bus on 3/2/11. She indicated there was no system in place at that time to double check all residents were off the bus and safely in the facility. An interview with the DoN on 3/21/11 at 4:25 P.M., indicated prior to the incident, staff would fill out a maintenance transportation request, and place the form in maintenance's mail box. The appointment would be written on the calendar, along with who would be transporting the resident. The DoN indicated no nurses note had been documented on 3/2/11, indicating Resident #A left the facility, and with whom he left with. An interview with the Administrator on 3/22/11 at 5:12 P.M., indicated prior to the incident on 3/2/11, there was no policy on the bus drivers responsibilities related to transporting a resident. An interview with LPN #1 on 3/23/11 at 11:10 A.M., indicated Resident #A left on the facility bus to pick up his dentures on 3/2/11 at approximately 1:15 P.M. LPN #1 indicated he normally documented a nurses noted when a resident left for an appointment with the time, type of appointment, and with whom the resident left with. Resident #A indicated he did not document a nurses note for resident #A on 3/2/11 when he left for his appointment. LPN #1 indicated on 3/2/11, he documented on the shift report, Resident #A was on leave of absence to the dentist, but failed to document how Resident #A was transported. An interview with RN #2 on 3/23/11 at 2:30 P.M., indicated on 3/2/11 she received in shift report Resident #A had left the faciity on day shift for an appointment , and when she glanced at the calendar she thought he was out of the facility with family. RN #2 indicated Resident #A was not in the facility for his evening meal. RN #2 indicated she called Resident #A's nephew when it was getting close to the end of her shift, and was informed Resident #A was not with him. RN #2 indicated Resident #A had been dressed in a shirt, pants, shoes, and jacket while left seated on the bus. RN #2 indicated Resident #A had been incontinent of his bladder while seated on the bus. RN #2 indicated Resident #A's buttock was slightly red with no open areas. A physician's orders [REDACTED].M., indicated to give Resident #A all of his 5:00 P.M., 7:00 P.M., 8:00 P.M., and 9:00 P.M., medications together except his 5:00 P.M., [MEDICATION NAME]. Resident #A's medication record indicated Resident #A received the following medications on 3/2/11 at 10:10 P.M.: [MEDICATION NAME] 0.4 milligram (mg) capsule, [MEDICATION NAME] 20 mg tablet, [MEDICATION NAME] 150 mg capsule, potassium chloride 20 millequivalents tablet, [MEDICATION NAME] 500 mg tablet, [MEDICATION NAME] 300 mg capsules (3 capsules), and [MEDICATION NAME] 50 mg tablet. A weekly skin sweep for Resident #A dated 3/21/11, indicated no open areas. An observation of Resident #A's skin on 3/23/11 at 2:05 P.M., indicated no open areas. The current abuse policy provided by the Administrator on 3/21/11 at 10:42 P.M., indicated the following: Purpose - To ensure that each resident is free of physical, mental, verbal, and sexual abuse, corporal punishment, mental and physical neglect, and involuntary seclusion. Policy - Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.... An Immediate Jeopardy (IJ) was identified on 3/22/11. The IJ began on 3/2/11, when a resident was left on the facility bus for approximately 5 1/2 hours after returning from a dental appointment. The facility failed to have a check system in place to ensure residents were returned safely to the facility after an appointment, and establish good communication procedures among staff to determine a residents whereabouts. The Administrator, and Director of Nursing (DoN) were notified of the IJ on 3/22/11 at 5:00 P.M. The IJ was removed on 3/23/11 at 3:22 P.M., when a through review of the facility's corrective policies, and interview with facility staff inserviced was completed. It was determined the facility implemented the plan of action to remove the IJ and the steps taken removed the immediacy of the problem. Even though the facility's corrective action removed the IJ, the facility remained out of compliance at isolated level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, because all staff had not been inserviced, and the need to incorporate policies into one policy. This federal tag relates to complaint IN 129 and IN 084 3.1-27(a)(3)