Every finding on record at Aperion Care Greenfield

Based on observation, interview, and record review, the facility failed to implement interventions as care planned for Resident 7's edema, failed to follow the user manual's guidelines for safe operation of a Broda chair for Resident 5, failed to set up a gynecologist appointment for Resident 18, failed to complete neurological checks for Resident 40 after an unwitnessed fall, and failed to monitor, document, and address drooling for Resident 8. The deficient practice affected 5 of 5 residents reviewed for quality of care. Findings include: 1. The clinical record for Resident 7 was reviewed on 9/29/2025 at 2:35 p.m. The medical diagnoses included atypical atrial flutter and schizophrenia. A Quarterly Minimum Data Set (MDS) assessment, dated 8/27/2025, indicated Resident 7 was cognitively intact and did not use diuretics. A cardiovascular care plan, initiated 6/9/2024 and last revised 6/9/2025, indicated to monitor for, document, and notify the provider of any edema. An order for a bilateral lower extremity doppler was ordered, on 9/23/2025, with a diagnosis of venous insufficiency. During an interview and observation on 9/25/2025 at 1:52 p.m., Resident 7 stated his legs were swollen and red. Resident 7's socks were noted to be indenting his ankles and redness was noted to his shins. A weekly skin assessment, dated 9/26/2025, indicated Resident 7 did not have edema. An interview and observation were conducted on 9/26/2025 at 12:03 p.m. Resident 7's socks were indenting into his ankles. Resident 7 indicated his ankles felt swollen and the Nurse Practitioner (NP) was working on getting him medicine to help with the swelling. During an interview on 9/26/2025 at 12:05 p.m., Qualified Medication Aide (QMA) 5 indicated Resident 7's legs were .usually like that, referring to his socks indenting his ankles and the red color. When asked how long they had been swollen, she stated she was not sure. During an observation on 9/29/2025 at 12:14 p.m., Resident 7 was noted to be sitting in the hallway. Resident 7's socks were noted to be indenting into his ankles and his shins were reddened. During an interview on 9/29/2025 at 1:05 p.m., the Assistant Director of Nursing (ADON) indicated Resident 7 was having some swelling and redness to his legs. The ADON reported to the NP and followed up with the NP when the doppler results were in, on 9/24/2025, and received no new orders. During an interview with the NP on 9/30/2025 at 10:05 a.m., the NP indicated Resident 7 approached her last week with some bilateral lower leg swelling and redness. She ordered a doppler and would be following up on Resident 7 today. Staff did not report any change between the 9/23/2025 visit and today. 2. The clinical record for Resident 5 was reviewed on 9/26/2025 at 11:45 a.m. The medical diagnosis included bipolar disorder and chronic obstructive pulmonary disease. An Annual MDS assessment, dated 9/5/2025, indicated Resident 5 was not cognitively intact, did not refuse care, had a 6 month or less prognosis, and was on hospice. Resident 7 was dependent on staff for transferring and utilizing a wheelchair. A care plan, dated 2/14/2025 and revised on 6/12/2025, indicated Resident 5 needed assistance with activities of daily living, including the use of a Broda chair. During an interview and observation on 9/25/2025 at 11:38 a.m., Resident 5 was in a Broda chair in the dining area with the footrest broken off. QMA 5 indicated the footrest had been broke off for awhile, but she wasn't sure how long. During an observation on 9/25/2025 at 12:50 p.m., Resident 5 was in a Broda chair in the dining area with the footrest broken off.During an interview on 9/25/2025 at 12:55 p.m., the Administrator indicated Resident 5's Broda chair broke yesterday and they were waiting for a replacement. A Broda chair user manual entitled, Broda Operating Manual, was provided by the ADON on 9/29/2025 at 2:10 p.m. The user manual indicated, .If a breakage, defect, or operational problem is detected, the chair must be successfully repaired, inspected and tested for function before it is returned to service. 3. The clinical record for Resident 18 was reviewed on 9/30/25 at 1:10 p.m. Her diagnoses included, but were not limited to, hemiplegia and hemiparesis. The 8/5/25 NP (Nurse Practitioner) 9 note indicated, The patient reports menorrhagia lasting approximately 7 days per cycle. Due to hemiplegia and hemiparesis on her left non-dominant side, she experiences difficulty accessing and using the bathroom in her facility, which is not fully handicap accessible. She expresses interest in either oral contraceptives or a referral to an OBGYN [obstetrician/gynecologist] for hormonal IUM [intra uterine device] placement to help regulate and lighten her menses. She is due for a breast cancer screening mammogram and colorectal cancer screening, but prefers to delay the latter until after her OBGYN consultation and mammogram .Assessment and Plan .Heavy menstrual bleeding: Patient experiences heavy menses lasting around 7 days, complicating her ability to manage hygiene due to hemiplegia and hemiparesis on her left non-dominant side. Plan: Prescribed Norgestrel 0.075 mg [milligrams] tablet, one tablet daily, to manage heavy menses while awaiting OBGYN appointment. Referred patient to OBGYN for evaluation and potential hormonal IUD placement to regulate and lighten menses. The 8/5/25 physician's order indicated to refer for mammogram for breast cancer screening and to an OB/GYN pap smear and IUD placement for management of heavy menses. There was no information in the clinical record that indicated an OB/GYN appointment was scheduled for Resident 18. An interview was conducted with NP 9 on 9/30/25 at 12:54 p.m. She indicated when she made referrals for outside services, it took the facility a long time to make appointments, and residents didn't always get to their scheduled appointments due to transportation issues and those missed appointments weren't always rescheduled. Resident 18 was due for a colonoscopy and mammogram, and was having horrible menses, soaking through her clothes. NP 9 made multiple referrals for her to be seen by an OB/GYN over the past month, but she was unsure of the status. She wasn't sure where appointments were documented once scheduled, because they were not in the orders section of the electronic health record. An interview was conducted with the ADON on 9/30/25 at 1:21 p.m. He indicated neither a mammogram nor an OB/GYN appointment was scheduled for Resident 18. He'd sent paperwork for the mammogram appointment and was waiting to hear back about an appointment. The OB/GYN appointment still needed to be scheduled. He did not know why there was a delay in scheduling the OB/GYN appointment, since the order to do so was from 8/5/25. 4. The clinical record for Resident 8 was reviewed on 9/25/25 at 12:45 p.m. His diagnoses included, but were not limited to, paranoid schizophrenia and personality disorder. The physician's orders indicated he was prescribed Invega Sustenna (antipsychotic medication) intramuscularly one time a day every 30 days and olanzapine (antipsychotic medication) 10 mg tablet by mouth two times a day, both for schizophrenia. The 8/27/24 psychotropic medication care plan indicated he used antipsychotic medications related to paranoid schizophrenia and personality disorder. The goal was for him to be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through the next review date. An intervention was to administer psychotropic medications as ordered by the physician, and to monitor for side effects and effectiveness every shift. Another intervention was to monitor/document/report as needed, any adverse reactions of psychotropic medications: unsteady gait, tardive dyskinesia, EPS (extrapyramidal symptoms) (shuffling gait, rigid muscles, shaking), frequent falls, etc. and behavior symptoms not usual to the person. An interview was conducted with the ADON on 9/29/25 at 3:21 p.m. He indicated they documented monitoring of side effects of psychotropic medications on the MAR (medication administration record). There was no documentation in the clinical record, including the MAR, to indicate Resident 8 was currently monitored for side effects of antipsychotic medications every shift, as care planned, nor was there an order to do so. An observation of Resident 8 was conducted on 9/25/25 at 12:47 p.m. He was sitting in his wheelchair in the dining room at a table. He was drooling and both hands were shaking consistently. An observation of Resident 8 was conducted on 9/30/25 at 10:00 a.m. He was sitting in his wheelchair in the hallway. His head was down, and he wiped drool from his mouth with a white blanket that was around his neck. Both hands were shaking continuously. An observation of Resident 8 was conducted with the ADON on 9/30/25 at 10:10 a.m. An interview was conducted with the ADON at that time. Resident 8 was sitting in his wheelchair in the hallway. His head was down, and he had drool dripping from his mouth down to his lap. His hands were shaking more aggressively than during the observation on 9/30/25 at 10:00 a.m. The ADON indicated he saw the drooling and hand shaking and would notify their psychiatric provider. An interview was conducted with the ADON on 9/30/25 at 10:08 a.m. He indicated the hand shaking and drooling were new symptoms for Resident 8. He reviewed his clinical record and indicated he didn't see any diagnosis or condition to which the symptoms could be attributed. An interview was conducted with CNA (Certified Nurse Aide) 7 on 9/30/25 at 10:38 a.m. She indicated Resident 8 had been drooling since she began working there on 4/11/24. She gave him paper towels to wipe the drool, when she noticed it, or she would wipe his mouth for him. The hand shaking began around six months ago. She'd spoken with QMA (Qualified Medication Aide) 3 about it. An interview was conducted with QMA 3 on 9/30/25 at 10:40 a.m. She indicated NP (Nurse Practitioner) 9 saw him last week about the drooling. An interview was conducted with NP 9 on 9/30/25 at 12:54 p.m. She indicated she did not know the drooling was a routine thing for him and had been happening for so long. It was concerning if it was happening a lot. No one told her it was a regular thing. The 9/12/25 psychotropic medication observation assessment did not have drooling or tremor check marked under the EPS symptoms section. An interview was conducted with the ADON on 9/30/25 at 11:04 a.m. He indicated he left a message with their psychiatric provider to inform of Resident 8's drooling and hand tremors, but he hadn't heard back yet. The Psychotropic Medication-Gradual Dosage Reduction policy was provided by the ADON on 9/30/35 at 11:25 a.m. It indicated, Staff will monitor residents for side effects, withdrawal symptoms and/or changes in behavior and report to physician and/or psychiatrist. Documentation of observed side effects by nursing staff will occur as indicated in the Nurses Notes and/or on the EMAR [electronic medication administration record.] 5. The clinical record for Resident 40 was reviewed on 9/29/25 at 2:26 p.m. The diagnoses included, but were not limited to, cognitive communication disorder, unspecified lack of coordination, and major depressive disorder. A nurse's note, dated 9/24/25 at 10:50 a.m., indicated Resident 40 had an unwitnessed fall out of his wheelchair and neurological checks were initiated. A fall risk assessment, dated 9/24/25 at 11:55 a.m., indicated Resident 40 was at risk for falls. The Quarterly MDS assessment, dated 6/20/25, indicated Resident 40 was moderately to severely cognitively impaired, used a wheelchair for ambulation, and required supervision or touching assistance with chair/bed-to-chair transfers. During a review of the Neuro Check forms provided by the Social Service Director (SSD) on 9/29/25 at 1:10 p.m., it indicated neuro checks were not completed from 9/24/25 at 10:02 p.m. to 9/25/25 at 6:39 p.m. Omissions were for 9/25/25 at 2:00 a.m., 6:00 a.m., and 10:00 a.m. The plan of care for Resident 40, dated 6/11/19, indicated the resident had a potential for falls related to gait/balance and dementia. The interventions included, but were not limited to, follow facility fall protocol. During an interview with the Director of Nursing (DON) on 9/29/25 at 2:26 p.m., indicated she did not know why neuro checks for Resident 40 were not completed every 4 hours for 24 hours. The DON indicated the nursing department was responsible to ensure these checks were completed. A Neurological Assessment policy was provided by the SSD on 9/29/25 at 1:10 p.m. It indicated, .4. Unless otherwise ordered by the physician, neuro checks will be completed at the time of the physician order, potential head injury or change in condition and every 4 hours for 24 hours . 3.1-37(a) 3.1-37(b)

Based on observation, interview and record review, the facility failed to ensure the narcotic reconciliation records were signed by the on-going nursing staff and the off-going nursing staff at each of three (3) shift changes daily to reflect the accuracy of the narcotic medication counts and the facility did not maintain expired medications within the facility for 1 of 1 resident. These actions had the potential to adversely affect all residents of the facility that receive narcotic medications and 1 of 1 resident who had one expired medication. (Resident 24) Findings include:1. An observation of the narcotic count sheets was conducted with Qualified Medication Aide (QMA) 3, on 9-26-25 at 11:55 a.m., for the facility's east medication cart for September, 2025. The form was set up to reflect the unit or hall for the count sheet, with entries to reflect each date for the month, entries to reflect the three shifts, identified as first, second and third shift, as well as entries to reflect the signature or initials of the nursing staff that was leaving the shift, specified as off, and the nursing staff that was coming on duty for the shift, specified as on. Several dates were observed to be blank, reflective of a lack of a narcotic count being conducted by the nursing staff for the east hall. Those specific dates were as follows: - 9-3-25, first shift.- 9-11-25, first shift.- 9-17-25, second and third shifts.- 9-18-25, first shift. An observation of the narcotic count sheets was conducted with QMA 4, on 9-29-25 at 10:04 a.m., for the facility's west medication cart for August and September, 2025. The form was set up to reflect the unit or hall for the count sheet, with entries to reflect each date for the month, entries to reflect the three shifts, identified as first, second and third shift, as well as entries to reflect the signature or initials of the nursing staff that was leaving the shift, specified as off, and the nursing staff that was coming on duty for the shift, specified as on. Several dates were observed to be blank, reflective of a lack of a narcotic count being conducted by the nursing staff for the west hall. Those specific dates were as follows: - 8-4-25, first shift.- 8-18-25, first shift.- 8-31-25, first shift. During an interview with the Administrator on 9-30-25 at 1:15 p.m., she indicated she was unaware of any dates in which the narcotic count logs were unsigned on either hall. That is something I should have been made aware of. 2. An observation of the west hall medication storage room, including the locked refrigerator, was conducted on 9-29-25 at 10:04 a.m., with QMA 4. During the observation, a box of six (6) Bisacodyl Suppositories, a stimulant laxative, for Resident 24, was observed. This box had an expiration date of 2-28-25. The labeled instructions indicated this medication was to be administered once every eight hours as needed for constipation. QMA 4 indicated she was unaware of this resident using this medication on a regular basis. On 9-30-25 at 10:15 a.m., the Director of Nursing provided a copy of a policy entitled, Narcotic/Controlled Substances-Counting, and dated 11-26-17. This policy indicated its purpose was, To count controlled substances with a partner and to verify the accuracy of the log sheets, and Knowledge of correct response should an error be discovered in the controlled substance count. It indicated, Always participate in the counting of the controlled substances at the beginning and ending of your shift. Never say, 'go ahead without me and I'll sign later.' Never leave it to someone else's discretion when you are the one on duty. If you do not observe the medications that you sign as being present, you may be implicated if the medications are later missing .Follow your facilities [sic] specific guidelines and use their specific log sheet. Obtain sign-out records/logs and keys to the controlled storage compartment. Have partner to assist in the count .Sign name, time and date of completed count .Procedure for Responding to Errors in a Controlled Substance Count: Obtain sign-out logs and keys to the controlled storage compartment. Have partner to assist in the count .Report the incorrect count to the nursing supervisor, Director of Nursing, or administrative staff present. On 9-29-25 at 3:21 p.m., the Assistant Director of Nursing provided a copy of a policy, dated 7-2-19, and entitled Medication Storage. This policy's purpose was cited as, To ensure proper storage, labeling and expiration dates of medications, biologicals, syringes, and needles. This policy indicated, Facility should ensure that medications and biologicals that: (1) have an expired date on the label .are stored separate from other medications until destroyed or returned to the supplier . 3.1-25(e)(3)3.1-25(o)

Based on observation, interview, and record review, the facility failed to assist a resident with putting on a bra, provide a resident with clean clothes and geriatric chair, and transport a resident in a geriatric chair in a dignified manner by pulling them backwards for 3 of 3 residents reviewed for dignity (Resident 38, Resident 5 and Resident 24). Findings include: 1. During an observation conducted on 9/25/25 at 12:20 p.m., Resident 38 was sitting in front of the dining room fully dressed. The resident had no bra in place. During an observation conducted on 9/26/25 at 12:10 p.m., Resident 38 was sitting in front of the dining room fully dressed with no bra in place. During an observation conducted on 9/29/25 at 1:18 p.m., Resident 38 was sitting in front of the dining room fully dressed with no bra in place. During an observation conducted on 9/30/25 at 11:25 a.m., Resident 38 was in the dining room in an activity with several other residents. She was fully dressed with no bra in place. During an interview with the Director of Nursing (DON) on 9/29/25 at 1:22 p.m., they indicated the nursing staff would be responsible to ensure Resident 38 had a bra on. Review of the record of Resident 38, on 9/29/25 at 1:50 p.m., indicated the resident's diagnoses included, but were not limited to, multiple rib fractures, fractures of nasal bones, vascular dementia, and unsteady gait. The Quarterly Minimum Data Set (MDS) assessment for Resident 38, dated 9/2/25, indicated the resident was severely impaired for daily decision making. The resident had no behaviors of refusal of care. The resident required partial/moderate assistance with dressing and putting on footwear. 2. The clinical record for Resident 5 was reviewed on 9/26/25 at 11:45 a.m. The medical diagnosis included bipolar and chronic obstructive pulmonary disease. An Annual MDS assessment, dated 9/5/25, indicated Resident 5 was not cognitively intact, did not refuse care, had a 6 month or less prognosis, and was on hospice. Resident 5 was dependent on staff for transferring and utilizing a wheelchair. A care plan, dated 10/21/24 and revised on 2/15/25, indicated Resident 5 would have a clean appearance. Interventions included Resident 5 was dependent on staff for hygiene needs. During an observation on 9/25/25 at 11:38 a.m., Resident 5 was in a Broda chair in the dining area. Resident 5 was noted to have food debris on his face, shirt, and Broda chair. Resident 5 did not have any food or drink evident, and no staff were directly assisting him. During an observation on 9/25/25 at 12:50 p.m., Resident 5 had finished lunch at this time. He was sitting in his Broda chair in the dining room with food debris on his shirt, face, and Broda chair. During an interview on 9/29/25 at 1:05 p.m., the Assistant Director of Nursing (ADON) indicated it was the expectation of the direct care staff to assist Resident 5 with cleanliness. 3. The clinical record for Resident 24 was reviewed on 9/25/25 at 12:20 p.m. His diagnoses included, but were not limited to, dementia, hemiplegia, chronic obstructive pulmonary disease, left thigh contracture, and right shoulder contracture. An observation of Resident 24 being assisted out of the dining room in his Broda chair was conducted on 9/29/25 at 12:55 p.m. QMA (Qualified Medication Aide) 5 pulled him backwards through the dining room. While pulling him, the side of his Broda chair hit the side of the vending machine. A long, metal strip attached to the side of the vending machine came unattached and fell onto the floor by Resident 24. QMA 5 had a shocked look on her face and stopped pulling him. An interview was conducted with QMA 5 on 9/29/25 at 12:57 p.m. She indicated it was easier to pull Resident 24 backwards in his chair, because the wheels moved back and forth, when she tried to push him forward. The metal strip that came off of the side of the vending machine had fallen off before. It could be popped back into place. An interview was conducted with the DON on 9/29/25 at 1:56 p.m. She indicated staff should push residents in their Broda chairs, not pull them. It was a dignity and safety concern. The Dignity policy was provided by the ADON on 9/29/25 at 3:21 p.m. It indicated, The facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. The facility shall consider the resident's life style and personal choices identified through the assessment processes to obtain a picture of his or her individual needs and preferences. Staff shall carry out activities in a manner which assists the resident to maintain and enhance his/her self-esteem and self-worth. 3.1-3(t)

Based on interview and record review, the facility failed to accurately encode a Minimum Data Set (MDS) assessment for 1 of 2 residents reviewed for hospice. (Resident 5)Findings include:The clinical record for Resident 5 was reviewed on 9/26/2025 at 11:45 a.m. The medical diagnosis included bipolar and chronic obstructive pulmonary disease.An Annual MDS assessment, dated 9/5/2025, indicated Resident 5 was not cognitively intact, did not refuse care, had a 6 month or less prognosis, and was on hospice.A nursing progress note, dated 8/28/2025, indicated Resident 5 was discharged from hospice.A census change, dated 8/28/2025, indicated Resident 5's payor source was changed from hospice to Medicaid. During an interview on 9/29/2025 at 1:45 p.m., the Assistant Director of Nursing (ADON) indicated Resident 5 was discharged from hospice and they were currently trying to get Resident 5 admitted to a new hospice company, but Resident 5 was currently not on hospice care. During an interview on 9/29/2025 at 2:05 p.m., the MDS Coordinator indicated it was the expectation to code to the Resident Assessment Instrument User Manual. Resident 5's hospice status was coded based on the active orders, but a modification would be initiated to reflect Resident 5's status at the time of assessment.A policy entitled Resident MDS Assessment and Care Planning Standard was provided by the ADON on 9/29/2025 at 2:10 p.m. The policy indicated all assessments are to be completed timely and accurately for the Resident Assessment Instrument Manual.

Based on observation, interview, and record review, the facility failed to implement an intervention after a fall, failed to provide appropriate footwear, and failed to have fall interventions in place as care planned for 2 of 2 residents reviewed for falls (Resident 38 and Resident 24). Findings include: 1. During an observation on 9/25/2025 at 12:20 p.m., Resident 38 had on house slippers with no nonskid soles on her feet while sitting in a regular chair. The resident was assisted into a wheelchair with standby assistance provided. During an observation on 9/26/2025 at 12:10 p.m., Resident 38 was sitting in a wheelchair with slippers on with no nonskid soles. During an observation on 9/29/2025 at 12:46 p.m., Resident 38 was sitting at the dining room table, with slippers on with no nonslip grip. During an observation on 9/30/25 at 11:25 a.m., Resident 38 was in the dining room with house slippers with no nonskid soles. During an interview with Certified Occupational Therapist Assistant (COTA) on 9/29/2025 at 12:36 p.m., they indicated she was not able to find where therapy had evaluated or treated Resident 38 since January 2025. During an interview with the Therapy Manager on 9/29/2025 at 12:39 p.m., they indicated Resident 38 was last treated by therapy from 1/23/25 to 2/20/25. Review of the record of Resident 38, on 9/29/25 at 1:50 p.m., indicated the resident's diagnoses included, but were not limited to, multiple rib fractures, fractures of nasal bones, vascular dementia, and unsteady gait. The Quarterly Minimum Data Set (MDS) assessment for Resident 38, dated 9/2/25, indicated the resident was severely impaired for daily decision making. The resident required partial/moderate assistance with putting on footwear. The resident was independent with transfers and ambulation. The plan of care for Resident 38, dated 3/5/25, indicated the resident had a fall related to unsteady gait. The interventions included, but were not limited to, encourage resident to wear gripper socks, wear proper footwear and Physical Therapy to evaluate and treat when the resident returns to the facility from the hospital (7/23/25). This indicated no other interventions were implemented after Resident 38 fell. The fall risk assessment for Resident 38, dated 4/21/25, indicated the resident was at risk for falls. The fall risk assessment for Resident 38, dated 7/21/25, indicated the resident was at risk for falls. A progress note for Resident 38, dated 7/21/25 at 10:49 a.m., indicated the resident had a witnessed fall outside the shower room. The resident was walking and tripped on her shoe. The resident had an open area on the left side of her nose (pressure applied due to bleeding). The Physician was notified and an x-ray was ordered. A progress note for Resident 38, dated 7/21/25 at 9:40 p.m., indicated the x-ray results came back and the resident had fractured ribs. A progress note for Resident 38, dated 7/22/25 at 1:31 p.m., indicated the resident was transported to the local hospital. A progress note for Resident 38, dated 7/22/25 at 4:53 p.m., indicated the resident was being transported from the local hospital to a major medical hospital for admission. The hospital discharge summary for Resident 38, dated 7/25/25, indicated the resident was admitted for a fall with traumatic injuries. The resident was at high risk for falls due to medical and physical impairment. The resident acquired a fracture of on the right side of ribs 3-7 and fracture on the left side of the ribs 3-8, sinus contusion with hematoma and nasal bone fracture. The Occupational Therapy and Physical Therapy recommendations were the resident would benefit from ongoing therapy when returned to the Extended Care Facility (ECF). During an interview with Director of Nursing (DON) on 9/29/25 at 1:22 p.m., they indicated the Interdisciplinary Team (IDT) were responsible to ensure Resident 38 had a fall intervention implemented after the resident fell. The DON indicated nursing staff were responsible to ensure Resident 38 had on appropriate footwear to prevent falls. 2. The clinical record for Resident 24 was reviewed on 9/25/25 at 12:20 p.m. His diagnoses included, but were not limited to, dementia, hemiplegia, chronic obstructive pulmonary disease, left thigh contracture, and right shoulder contracture. The fall care plan, revised 5/1/25, indicated he had actual falls related to gait/balance problems, decreased safety awareness, shortness of breath with activity, dementia, and psychotropic medication use. Interventions were to ensure the television remote was within reach; a safe environment with a working and reachable call light; call light within reach and encourage the resident to use it for assistance as needed; and bed in lowest position at all times. An observation of Resident 24 was conducted on 9/29/25 at 1:12 p.m. He was lying awake in bed in his room. His bed was not in the lowest position; there was no television remote within reach, and the television was on; and his call light cord was wedged between the wall and the mattress with the actual call light not within reach. There were no staff present in the room. An observation of Resident 24 was conducted with CNA (Certified Nurse Aide) 8 on 9/29/25 at 1:20 p.m. An interview was conducted with CNA 8 at that time. The call light cord was still wedged between the wall and the mattress. CNA 8 pulled on the cord for a while to retrieve the actual light and placed it on top of Resident 24. CNA 8 indicated Resident 24 was not able to pull the cord from between the wall and mattress himself, as he required total assistance. CNA 8 then retrieved the television remote from a drawer in his room. CNA 6 entered the room and used the bed remote to lower the bed to its' lowest position. The Fall Prevention Program policy was provided by the SSD (Social Services Director) on 9/29/25 at 1:10 p.m. It indicated, Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary Guidelines: .Care plan incorporates: .Interventions are changed with each fall, as appropriate .Standards: .Safety interventions will be implemented for each resident identified at risk .Fall/Safety interventions may include but are not limited to: .The nurse call device will be placed within the resident's reach at all times .The resident's personal possessions will be maintained within reach when possible .Foot wear will be monitored to ensure the resident has proper fitting shoes and/or footwear is non-skid. 3.1-45(a)(1) 3.1-45(a)(2)

Based on interview and record review, the facility failed to follow a physician's order to flush an indwelling catheter ( a thin, flexible tube inserted into the bladder to drain urine continuously) with normal saline every shift as ordered for 1 of 1 resident reviewed for catheter care. (Resident 40)Findings include: The clinical record for Resident 40 was reviewed on 9/29/2025 at 11:07 a.m. The diagnoses included, but were not limited to, neuromuscular dysfunction of the bladder, dementia, and benign prostatic hyperplasia (the prostate gland, located below the bladder in men, enlarges) with lower urinary tract symptoms. The Quarterly Minimum Data Set assessment, dated 6/20/25, indicated Resident 40 had an indwelling catheter. A physician's order, dated 2/24/24, indicated to irrigate/flush catheter with 30 cc (milliliters) of normal saline every shift. The September 2025 Medication Administration Record (MAR) was reviewed on 9/29/25 at 11:30 a.m. It indicated a physician's order for catheter: irrigate/flush with 30 cc (milliliters) of normal saline every shift. Omissions indicated for day shift for the following dates: 9/5/25, 9/12/25, 9/16/25, 9/17/25, 9/23/25, and 9/24/25. During an interview with the Director of Nursing (DON) on 9/29/25 at 2:36 p.m., they indicated they did not know why these medication omissions occurred and the nurse who was caring for the resident was responsible to ensure orders were followed. 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure only medications with appropriate labels were present in 1 of 2 medication carts during 1 of 2 medication cart observations. (Facility) Findings include:On 9-29-25 at 10:04 a.m., an observation of the west hall medication cart was conducted with Qualified Medication Aide (QMA) 4. One bottle of Milk of Magnesia, a saline laxative, was observed which had only the manufacturer's label present. There was no labeling present which indicated the resident's full name, physician's name, specific physician instructions for use, prescription number, date of issue, date opened, or name and address of the pharmacy which dispensed the medication. The label appeared to have been torn off. In an interview with QMA 4 at this time, she indicated it appeared as if the label had been torn off the bottle in some manner as a small piece of label-type material was located on the side, but was without any identifying information. The manufacturer's label indicated directions for use which included, but was not limited to, administer 2 to 4 tablespoons daily, preferably at bedtime which can be given in divided doses and/or as directed by the physician, and to give with 8 ounces of fluid with each dose. On 9-29-25 at 3:21 p.m., the Assistant Director of Nursing provided a copy of a policy, dated 7-2-19, and entitled Medication Storage. This policy's purpose was cited as, To ensure proper storage, labeling and expiration dates of medications, biologicals, syringes, and needles. This policy indicated, Facility should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels. 3.1-25(j)3.1-25(k)(1)3.1-25(k)(2)3.1-25(k)(3)3.1-25(k)(4)3.1-25(k)(5)3.1-25(k)(6)3.1-25(k)(7)3.1-25(l)(1)3.1-25(l)(2)

Based on interview and record review, the facility failed to report an allegation of abuse to the Indiana Department of Health (IDOH) timely for 1 of 3 residents reviewed for abuse. (Resident B) Findings include: The clinical record for Resident B was reviewed on 10/15/24 at 10:14 a.m. Her diagnoses included, but were not limited to, anxiety and depression. An interview was conducted with Resident B on 10/11/24 at 12:20 p.m. She indicated on Sunday, 10/6/24, Certified Nursing Assistant (CNA) 3 grabbed her left arm and shook her, telling her 'you don't talk to me like that,' and called her a crazy b**** along with other names. CNA 3 ran out of the room when one of the nurses came in. CNA 3 was screaming she was never going in that 'damn b****'s' room again. Resident B reported this to the night shift nurse, who was right outside the door when CNA 3 was still screaming. On 10/11/24 at 1:11 p.m., the Business Office Manager (BOM) provided a copy of an email sent to her from Resident B on Monday, 10/7/24 at 6:14 a.m., with Serious complaint in the subject line. The email indicated CNA 3 grabbed Resident B's left arm and forcefully shook her repeatedly; that CNA 3 refused to leave her room; that CNA 3 left her hanging over the bed in the Hoyer lift; that CNA 3 refused to reposition her in the bed, telling her to 'figure that out yourself;' that her call light wasn't answered for 11 hours the night of 10/5/24; along with several other allegations. The email read, All of [name of CNA 3's] actions this weekend have been either neglect or abusive. An interview was conducted with the BOM on 10/11/24 at 1:01 p.m. She indicated she received the email from Resident B the morning of 10/7/24. She responded to Resident B via email the same day that an investigation was started. Resident B replied, thanking her for the quick response, and they began to investigate. The Administrator was on vacation, on 10/7/24, and currently still was, as she left for vacation on 10/3/24. This allegation of abuse by Resident B was not reported to the IDOH. The BOM assumed it was the Assistant Director of Nursing (ADON) who was responsible for reporting it. They just reported it today, 10/11/24. On 10/11/24 at 1:03 p.m., the Regional Nurse Consultant (RNC) provided a copy of a reportable, dated 10/11/24, regarding Resident B's allegations of abuse against CNA 3. On 10/15/24 at 12:45 p.m., an interview was conducted with the Administrator. She indicated the BOM and ADON were responsible for reporting to IDOH in her absence. The Abuse Prevention and Reporting policy was provided by the BOM on 10/11/24 at 1:21 p.m. It read, Any allegation of abuse or any incident that results in serious bodily injury will be reported to the Department of Public Health immediately, but not more than two hours after the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours. This citation relates to Complaint IN00444277. 3.1-28(c)

Based on observation, interview, and record review, the facility failed to ensure trash was contained within the dumpster and lids were closed on the dumpster for 52 of 52 residents in the facility. Findings include: A tour of the kitchen was conducted with the DM (Dietary Manager) on 8/27/24 at 11:15 a.m. During the tour, an observation was made of the outside dumpster area. There were two dumpsters next to each other located near the outside dry storage food shed. Each dumpster had two lids. The left lid of the left dumpster, when facing the dumpsters, was completely opened. There was a clear bag of trash on the ground to the left of the left dumpster. There was a blue glove on the ground to the right of the left dumpster. There were several bags of trash inside of the opened dumpster. An interview was conducted with the DM during observation of the outside dumpster area. She indicated she was unable to reach the dumpster door. On 8/28/24 at 10:04 a.m. and 8/29/24 at 11:28 a.m., the same dumpster lid as reference in the 8/27/24, 11:15 a.m. kitchen tour was observed open again. The Garbage and Rubbish Disposal policy was provided by the MDSC (Minimum Data Set Assessment Coordinator) on 8/30/24 at 10:52 a.m. It read, Procedure: 4. All containers will be provided with tight-fitting lids or covers, and will be leak proof and waterproof 8. Outdoor trash receptacles will be kept covered and the surrounding area kept free of litter. 3.1-21(i)(5)

Based on observation, interview, and record review, the facility failed to ensure fluids were available at the bedside for 7 of 7 residents reviewed for accommodation of needs. (Residents 21,19, 30, 43, 41, 31, and 35) Findings include: 1. Resident 21's record, reviewed on 8/28/24 at 2:40 p.m., indicated diagnoses that included, but were not limited to, type 2 diabetes mellitus, schizoaffective disorder, bipolar, and dementia. During an observation and interview on 08/27/24 at 12:34 p.m., Resident 21 indicated no ice water was ever passed. Resident 21 indicated staff used to pass ice water at night, now if they wanted water, they got it themselves. A cup was located at Resident 21's bedside and was less than half full. Fresh ice water had not been passed, thus far, on 8/27/24. During an observation on 08/29/24 at 10:26 a.m., a Styrofoam cup was on the bedside table with 8/28 written on it. Another empty cup was sitting on the bedside table. An Admission Minimum Data Set (MDS) assessment, dated, 7/19/24, indicated Resident 21 was cognitively intact for daily decision making. Resident 21 had a care plan, dated 6/30/24, indicating to encourage fluids. 2. Resident 31's record, reviewed on 8/28/24 at 2:41 p.m., indicated diagnoses that included, but were not limited to, chronic obstructive pulmonary disease, cerebral infarction, heart failure, and schizophrenia. During an observation on 8/28/24 at 10:47 a.m., Resident 31 did not have any water at the bedside. During an observation on 8/29/24 at 10:33 am., Resident 31 had no cup of water at the bedside. 3. Resident 35's record, reviewed on 8/28/24 at 2:43 p.m., indicated diagnoses that included, but were not limited to, fibromyalgia, alcoholic cirrhosis, chronic obstructive pulmonary disease, bipolar, anxiety, and hepatic encephalopathy. During an observation and interview on 8/27/24 at 1:31 p.m., Resident 35 had no water at the bedside. Resident 35 indicated, we rarely ever get fresh ice water and definitely not daily. During an observation on 8/29/24 at 10:33 a.m., Resident 35 had no cup of water at the bedside. A Quarterly MDS assessment, dated 8/20/24, indicated Resident 35 was cognitively intact. 4. Resident 41's record, reviewed on 8/28/24 at 2:38 p.m., indicated diagnoses that included, but were not limited to, acute respiratory failure, encephalopathy, paraplegia, type 2 diabetes, anemia, and hypertension. During an observation and interview on 8/28/24 at 10:38 a.m., Resident 41 had no water at the bedside. They indicated there was never any drinking water brought in the room. Resident 41 indicated the only water in the room was the one to flush out the feeding tube. During an observation on 8/29/24 at 10:36 a.m., Resident 41 had no water at the bedside. During an observation on 8/30/24 at 10:01 a.m., Resident 41 had no water at the bedside. An Admission MDS assessment, dated 7/16/24, indicated Resident 41 was cognitively intact. 5. Resident 43's record, reviewed on 8/28/24 at 2:37 p.m., indicated diagnoses that included, but was not limited to, hemiplegia and hemiparesis following a cerebral infarction, acute respiratory failure, aphasia, and hypertension. During an observation and interview on 8/27/24 at 1:48 p.m., Resident 43 indicated there was no water at the bedside. They hardly had any ice water brought into their room. During an observation on 8/29/24 at 10:31 a.m., Resident 43 had no water at the bedside. During an observation on 08/30/24 10:47 a.m., Resident 43 had no water cup at the bedside. Resident 43 indicated, they did come in one time yesterday with a cup of fresh water, but no one has been in today. A MDS assessment, dated, 8/19/24, indicated Resident 43 was cognitively intact. During an interview on 08/29/24 at 10:37 a.m., Certified Nursing Assistant (CNA) 10 indicated she typically passed water to the residents in the morning, but it depended on how busy it was and how long showers took. If the staff don't pass ice water in the morning, they attempt to get it done after lunch or before the shift ended. 45291 6. The clinical record for Resident 19 was reviewed on 8/30/2024 at 1:30 p.m. The medical diagnoses included stroke. A Quarterly MDS assessment, dated 7/26/2024, indicated Resident 19 was cognitively impaired and needed set-up assistance for daily tasks of eating. During an observation on 8/27/2024 at 11:45 a.m., Resident 19 was sitting in a wheelchair in his room. Resident 19 had no fluids available in the room. A clear plastic cup was on the floor under the bed. During an observation on 8/29/2024 at 1:46 p.m., Resident 19 was sitting in a wheelchair is his room. Resident 19 had no fluids available in his area of the room. 7. The clinical record for Resident 30 was reviewed on 8/31/2024 at 11:05 a.m. The diagnoses included Alzheimer's disease. An Annual MDS assessment, dated 7/26/2024, indicated Resident 30 was cognitively impaired and was dependent on staff for daily tasks of eating. During an observation on 8/27/2024 at 1:35 p.m., Resident 30 was sitting in a wheelchair in her room. Resident 30 had no fluids available in the room. During an observation on 8/29/2024 at 2:20 p.m., Resident 30 was sitting in a wheelchair in her room. Resident 30 had no fluids available in her area of the room. During an interview on 8/27/2024 at 2:05 p.m., CNA 17 indicated staff had no time to pass fluids this shift yet. Residents were able to get fluids with meals and if they requested it. During an interview on 8/30/2024 at 1:30 p.m., the Executive Director indicated all staff can pass fluids, but the direct care staff were primarily responsible to pass fresh fluids to residents' rooms every shift unless clinically contraindicated. A policy entitled, Water Pass- Hydration, was provided by the Social Service Director on 8/30/2024 at 2:10 p.m. The policy indicated that fresh cold ice water would be provided to each resident at a minimum of three times a day. 3.1-3(v)(1)

Based on interview and record review, the facility failed to ensure residents were free from physical abuse for 5 of 5 residents reviewed for abuse. (Residents 2, 13, 31, 33, and 45) Findings include: 1. The clinical record for Resident 45 was reviewed on 8/28/24 at 12:15 p.m. Her diagnoses included, but were not limited to, dementia and major depressive disorder. She was admitted to the facility on [DATE] from another facility. The 8/1/24 Quarterly Minimum Data Set (MDS) assessment indicated she was severely cognitively impaired. An interview was conducted with Family Member 2 on 8/28/24 at 12:29 p.m. She indicated Resident 45 was transferred to her current facility from another facility. Family Member 2 received a voicemail from the previous facility that Resident 45 was being transferred the following day. By the time Family Member 2 received the voicemail, Resident 45 was already transferred to her current facility. Resident 45 had behaviors daily. She was combative and hallucinated. Another male resident smacked her at the facility about a month ago. The potential for aggressive behaviors care plan, revised 7/29/24, indicated the goal was for Resident 45 to not harm herself, residents, or others. 2. The clinical record for Resident 31 was reviewed on 8/30/24 at 12:00 p.m. Her diagnoses included, but were not limited to, bipolar disorder, depression, psychotic disorder, and schizophrenia. The behavior care plan, revised 2/29/24, indicated she had behaviors directed towards others. The goal was for her to not show behaviors of yelling, hitting, and throwing items. The investigative file into a resident to resident altercation between Resident 45 and Resident 31 was provided by the DON (Director of Nursing) on 8/30/24 at 8:40 a.m. The file included an incident report dated 3/11/24. The report indicated, on 3/11/24, Resident 45 was sitting at the dining room table drinking her coffee when Resident 31 wheeled up behind Resident 45 in her wheelchair hitting Resident 45 with open hand on her back. Resident 45 then stood up and they both began swinging at each other making contact with each other's face and arms. Head to toe assessments were completed on both residents. Both residents were placed on one to one supervision. The file included three, undated, documented interviews conducted by the Executive Director (ED) with the (ADON) Assistant Director of Nursing, (QMA) Qualified Medication Aide 3, and (CNA) Certified Nursing Assistant 4. The undated, documented interview with the ADON read, I was the nurse on duty. I immediately separated the residents, assessed, notified families. Admin [Administrator] present made aware. The undated, documented interview with QMA 3 read, I heard a lot of noise in the hallway. When I ran around the corner ADON was taking care of the problem. I assisted with getting [name of another resident] out the dining room. Admin came and asked what happened so was made aware. The undated, documented interview with CNA 4 read, I seen the two women swinging at each other. I ran and helped pull them away from each other. Admin and ADON present and helped. 3. The clinical record for Resident 2 was reviewed on 8/30/24 at 12:02 p.m. His diagnoses included, but were not limited to, dementia and schizophrenia. The behavior care plan, revised 5/25/24, indicated he had physical aggression towards others. The goal was for him to have a decrease in episodes of physical abuse or yelling out towards others with redirection from staff. The investigative file into a resident to resident altercation between Resident 2 and Resident 45 was provided by the DON (Director of Nursing) on 8/30/24 at 8:40 a.m. The file included an incident report dated 7/1/24. The report indicated, on 6/30/24, Resident 2 was sitting in his wheelchair trying to get outside to smoke and Resident 45 was sitting in her wheelchair in the way. Resident 2 attempted to move Resident 45 and when Resident 45 asked him to leave her alone, Resident 2 swung with an open hand making contact with her left eye. Head to toe assessments were completed on both residents. Resident 2 was placed on one to one supervision. The file included two undated, documented interviews conducted by the ED with LPN (Licensed Practical Nurse) 5 and LPN 6. The undated, documented interview with LPN 5 read, I was the nurse on duty. I yelled for help to separate the residents, assessed, notified families. Admin [Administrator] just left so I called her to inform. She came back and started talking to residents and staff. The undated, documented interview with LPN 6 read, I was standing in the dining room, assisting the staff for smoke break. I helped [name of LPN 5] separate and assess the residents. I was standing next to [name of LPN 5] when he called Admin. 4. The clinical record for Resident 13 was reviewed on 8/30/24 at 12:04 p.m. Her diagnoses included, but were not limited to, schizoaffective disorder, major depression, and anxiety. The investigative file into a resident to resident altercation between Resident 13 and Resident 45 was provided by the DON (Director of Nursing) on 8/30/24 at 8:40 a.m. The file included an incident report dated 7/25/24. The report indicated, on 7/25/24, Resident 13 was in her wheelchair rolling down the hallway where she got too close to Resident 45. Resident 45 reacted by swinging with an open hand making contact with the back of Resident 13's head. Both residents were separated and assessed. Resident 45 was placed on one to one supervision. The 7/29/24 follow up section indicated both residents were seen by their physicians. The file included three, undated, documented interviews conducted by the ED with QMA 7, the ADON, and CNA 8. The undated, documented interview with QMA 7 read, I heard [names of Resident 45 and Resident 13] got into it but I was down getting report so I didn't see anything. I didn't assist with anything. Admin [Administrator] was present and handling situation. The undated, documented interview with the ADON read, I was walking past the MDR [main dining room] when I saw [name of Resident 45] swing and hit [name of Resident 13.] I separated them with the help of admin and staff. Notified M.D. [Medical Director], families, and completed assessments. Assisted with 1:1s [one to one supervision] . The undated, documented interview with CNA 8 read, I heard a lot of noise coming from the dining room, as soon as I turned the corner the ADON was already there. I helped get [Resident 13] out of the dining room. Admin was also in the dining room helping. 5. The clinical record for Resident 33 was reviewed on 8/30/24 at 12:06 p.m. His diagnoses included, but were not limited to, traumatic brain injury, bipolar disorder, and depression. The 7/29/24 investigative file into a resident to resident altercation between Resident 31 and Resident 33 was provided by the Housekeeping Supervisor on 8/30/24 at 8:55 a.m. The file included an incident report dated 8/5/24. The report indicated, on 7/29/24, both residents were in the hallway in their wheelchairs. Resident 33 was passing by Resident 31 when Resident 31 reached over and slapped Resident 33 in the face and back of the head. Both residents were immediately separated and assessed. Neurological checks were initiated on Resident 33. The 8/5/24 follow up section indicated Resident 31 was seen by her physician and medications were adjusted. The file included three, undated, documented interviews conducted by the ED with LPN 6, Staff Member 50, and CNA 9. The undated, documented interview with LPN 6 read, I heard a lot of noise so I can [sic] around the corner. I didn't witness it but was made aware by staff and admin [Administrator.] I assessed resident and made notifications to families and M.D. Admin was present so I didn't report to anyone. The undated, documented interview with Staff Member 50 read, I was in the dining room when it happened. I got [name of Resident 33] while another staff member got [name of Resident 31.] Admin came around the corner and asked what happened and I told her. The undated, documented interview with CNA 9 read, I hurried up and grabbed [name of Resident 31] and got her out the dining room. Admin came around the corner and assisted with the incident. An interview was conducted with the ED on 8/30/24 at 9:52 a.m. She indicated after investigating, she substantiated resident to resident abuse for all four altercations, as she was present for most of them, and all four of them were witnessed by staff. The Abuse Prevention and Reporting policy was provided by the SSD (Social Services Director) on 8/29/24 at 12:23 p.m. It read, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents Abuse: Abuse means any physical or mental injury or sexual assault inflected upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. 3.1-27(a)(1)

Based on observation, interview, and record review, the facility failed to place soiled linen in bags when transported through the hallway; ensure soiled linen was contained in soiled utility bins located in the hallway of the facility; and ensure PPE (personal protective equipment) was properly discarded after resident care, prior to leaving the room for 2 of 2 soiled utility bins randomly observed; 1 of 1 random observation of soiled linen transportation by staff; and 7 of 7 residents who were or resided in rooms with a roommate who were in EBP (enhanced barrier precautions). (Residents 5, 11, 29, 30, 36, 45, and 150) Findings include: On 8/27/24 at 1:10 p.m., an observation of a soiled linen bin in the hallway was made. There was unbagged, soiled linen hanging out of the bin. The unbagged, soiled linen was piled so high within the bin, that the lid was unable to be closed and was resting on top of the soiled linen. On 8/29/24 at 10:16 a.m., an observation of a soiled linen bin in the hallway near the social services office was made. There was white linen hanging out of the bin, draped over the side. The linen hanging out of the bin was not contained within the bin or within a bag. An interview was conducted with CNA (Certified Nursing Assistant) 10, who happened to be in the area of the above referenced soiled linen bin, on 8/29/24 at 10:16 a.m. She indicated they brought the soiled linen from the residents' rooms and placed them into the bins in the hallway, as they did not bring the bin itself into residents' rooms. At the end of their shift, they brought the soiled linen bins into the soiled linen room. On 8/29/24 at 3:45 p.m., an observation of CNA 11 was made. She walked down the hallway from the employee breakroom area towards the dining room with a trash bag and a cloth bed pad partially rolled up in her gloved hand. There was a brown substance on the floor in three spots in the area located between the employee break room and the nurses' station. LPN 6 was observed to bend over and pick up the brown substances from the floor. An interview was conducted with LPN 6 on 8/29/24 at 3:45 p.m. She indicated she didn't know what the brown substance was and just picked it up. On 8/30/24 at 10:19 a.m., an observation of a soiled linen bin in the hallway near the beauty shop was made. There was unbagged, soiled linen hanging out of the bin. The unbagged, soiled linen was piled so high within the bin, that the lid was unable to be closed and was resting on top of the soiled linen. An interview was conducted with CNA 4 on 8/30/24 at 10:19 a.m. during the above observation. He indicated the soiled linen was supposed to be in a bag. They bagged the soiled linen in the residents' room, then put it into the soiled linen bin in the hallway. He stated, I'm not sure why this isn't in a bag. On 8/27/24 at 11:12 a.m., an observation of an uncovered trash receptacle in the hallway outside of Resident 5's room was made. The receptacle had no lid and there was trash visible inside of the receptacle. There was a sign on the doorway indicating this room was being utilized by a resident who was in EBP (enhanced barrier precautions-infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.) On 8/27/24 at 1:05 p.m., an observation of an uncovered trash receptacle in the hallway outside of Resident 5's room was made. The receptacle had no lid and there was used PPE (personal protective equipment,) including gowns and gloves visible inside of the receptacle. On 8/27/24 at 1:05 p.m., an observation of an uncovered trash receptacle in the hallway outside of Resident 11's and Resident 30's room was made. The receptacle had no lid and there was trash visible inside of the receptacle, including used PPE. There was a sign on the doorway indicating this room was being utilized by a resident who was in EBP. On 8/27/24 at 1:09 p.m., an observation of an uncovered trash receptacle in the hallway outside of Resident 36's and Resident 150's room was made. The receptacle had no lid and there was trash visible inside of the receptacle, including used PPE. There was a sign on the doorway indicating this room was being utilized by a resident who was in EBP. On 8/27/24 at 1:11 p.m., an observation of an uncovered trash receptacle in the hallway outside of Resident 29's and Resident 45's room was made. The receptacle had no lid and there was trash visible inside of the receptacle, including used PPE. There was a sign on the doorway indicating this room was being utilized by a resident who was in EBP. An interview was conducted with the ADON (Assistant Director of Nursing) on 8/27/24 at 1:07 p.m. He indicated staff were doffing their PPE in the hallway and throwing it away in the uncovered trash receptacles. He did not know where the lids to the trash receptacles were, but the receptacles should probably be covered. The Linen Handling Principles policy was provided by the Social Services Director on 8/30/24 at 2:10 p.m. It read, Purpose: To ensure proper handling of soiled and clean linen and personal laundry to prevent the spread of microorganisms. Guidelines: .8. Soiled linen hampers shall be transported to the Laundry Department on a regular schedule to prevent overflowing by assigned personnel 10. Soiled linens shall be carefully removed from beds, rolled inward, and placed directly into plastic bag or soiled linen containers, at the location of use and not transported openly through corridors (unless in plastic bag.) 3.1-18(b)(1)(A) 3.1-18(b)(2) 3.1-18(j)

Based on observation, interview, and record review, the facility failed to provide a homelike environment for 2 of 12 residents reviewed for a clean environment. (Resident 43 and Resident 31) Findings include: 1. Resident 43's clinical record, reviewed on 8/28/24 at 2:47 p.m., indicated diagnoses that included, but were not limited to, type 2 diabetes mellitus, alcoholic cirrhosis of the liver, and schizophrenia. During an observation on 8/27/24 at 1:43 p.m., Resident 43's bathroom floor was sticky to walk on, a bedpan, uncovered, with an open bag of adult diapers were laying on the floor, and there was paint peeling off the walls behind the bed frames. During an interview on 8/30/24 at 2:00 p.m., the Executive Director (ED) indicated she was aware of the paint peeling on the wall. The ED indicated the two residents in the room kept moving their beds around and [scuffing] up the paint on the wall. The ED indicated maintenance had been in the room to repaint it several times. 2. Resident 31's clinical record, reviewed on 9/30/24 at 12:46 p.m., indicated diagnoses that included, but were not limited to, chronic obstructive pulmonary disease, cerebral infarction, heart failure, and hypertension. During an observation on 8/28/24 at 10:48 a.m., Resident 31's bathroom floor had a Styrofoam cup, lid, straw, wash basin and toilet paper on it. During an observation on 08/30/24 at 12:00 p.m., Resident 31's toilet bowl lid was off the toilet and sitting on the bathroom floor. An open toilet paper roll and a wash basin were laying on the floor. During an interview on 08/30/24 at 02:11 p.m., the ED indicated the resident had just taken the toilet bowl lid off and it was now back in place. A care plan, revised 3/7/24, indicated Resident 31 will be provided with a homelike environment. An admission packet included resident rights provided by the ED, on 8/28/24 at 10:45 a.m., indicated, .you have the right to a safe, clean, comfortable, and homelike environment . 3.1-19(f)(5)

Based on interview and record review, the facility failed to maintain documentation Resident 5's representative was provided with a bed hold policy for 1 of 1 resident reviewed for hospitalization . Findings include: The clinical record for Resident 5 was reviewed on 8/29/24 at 2:34 p.m. The diagnoses included stroke. A Quarterly Minimum Data Set (MDS) assessment, dated 6/28/24, indicated Resident 5 was cognitively intact. The census flowsheet for Resident 5 indicated a therapeutic leave from 7/22/24 to 7/26/24. During an interview on 8/30/24 at 1:45 p.m., Resident 5 indicated he did not know what a bed hold policy was and did not receive any paperwork prior to going to the hospital in July of 2024. During an interview on 8/30/24 at 3:20 p.m., the Executive Director indicated the staff could not find the bed hold policy for Resident 5's July hospitalization . The expectation was nursing staff would provide the bed hold policy at the time of transfer to the resident or their representative. A blank copy of the Bed Hold Policy Notice was provided, on 8/30/24 at 3:20 p.m., by the Executive Director. The policy contained the availability to indicate when a resident was unable to sign, copy mailed to representative, and a place for resident signature. 3.1-12(a)(25)(A) 3.1-12(a)(25)(B)

Based on interview and record review, the facility failed to accurately encode Minimum Data Set (MDS) information for 2 of 19 residents reviewed from MDS accuracy. (Resident 5 and Resident 19) Findings include: 1. The clinical record for Resident 5 was reviewed on 8/29/24 at 2:34 p.m. The diagnoses included bipolar disorder. An Admission MDS assessment, dated 2/1/24, indicated that Resident 5 did not have a PASARR (Preadmission Screening and Resident Review) Level II. A PASARR Level II, dated 6/21/19, indicated Resident 5 had a serious mental illness but did not need specialized services. During an interview on 8/30/24 at 11:45 a.m., the Social Services Director indicated Resident 5 had a serious mental illness and the most current Level II was the one dated 6/21/19. 2. The clinical record for Resident 19 was reviewed on 8/30/2024 at 1:30 p.m. The medical diagnoses included chronic obstructive pulmonary disease. A Quarterly MDS assessment, dated 7/26/24, indicated Resident 19 did not have a prognosis of six months or less but received hospice services. A hospice care plan, revised on 3/13/24, indicated Resident 19 received hospice care. A certification of terminal illness for Resident 19 provided, on 8/30/24 at 10:45 a.m., by the Executive Director indicated a terminal diagnosis with a life expectancy of six months or less if the disease runs its projected course. During an interview, on 8/30/24 at 12:45 p.m., the MDS Nurse indicated the aforementioned assessments for Resident 5 and Resident 19 were coded incorrectly due to oversight. A policy entitled, Resident MDS Assessment and Care Planning Standard, was provided by the Social Services Director on 8/30/24 at 2:10 p.m. The policy indicated all assessments are to be completed timely and accurately for the Resident Assessment Instrument Manual.

Based on interview and record review, the facility failed to ensure Resident 11 had a completed Preadmission Screening and Resident Review (PASARR) prior to admission to the facility for 1 of 3 residents reviewed for PASARR. Findings include: The clinical record for Resident 11 was reviewed on 8/30/24 at 12:15 p.m. The diagnoses included schizophrenia. An Admission Minimum Data Set (MDS) assessment, dated 2/1/24, indicated Resident 11 did not have a PASARR Level II. Per the Indiana State Department of Family and Social Services Administration, all applicants to Medicaid-certified nursing facilities in Indiana are entered in the state's web-based PASARR system, and a Level I screen is completed to initiate the PASARR process. If indicated, a PASARR Level II evaluation is performed to identify the specialized needs of individuals with mental illness (MI), intellectual or developmental disability ID/DD, or both (MI/ID/DD). A PASARR Level I for Resident 11, dated 1/24/19, indicated that Resident 11 needed an on-site Level II review. During an interview on 8/30/24 at 12:55 p.m., the Social Service Director (SSD) indicated the facility did not have documentation for a Level II completed for Resident 11 after 1/24/2019. The SSD indicated the facility received an influx of residents around the time Resident 11 admitted and that the Level II was not completed due to oversight. A policy entitled, Preadmission Screening and Annual Resident Review (PASARR), was provided by the Director of Nursing on 8/30/24 at 8:40 a.m. The policy indicated, .The facility will participate in or completed the Level I screen for all potential admissions regardless of payer source .Based on the Level I, if an individual is determined to meet the above criterion, the facility will not admit and individual, the facility will refer the potential admission to the State PASARR representative for a Level II screening process . 3.1-16(d)(1)

Based on interview and record review, the facility failed to hold regularly scheduled care plan meetings for 1 of 2 residents reviewed for care planning. (Resident 45) Findings include: The clinical record for Resident 45 was reviewed on 8/28/24 at 12:15 p.m. Her diagnoses included, but were not limited to, dementia and major depressive disorder. She was admitted to the facility, on 11/6/23, from another facility. The 11/6/23 nursing note read, Resident is a new admit from [name of previous facility,] came to the facility via facility van. Resident is alert to name but confused with place where she is and time of day . The 8/1/24 Quarterly Minimum Data Set (MDS) assessment indicated she was severely cognitively impaired. An interview was conducted with Family Member 2 on 8/28/24 at 12:29 p.m. She indicated Resident 45 was transferred to her current facility from another facility. Family Member 2 received a voicemail from the previous facility that Resident 45 was being transferred the following day. By the time Family Member 2 received the voicemail, Resident 45 was already transferred to her current facility. Family Member 2 received several phone calls about missed appointments from a local hospital provider regarding missed oncology, optometry, and diabetic clinic appointments. She hadn't had any scheduled care plan meetings with the current facility to discuss these things. The electronic health record (EHR) indicated Resident 45 had a, 11/14/23, Admission MDS assessment and, 5/1/24, Quarterly MDS assessment, but no corresponding care plan meetings were found. The 4/29/24, 3:12 p.m. care plan invite note indicated there would be a care plan meeting held, on 5/23/24, and that Family Member 2 was planning on attending. There was no information in the clinical record indicating the, 5/23/24, care plan meeting ever took place. An interview was conducted with the Social Services Director (SSD) in the presence of the ADON (Assistant Director of Nursing) on 8/30/24 at 11:08 a.m. The SSD indicated they held care plan meetings for residents quarterly. The meetings were documented in the EHR under a care plan meeting note. He was out of the facility in May 2024, so he couldn't speak as to whether the, 5/23/24, care plan meeting was held. He reviewed Resident 45's clinical record and indicated he did not see actual verification the, 5/23/24, care plan meeting was held, and there was no verification of a, November 2023, care plan meeting held, or verification of family invitation to a meeting after Resident 45's, 11/6/23, admission to the facility. He'd spoken to Family Member 2 on the phone previously, but he had no knowledge of any missed appointments. The Comprehensive Care Plan policy was provided by the (DON) Director of Nursing on 8/30/24 at 10:30 a.m. It read, A comprehensive care plan must be .Prepared by an interdisciplinary team that includes but is not limited to .To the extent practicable, the participation of the resident and the resident's representative(s). An explanation should be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan The resident and/or resident representative shall be invited to review the plan of care with the interdisciplinary team either in person, via telephone or video conference (if available) at least quarterly. As a best practice, thee interdisciplinary team should attempt to schedule an initial meeting with the resident and/or resident representative within 5 days of admission to review the baseline plan of care and make updates or revisions as indicated based on feedback and input of the resident and/or representative prior to the development of the comprehensive care plan. 3.1-35(d)(2)(B)

Based on observation, interview, and record review, the facility failed to follow scheduled activities calendar or provide outside activities for 3 of 3 residents reviewed for activities. (Resident 34, Resident 41, and Resident 35). Findings include: 1. Resident 35's record, reviewed on 8/28/24 at 2:43 p.m., indicated Resident 35 had diagnoses that included, but were not limited to, fibromyalgia, type 2 diabetes, alcoholic cirrhosis, chronic obstructive pulmonary disease, and alcohol abuse. A Quarterly Minimum Data Set (MDS) assessment for Resident 35, dated 8/20/24, indicated he was cognitively intact for daily decision making. During an interview on 8/27/24 at 1:16 p.m., Resident 35 indicated that the activities director did not offer a variety of activities. We were supposed to play cards one day, which it was on the activities calendar, but no one had any cards, so we couldn't play. Resident 35 had requested to go on outings with the facility, but the facility told him no, because they do not have enough transportation for all the residents. 2. Resident 41's clinical record, reviewed on 8/28/24 at 2:38 p.m., indicated diagnoses that included, but were not limited to, acute respiratory failure, encephalopathy, major depressive disorder, and hypertension. An Admission MDS assessment, dated 7/16/24, indicated Resident 41 was cognitively intact for daily decision making. During an interview on 8/28/24 at 10:30 a.m., Resident 41 indicated he wanted to leave the facility for outings, but they did not provide it. Resident 41 indicated they do not get to go anywhere, and it was upsetting to him. Resident 41 had a care plan, dated 2/3/24, and indicated he enjoyed anything outdoors and enjoyed going outside when the weather was nice. During an interview on 8/30/24 at 10:52 a.m., the Activities Director (AD) indicated the facility had not been able to leave or go on outings because they only had a small van that held three to four people and one wheelchair. The AD indicated the facility had not been out in the community since February 2024. The AD indicated the residents can go outside during smoking hours. 30344 3. The clinical record for Resident 34 was reviewed on 8/28/24 at 1:00 p.m. His diagnoses included, but were not limited to, hemiplegia and hemiparesis, cerebral vascular accident, and hypertension. He was admitted to the facility on [DATE]. The August 2024 Activity Calendar was posted on the wall in the hallway outside of the dining room. It indicated on 8/28/24 at 11:00 a.m. Daily Chronicle was scheduled and Church with (name of volunteer) was scheduled for 8/28/24 at 11:15 a.m. On observation of residents, including Resident 34, in the main dining room was made on 8/28/24 from 11:11 a.m. to 11:15 a.m. There was no Daily Chronicle or Church with (volunteer name) activity occurring. The television was playing a national news network, but none of the residents, including Resident 34, were watching. There was no substitute activity occurring in place of the Church activity. Resident 34 was sitting at a table. Drinks were being passed by staff, but no activities were occurring. The 8/13/24 Significant Change MDS assessment indicated he was cognitively intact. An interview was conducted with Resident 34 in his room on 8/28/24 at 1:03 p.m. He indicated they didn't really do group activities in the facility, except bingo twice a week. He was unaware of what the Daily Chronicle activity, referenced on the August 2024 activity calendar daily, actually was. The Church activity, referenced for 11:15 a.m. today was a volunteer activity, but the volunteer didn't come today. The August 2024 Activity Calendar, posted on the wall in the hallway outside of the dining room, indicated manicures was scheduled for 8/29/24 at 2:30 p.m. An observation of the dining room was made on 8/29/24 at 2:38 p.m. There was one resident receiving a manicure by activity staff. There were ten other residents sitting in the dining room, with no other activity, music, art project, or anything occurring. The television was playing a national news network, but none of the residents were watching, and it was not turned up loud enough to be heard throughout the dining room. An interview and observation was conducted with Resident 34 in his room on 8/29/24 at 2:42 p.m. He was watching television. He indicated he had no interest in doing manicures. As far as activities outside of the facility, there was a fishing activity back in May or June 2024, but that was the last time they left the facility to attend an activity. He would like for the facility to have more activities outside of the facility. Resident 34's activity care plan, revised 8/29/24, did not reference his preference for activities away from the facility. It referenced inviting him to go outdoors to get fresh air, but not activities away from the facility. The August 2024 Activity Calendar, posted on the wall in the hallway outside of the dining room, did not include any activities away from the facility. The Activities Program policy was provided by the DON (Director of Nursing) on 8/30/24 at 8:40 a.m. It read, Purpose: To provide an ongoing program of activities designed to appeal to the residents' interests and to enhance his or her highest practicable level of physical, mental, and psychosocial well-being. Guidelines: The Activity Director, trained staff, or volunteer will: 1. Identify and involve each resident in an ongoing program of activities that is designed to appeal to his or her interests and needs 3. A minimum of 4-7 organized activities will be scheduled daily .7. The program of activities will include a system that allows thee activity staff to develop, implement, and evaluate the resident's interests and involvement in the activities provided and adjust the daily programming as needed in order to meet the needs of the residents. 3.1-33(a) 3.1-33(b)(3)

Based on interview, observation, and record review, the facility failed to date a dry dressing to a skin impairment (Resident 1) and failed to complete skin assessment as care planned (Resident 34) for 2 of 2 residents reviewed for skin impairments. Findings include: 1. The clinical record for Resident 1 was revied on 8/30/24 at 1:50 p.m. The medical diagnoses included schizophrenia. A Quarterly Minimum Data Set assessment, dated 8/15/24, indicated that Resident 1 was cognitively impaired. Resident 1 needed minimal to substantial assistance for activities of daily living and was at risk for developing skin alternations. A nursing assessment, dated 8/20/24, indicated that Resident 1 was at high risk of skin alternations. A wound evaluation, dated 8/28/24, indicated Resident 1 had a non-pressure wound to the scalp with undetermined thickness from a fall. Measurements for the wound were 3 centimeters (cm) x 2 cm x Not Measurable. A skin care plan, revised 8/28/24, indicated Resident 1 had an abrasion to the forehead. An intervention indicated to provide treatment as ordered. A physician order, dated 8/28/24, indicated to cover area to Resident 1's right forehead with a dressing daily. During an observation, on 8/28/24 at 1:55 p.m., Resident 1 had a white dry dressing on the right side of the forehead. The dressing did not indicate a date, time, or initials of the staff member which had applied the dressing. During an observation, on 8/29/24 at 12: 20 p.m., Resident 1 was in the main dining room. Resident 1 had a white dry dressing on the right side of the forehead. The dressing did not indicate a date, time, or initials of the staff member which had applied the dressing. During an observation, on 8/29/24 at 2:00 p.m., Resident 1 was laying in bed. Resident 1 had a white dry dressing on the right side of the forehead. The dressing did not indicate a date, time, or initials of staff. LPN 13 verified that the dressing did not contain date, time, or initials of the staff member which had applied the dressing. LPN 13 stated that she would change the dressing and did not know when it was last changed. 30344 2. The clinical record for Resident 34 was reviewed on 8/24/24 at 1:00 p.m. His diagnoses included, but were not limited to, hemiplegia and hemiparesis, cerebral vascular accident, and hypertension. He was admitted to the facility on [DATE]. The 8/13/24 Significant Change Minimum Data Set assessment indicated he was cognitively intact. An interview and observation was conducted with Resident 34 in his room on 8/28/24 at 1:14 p.m. He indicated, I have these dark spots all over my arms, for the past three weeks. They say it's from blood thinners. Resident 34 had dark reddish, brown spots of various shapes covering both forearms. The physician's orders indicated for one tablet of Clopidogrel Bisulfate (antiplatelet medication used to prevent heart attacks and strokes) 75 milligrams (mg) to be administered one time a day for stroke, starting 8/24/24. The 8/7/24 antiplatelet therapy care plan indicated an intervention was, Daily skin inspection. Report abnormalities to the nurse, initiated 8/7/24. The electronic health record (EHR) indicated one skin assessment was completed thus far in August 2024. It was dated 8/6/24 and referenced bruising to his abdomen. It did not reference his arms. There were no subsequent skin assessments for August 2024 in the EHR. An interview was conducted with the DON (Director of Nursing) on 8/29/24 at 10:27 a.m. She indicated skin assessments were completed weekly and on shower days. The assessments should be documented in the EHR under the assessments tab. The DON reviewed Resident 34's EHR at this time and indicated she only saw the, 8/6/24, skin assessment. She was unaware who was responsible for the daily skin inspections referenced in his, 8/7/24, antiplatelet therapy care plan, but they should also be documented in the EHR. She would look further into this. An interview was conducted with the DON on 8/29/24 at 2:05 p.m. She indicated she did not have verification of any other skin assessments for Resident 34 in August 2024 beyond the, 8/6/24, assessment and no verification of any daily skin assessments, as care planned. The Skin Condition Assessment & Monitoring policy was provided by the DON on 8/30/24 at 8:40 a.m. It read, Purpose: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other non-pressure skin conditions and assuring interventions are implemented. Guidelines: .Non-pressure skin conditions (bruises/contusions, abrasions, lacerations, rashes, skin tears, surgical wounds, etc.) will be assessed for healing progress and signs of complications or infection weekly Residents identified will have a weekly skin assessment by a licensed nurse. A wound assessment will be initiated and documented in the resident chart when pressure and/or other non-pressure skin conditions are identified by licensed nurse. Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA (Certified Nursing Assistant.) Changes shall be promptly reported to the charge nurse who will perform the detailed assessment Wound Assessment/Measurement: .3. Dressings which are applied to pressure ulcers, skin tears, wounds, lesions or incisions shall include the date of the licensed nurse who performed the procedure. Dressing will be checked daily for placement, cleanliness, and signs and symptoms of infection. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure optometry services were provided timely to a resident who consented to receive optometry services for 1 of 3 residents reviewed for vision or hearing services. (Resident 34) Findings include: The clinical record for Resident 34 was reviewed on 8/28/24 at 1:00 p.m. His diagnoses included, but were not limited to, hemiplegia and hemiparesis, major depressive disorder, and hypertension. He was admitted to the facility on [DATE]. The 2/9/22 ancillary services care plan, revised 7/15/24, indicated he consented to receive optometry services through the facility's optometry provider with interventions for him to be seen by the appropriate provider to ensure any issue was resolved. The 10/30/22 physician's order indicated he may be seen by the optometrist, as needed. The 8/12/24 Ancillary Services Assessment form indicated Resident 34 needed assistance with corrective lenses. The 8/13/24 Significant Change Minimum Data Set assessment indicated he was cognitively intact. An observation and interview were conducted with Resident 34 in his room on 8/28/24 at 1:10 p.m. He indicated he currently wore reading glasses, but used to wear regular glasses, and thought he needed to wear regular glasses now. Resident 34 was not wearing any glasses during the interview. There were no optometry consultations in Resident 34's clinical record. An interview was conducted with the SSD (Social Services Director) on 8/29/24 at 10:33 a.m. The SSD indicated they'd worked at the facility since November 2023. The facility used a specific provider for optometry services. The optometry provider gathered consent forms and scheduled appointments for residents. The optometry provider remained in touch with the SSD to let them know when they would be coming to the facility. At each MDS assessment, the SSD would reach out to their optometry provider, if the resident needed services. The optometry provider was in the facility on 8/19/24, but Resident 34 was not seen at that visit. The SSD reviewed the upcoming optometry list, but Resident 34 was not on it. The SSD reviewed Resident 34's clinical record at this time and indicated he did not see that Resident 34 had received optometry services in the facility, at least since he'd worked there. The On-Site Health Care Services policy was provided by the SSD on 8/29/24 at 12:23 p.m. It read, It is the policy of the facility to assist residents in arranging health services on site as needed per resident request. Standards: 1) Facility will make appointments for ancillary services as requested by resident. 2) On-Site services available: .c) Optometry. 3.1-39(a)(1)

Based on interview and record review, the facility failed to ensure 1 of 6 residents, reviewed for abuse, with allegations of verbal, mental and sexual abuse by a peer did not suffer from psychological harm as demonstrated by tearfulness and expressing being nervous and upset since that time when the alleged perpetrator is seen by this resident . (Residents B, F and G) Findings include: In an interview on 6-15-21 at 1:52 p.m., with Resident B, she indicated about 2 weeks ago during the middle of second shift, I had a male resident ask to come into my room, he said to give me a gift. When he came in, he said he wanted to suck my t-----s and said 'I won't tell if you won't tell.' That right there is the sign of someone who has done that before and will try it again. I reported it to the nurse .immediately. She must have reported it to [name of Administrator] because he came in right after that to talk to me. Him and the Social Worker told me that they were sending him out [to the hospital] and they did. I asked them at the time if they was gonna let him come back and they said they wouldn't, but they did. He is back now and every time I see him in the hall, it makes me nervous and upset. I had experience with sexual abuse years ago and it just brings back bad memories. That guy has not been back in my room or even tried to talk to me since he came back, but it still worries me. She indicated the male resident was Resident F. Resident B was observed to be very tearful during the interview while recounting the abuse allegations. Resident B clarified Resident F did not come in contact with her as she demanded he leave her room and he did so. In an interview with the Administrator on 6-15-21 at 3:40 p.m., he indicated he was unfamiliar with any such event. He was aware of Resident F being sent out to a psychiatric facility previously, but unrelated to Resident B's allegations. The Administrator indicated he has had no other allegations of abuse since the annual survey in April, 2021, which were investigated at that time. He would immediately file a reportable incident with the Indiana Department of Health's Long Term Care Division and begin an investigation into the allegation. In an interview on 6-15-21 at 4:50 p.m., with the Social Services Designee [SSD] She indicated Resident B has not addressed any issues with me about [name of Resident F], let alone any sexual or verbal abuse allegations. [Name of Resident B] is normally pretty alert and oriented. [Name of Resident F] does have dementia and has poor emotional control and gets angry easy, but that does not sound familiar in any manner. In a review of Resident F's clinical record on 6-16-21 at 9:53 a.m., an entry, dated 5-25-21 at 2:53 p.m., from the SSD indicated, Admin [Administrator] called writer notifying of resident being sexually aggressive towards 3 other residents. Resident was forcibly kissing a resident and going into her room. Resident was at the doorway of a resident stating 'I'm coming to suck your t-----s'. Resident was found kissing another resident who has dx [diagnosis] of alzheimers disease. Writer/Admin spoke with resident who denies inappropriate sexual behavior. While speaking with resident he displayed increased verbal aggression with threats to staff members/peers. Witnessed by staff and other residents. Residents are fearful of resident. Writer obtaining order for psych send out. Guardian notified. In an interview on 6-16-21 at 11:36 a.m., with the Administrator, he indicated at the time [5-25-21] we were looking at them [Resident F's behaviors] in terms of his general aggression. It should have been reported. I need to talk to[name of SSD] about this. In an interview on 6-16-21 at 12:05 p.m., with the SSD, she indicated, The note I had written [on 5-25-21] was based on what had been told to me by a staff member. I can't remember now if it was a regular staff or agency. I can only remember the name of one of the residents, [name of Resident G]. Apparently, [name of Resident F] was trying to kiss her. I do remember that we did one to one [1:1] monitoring on him until he left the building for psych. I remember me, the DON [Director of Nursing] and the ADON [Assistant Director of Nursing] took turns doing 1:1 during the day shift. Have no idea who did it the rest of the time, you would need to check with the nursing staffing on that. I have no idea why this was not reported as an abuse allegation to State. In my opinion, it should have been. I'm sorry my notes were not very good and that I didn't write down where the information came from or which residents were involved. But, I do remember that [name of Resident B] did not report any of this until she talked to you yesterday. I know it sounds like I was trying to be misleading, but I really am not. In an interview with the Administrator on 6-17-21 at 11:33 a.m., he indicated, Even though the note from [name of the SSD] said I was the one that gave her the information about the sexual aggression of the 3 residents, I am telling you I was not aware of it. I was aware of his increasing behaviors that he had been having. If I had known that information, I would have immediately started an investigation. Sexual aggression would have been a new behavior we hadn't seen him display before. I don't know why his chart and his notes weren't reviewed in morning meeting. They should have been. The clinical record of Resident F was reviewed on 6-16-21 at 9:53 a.m. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His admission Minimum Data Set (MDS) assessment, dated 3-11-21, indicated he usually understands and usually is understood, is moderately cognitively impaired, has behaviors of delusions, verbal behaviors directed towards others 4 to 6 times weekly with no impact on self or others and rejects care provision 1-3 times weekly. It indicated Resident F has been sent out for additional psychiatric care associated with aggressive behaviors on three separate occasions, totaling 42 days since admission on 3-4-21, not including his most recent transfer on 6-17-21. The clinical record of Resident B was reviewed on 6-15-21 at 3:38 p.m. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her most recent MDS assessment, dated 4-16-21, indicated she is cognitively intact and has no behaviors. The clinical record of Resident G was reviewed on 6-17-21 at 10:22 a.m. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her most recent MDS assessment, dated 4-16-21, indicates she rarely understands, rarely is understood, has unclear speech, has short term and long term memory problems and is severely cognitively impaired. On 6-15-21 at 2:10 p.m., the SSD provided a copy of a policy entitled, Abuse & Neglect Policy, with a revision date of 11-19-18. This policy indicated, Each resident has the right to be free from abuse, neglect, and misappropriation of resident property. All allegations will be reported according to State and Federal Law and investigated. 3.1-27(a)(1) 3.1-27(b)

A. Based on interview and record review, the facility failed to provide the supervision necessary to prevent the reoccurrence of the ingestion of potentially hazardous materials, batteries, for 1 of 1 resident with a history of ingestion of foreign bodies for 1 of 3 residents reviewed for accidents and self-harm behaviors. (Resident B) The Immediate Jeopardy began on 3/9/18 at 11:15 p.m. when Resident B informed facility staff he had ingested a battery. Administrator 1 was notified of the immediate jeopardy on 3-28-18 at 3:55 p.m. B. Based on interview and record review, the facility failed to ensure 1 of 3 residents reviewed for accidents and self-harm behaviors did not have access to a secured shower room in which she could obtain a disposable razor, resulting in the resident performing self-mutilation of cuts to her arm. (Resident C) Findings include: A. On 3/27/18 at 8:12 p.m., Administrator 1 provided a copy of an unusual occurrence report sent to the Indiana State Department's Long Term Care Division on 3/21/18. This report indicated, on 3/9/18 at 9:01 p.m., Resident B informed the charge nurse he swallowed a battery. The attending physician was notified of the event and provided an order to send the resident to the local emergency room for evaluation and treatment. In an interview with Administrator 1, on 3/27/18 at 7:35 p.m., he indicated Resident B had removed the battery from his TV remote control, swallowed the battery, and told one of the staff right after he did it. He was sent out to the emergency room and then transferred to psych (psychiatric facility) . Review of the clinical record included a copy of an Incident/Accident Report, dated 2/25/18 at 11:15 p.m., and signed by LPN 3. This report indicated Resident B was sitting up in his wheelchair watching TV and informed the CNA that he had swallowed a battery. No employee had observed the resident swallow the battery. The attending physician and family were notified of the event and the resident was sent out to an area emergency room . The emergency room was called by the facility at approximately 4:00 a.m. on 2/26/18 and the facility was informed that a battery was present in the resident's abdomen. The Nurse Practitioner's follow up visit, dated 2/28/18, indicated Resident B had passed the battery per staff. (The resident) has since swallowed coins that have not passed. A written note from CNA 2, dated 3/9/18, detailed between 10:15 p.m. and 10:30 p.m., indicated the CNA responded to Resident B's call light and was informed by the resident that he had swallowed four batteries. The CNA immediately notified the nurse on duty. Review of the emergency room visit, dated 3/10/18 at 12:04 a.m., indicated Resident B was sent to the hospital due to possibly ate 3 AA batteries. The resident had a history of [REDACTED]. An X-ray of the abdomen indicated a foreign body in the right upper and lower quadrants of his abdomen. A subsequent CT scan of the abdomen and pelvic area demonstrated foreign bodies within the colon, specifically in the cecum and at the level of the hepatic flexure. The foreign bodies leading to significant streak artifacts and are actually better assessed on prior radiographic examinations. This may reflect the patient's known history of of battery ingestion. The emergency room physician's recommendations included, but were not limited to a [DIAGNOSES REDACTED]. A physician visit note, dated 3/14/18, indicated Patient went out to ER again on 3/10/18 for foreign body ingestion. It was presumed that he swallowed three AA batteries from a remote control, but patient was unable to give history. The note indicated an abdominal X-ray, dated 3/10/18, indicated foreign bodies were located in Resident B's right upper and lower area of the abdomen. During an interview with Administrator 2 and the Corporate Nurse, on 3/28/18 at 3:01 p.m., Administrator 2 indicated the facility did not file a report of an unusual occurrence related to the battery ingestion on 2/26/18, because the doctor said there was no proof of him ever actually swallowing a battery. The Corporate Nurse added Resident B went out to an area psychiatric hospital for inpatient services soon after the 2/26/18 event. When he came back on the 9th or 10th, he told several different stories to different staff, that he had swallowed a battery at the psych hospital to he had swallowed several (batteries) here. She was aware that the emergency room visit, on 3/9/18 identified foreign bodies in his colon, but had no information as to if rays had been conducted during the 2/26/18 emergency room visit. In an interview, on 3/28/18 at 1:02 p.m., with the attending physician's Nurse Practitioner, she indicated she was aware Resident B had two different times in which he had swallowed batteries since he was admitted , on 2/12/18, to the facility. From my understanding, this (ingestion of foreign bodies) has been an issue at any facility he has been at. Most recently, he was at (name of other facility), a sister facility. His history includes some type of abdominal surgery for [REDACTED].He has a long-standing history of mental health issues. In an interview, on 3/28/18 at 10:10 a.m., with Resident B, he indicated, Yes, I swallowed some coins and batteries not too long ago. I've done that off and for years .The stuff still hasn't passed yet, but I guess they will . Resident B's clinical record was reviewed on 3/28/18 at 12:27 p.m. His [DIAGNOSES REDACTED]. Additional diagnoses, from his psychiatric hospital stay, dated 2/28/18, added swallowed foreign body and abdominal pain. An admission Minimum Data Set assessment, dated 2/19/18, indicated he was moderately cognitively impaired, usually understands and sometimes was understood. His behaviors were identified as verbal behaviors toward others and rejection of care, each occurring 1 to 3 days out of 7 days. Review of the care plans developed for Resident B included, but were not limited to, a care plan for a concern of being at risk for stomach upset related to a history of pica due to the resident swallows small objects. Has swallowed batteries most recently, sent to hospital with hospital returning resident with no new orders. This care plan was initiated on 2/14/18 and revised on 3/13/18. Interventions initiated, on 2/14/18, included, but were not limited to, administer stool softener as ordered, notify the physician and POA (power of attorney) of suspected pica activity, notify the physician, POA and Director of Nursing if resident swallows inappropriate items, obtains vitals signs, and remove all small items from resident's general area in his room. Interventions initiated ,on 3-13-18, included, but were not limited to, notify the physician if the resident swallows (inappropriate) items and follow physician orders, provide supervision during activities programs to ensure resident does not obtain small items to swallow, and resident moved to different room to aide in the management of what he was able to obtain. The Immediate Jeopardy began on 3-9-18 and was removed on 3-30-18 when the facility instituted monitoring every 15 minutes and the documentation of the monitoring of Resident B continued staff education regarding the care needs of Resident B in relationship to ingestion of small items and/or non-food items. The noncompliance remained at a lower scope and severity level of isolated, no actual harm with the potential for more than minimal harm that is not immediate jeopardy because the facility has not completed staff education with all staff and the resident has the potential for continued ingestion of small items and/or non-food items. B. The facility provided a copy of an unusual occurrence report indicating on 3-24-18 at 11:30 a.m., Resident C obtained a safety razor from the locked shower room, then cut herself with a disposable razor. This report was denoted to have been sent to the Indiana State Department of Health on 3-26-18 at 12:30 p.m. In an interview with Resident C on 3-27-18 at 6:14 p.m., she indicated she has resided at the facility for approximately 4 years and doesn't think the code to the locked shower room has been changed during that time frame. She indicated she has borderline personality and kind of a split personality with two other people in my head. Resident C identified the reason her left arm got cut is that Lila (the name of one of her other personalities) came out and caused this to happen .What happened is that I went into the shower room and got a new disposable razor from in there and cut myself. She explained she had multiple cuts to arm that were not deep cuts. I've been out to the psych hospital several times, for stuff like cutting myself. But usually by the time I get there, I have settled down and they just send me back. Resident C insisted the cutting was not a suicide attempt. An observation at this time demonstrated the left arm was wrapped in gauze from wrist to elbow with no obvious drainage, with the resident able to move both arms with no difficulty. Resident B indicated she received care for her cuts at the facility and was not sent out to the hospital. In an interview on 3-28-18 at 1:07 p.m., with the Nurse Practitioner, she indicated this was the first time she was aware in which Resident C had displayed self-mutilation behaviors. She tells me she has done this before, and I heard for the first time the issue of possible multiple personality disorder. This morning when I saw her, she was very cheerful and pleasant. A short time after that, therapy staff came to me and said she was screaming & cussing at them, demanding more therapy .Her disposition can change very rapidly. In an interview with Administrator 1 on 3-27-18 at 7:35 p.m., he indicated Resident C is able to do her own shower without assistance and it is not uncommon for her to to go into the shower room unsupervised. Apparently she got a safety razor .She self-reported to one of the aides that she had cut her arms and the aide immediately notified the nurse, who then assessed her. The nurse notified the doctor . Apparently the cuts were fairly superficial and the resident said she was not trying to commit suicide. She does have a history of self-cutting. When I talked with the resident, she told me that she had another personality and she did it. This was the first I was aware of any multiple personality issue with this person and could not find any documentation that reflected such a diagnosis. She was scheduled to see psych services today. On 3-28-18 at 10:07 a.m., the MDS Coordinator indicated the lock code for the shower room door was changed on 3-24-18, after the incident. On 3-28-18 at 10:15 a.m., LPN 4 indicated the cuts on Resident C's arms were looking inflamed and were warm to touch with a fair amount of weeping on the previous day, but this date, the areas were looking less inflamed and no warmth, with very little weeping. She added the Nurse Practitioner changed Resident C's antibiotic due to an allergic reaction of a fine rash on her trunk. The clinical record of Resident C was reviewed on 3-27-18 at 8:27 p.m. Her [DIAGNOSES REDACTED]. Her most recent MDS (Minimum Data Set) assessment, dated 2-21-18, indicated she is cognitively intact, demonstrated behaviors, specific to unspecified physical behaviors toward others and has mood issues specific to depression, tiredness/lack of energy, feels bad about her self and has difficulty with concentration. It indicated she currently takes an antidepressant at least daily. This Federal tag relates to Complaint IN 562 and Complaint IN 988. 3.1-45(a)(1) 3.1-45(a)(2)

A. Based on observation, interview and record review, the facility failed to ensure 15 of 15 residents who smoked were properly supervised to prevent accidents. This resulted in 1 of 15 residents having oxygen tubing present in her wheelchair, which when a cigarette was dropped near the oxygen tubing resulted in the cigarette flaming out, causing damage to the oxygen tubing and rendering it unusable. (Residents D, E, H, J, K, L, M, N, P, Q, R S T U and V) The Immediate Jeopardy began on 10-10-17 when an estimated 15 unspecified residents were observed to be in the facility's designated smoking area with one staff person to supervise the residents. One resident with portable oxygen connected to a nasal cannula was allowed to enter the designated smoking area and was provided a cigarette by a peer and the cigarette was lit by the staff member. When the resident dropped the cigarette near the oxygen tubing, the cigarette flamed out, causing damage to the oxygen tubing. The Administrator was notified of the Immediate Jeopardy on 10-13-17. The Immediate Jeopardy was removed on 10-16-17, but the noncompliance remained at the lower scope and severity of pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy. B. Based on interview and record review, the facility failed to prevent the elopement of a cognitively impaired resident and failed to prevent falls by not securing the straps to a wheel chair while in the facility van and not locking a resident's wheelchair during a transfer for 1 of 1 residents reviewed for elopement and 2 of 3 residents reviewed for accidents. (Resident B, Resident H, and Resident M) Findings include: 1. Interview with the Administrator on 10-12-17 at 5:52 p.m., she referred to a copy of an Indiana State Department of Health (ISDH) Incident Report Form, regarding an incident involving Resident E on 10-10-17. The form, dated 10-11-17, for the incident occurrence on 10-10-17, indicated the Administrator was informed Dietary Staff 2 had taken the residents who smoke out for a smoke break at 7:00 pm (sic). Resident (E), who is a smoker, but did not have any cigarettes, wanted to go out at that time to get some fresh air. (Name of Resident E) was taken outside with her portable oxygen tank, but was seated well away from the smokers. (Name of Resident E) then started pleading with the smokers to give her a cigarette. (Name of Resident H) gave her a cigarette. (Name of Resident E) was still sitting in the same position away from the smokers. (Name of Dietary Staff 2) removed (name of Resident E)'s nasal cannula and laid it beside her in the wheelchair and lit the cigarette. The cigarette was burned down, (name of Resident E) stated that she need and (sic) ashtray to put it out when the lit tobacco dropped from the end of the cigarette and onto the nasal cannula (part of the oxygen tubing) laying in the wheelchair. The oxygen cause (sic) the lit tobacco to flare up and Dietary Staff 2 ran over patted out the embers. The Administrator indicated Dietary Staff 2 currently remained on suspension, pending the results of the investigation. We are continuing to educate the staff on our smoking policies, on oxygen use and reporting policies. We are about 25% complete. We are trying to do individual training to the employees .We have not provided any education to the residents or families. The residents that smoke and use O-2 (oxygen) already know to leave their O-2 tanks either in their rooms or the dining room. This was not reported to me until the next morning by the Regional Clinical person, who got here before me or the Director of Nursing (DON). The resident had not been assessed until the morning after the incident, right after we were notified. There was no injury to the resident or to her clothing. The dietary staff (member) told us that she told the nurse on duty, (name of LPN 3), about it as soon as they came back into the building. (Name of LPN 3), when questioned, said she had no knowledge of it at all .The residents told me it was discussed quite a bit that evening. There were two nurses on duty that evening. The other nurse was (name of LPN 4) .We have not talked to her yet. The residents described the fire as a little flame and that (name of Resident E) started patting at it and then the dietary worker came and patted it out. In an interview with (name of Dietary Staff 2) she said she was not familiar with the O-2 policy. I am not aware of any training she had received on it and found nothing in her employee file that mentioned it. Our policy says the residents are not to have any oxygen tanks out in the smoking area. The area is a part of our patio which is very large. If someone wants just to go out for some fresh air, we have them closer to the building and away from the smoking area, just like what happened with (name of Resident E) that evening. We normally have one staff member outside with the residents at smoke time and another who will help them out to the smoking area. Dietary staff usually take their turn at the 10:00 a.m. smoke time. (Name of Resident E) started asking for a cigarette and (name of Resident H) gave her one. As per our smoking policy, the staff member lit the cigarette for her, after the oxygen tubing was removed and laid in her wheelchair, beside her. I have no idea if the tank was turned off. And I have no idea if the oxygen tank was checked when it came back in the building, because somehow, (name of Resident E) ended up with another resident's portable oxygen tank and tubing. There does not seem to be any change in (name of Resident E)'s behaviors. She had a history of [REDACTED]. Interview with LPN 4 on 10-12-17 at 7:07 p.m., she indicated she was working on the evening of 10-10-17. At the time, I had no idea there was anything going on with a cigarette and oxygen. She explained when the residents had returned into the building from smoking,she heard a great deal of yelling, from Resident E and Resident K, regarding Resident E taking Resident K's oxygen tank and tubing. (Name of Resident K) said (name of Resident E) had dropped her cigarette and burned a big hole in her pants and then (name of Resident E) said that wasn't true. I took the time to look at name of Resident E)'s pants and saw nothing out of the ordinary. You have to understand, last week was very chaotic here with a lot of yelling and acting out behaviors, so I had no idea if what they were telling me was credible or not. I feel bad that I did not confer with (LPN3), the other nurse. I did take (name of Resident E) down to (name of LPN 3), but she was on the phone at the time and I didn't get to talk with her .The funny thing is, not a single resident said anything about a fire that evening to me. You would have thought someone might have mentioned it to me or to (name of LPN3) .I feel bad that I did not investigate further. On 10-12-17 at 6:10 p.m., the Administrator provided a copy of the facility's scheduled smoking times and the staff who are responsible to supervise the residents during each scheduled smoke time. For the 10-10-17 8:00 p.m., smoke time, the staff identified were to be the West Hall Nurse and the East Hall CNA. The instructions on the smoking schedule did not address how many staff were to be present during smoking times for supervision or the use of oxygen in the designated smoking area. In interview with the Director of Nursing on 10-13-17 at 10:30 a.m., he clarified, The smoking schedule for who goes out with the residents (to supervise smoking) is just a suggestion. We will have staff to volunteer to take the residents out at the scheduled times. I don't know that we have any particular training for the staff that take the residents out to smoke. It is mentioned at our monthly staff meetings. So, there probably isn't anything in the employee files about that. Interview on 10-14-17 at 3:07 p.m., with LPN 3, she indicated one or two staff always go with residents to supervise or assist residents with smoking, depends on what our staffing is like. No oxygen is allowed out at the patio area during smoke times, not even if the person is not smoking. Any O-2 is left in the dining room. I was working on 10-10-17, the evening of the incident with the smoking and oxygen. I was not made aware of anything until the next day. From what I was told, the dietary person was yelling my name from the patio doors at the far end of the dining room. I was down the hall and on the phone trying to get a new residents medicine orders straightened out and didn't hear her. Plus, the other nurse that was working knew about it, after the incident between the two ladies, and she didn't mention it to me. I was told that she checked out (name of Resident E), but she seemed okay. No one mentioned it to me, so that I could have done a proper assessment and then called her doctor, the Administrator, DON and the family. This was very upsetting to me. This definitely is not the normal way to do things. Interview with Dietary Staff 2 on 10-16-17 at 3:28 p.m., she shared she had worked at the facility approximately 14 months and had never received any training on smoking policies and was not familiar with the use of supplemental oxygen. The residents asked for me to take them out to smoke. Both nurses, (names of LPN 3 and LPN 4) said it was okay for me to take them out. Had supervised smoking previously. (Name of Resident E) had no cigarettes and wanted to go out anyway for fresh air. She was sitting near the exit door from the dining room to the patio the whole time. She then started asking for someone to give her a cigarette and one of the men gave her one and I lit it. I cannot remember even seeing her oxygen tank or oxygen tubing. When her cigarette was about half-smoked she had ashes falling on her and I cleaned them off of her (demonstrated using a sweeping motion with her hands) clothes. It was a little later that she put her hand down by her leg, while holding the cigarette that it flamed out. I immediately went to her and took care of getting the cigarette away. So, I tried to get her back in the dining room as quick as I could. I yelled at (name of LPN 3) because she was in the hall passing pills. I have no idea if she heard me or not. I also said something to one of the aides about her oxygen tubing needing changed. There was a big problem between (name of Resident E) and another patient and they must have gotten their tanks mixed up and got the wrong one, because one of the tubings was messed up. Not sure if the tubing got hot from when it flamed up, or what. So, the other nurse, (name of LPN 4) knew about all this and got new oxygen tubings for them. In a written statement from Dietary Staff 2, dated 10-10-17, she had taken the residents who smoke out to smoke. It indicated Resident E elected to go out also, despite not having any cigarettes, then Resident E started screaming for a cigarette and an unidentified resident provided one to her. She burned herself with the cigret (sic) so I took her inside and told the (unidentified) nurse she burned herself with the cigret (sic) that she needs to change the oxygen for her . Interview with Resident L on 10-14-17 at 2:50 p.m., he recalled the events of the evening of 10-10-17. Yes, I was out smoking the other evening when there was some excitement. This one woman .was out on the patio area with her O-2 on and sitting in her wheelchair, near the building. She was asking the others for a cigarette, because she didn't have any. Somebody gave her a cigarette and it got lit. She didn't seem to hardly know how to hold it. From where I was sitting, I'm not sure if she had O-2 on at the time. I did see that she had dropped her cigarette down by her leg in the wheelchair and I saw some ashes dropping, then it flamed out. She wasn't hurt. He identified this woman as Resident E. He indicated, There are certain smoke times. No O-2 is allowed out in smoking area and we have to sit under the porch area, those are both new things since yesterday. It's basically just a safety thing. During an observation of residents smoking on 10-12-17 at 8:03 p.m., 15 residents were present smoking, Residents D, E, H, J, K, L, M, N, P, Q, R S T U and V. None of the residents were observed to wear any protective garments, such as a smoking apron. The Activities Director was observed to take large black box, resembling a fishing tackle box, with smoking supplies for residents and hand out cigarettes to each resident and to light each resident's cigarette. She provided close attention and assistance to Resident D while he was smoking. The Administrator was also present. Residents E and K left their oxygen tanks and tubing in the dining room, prior to exiting outside to smoke. During an observation of residents smoking on 10-14-17 at 2:16 p.m., 15 residents were present smoking, Residents D, E, H, J, K, L, M, N, P, Q, R S T U and V. Residents D and E were observed to wear a smoking apron. Activities Assistant 5 was observed to take large black box, resembling a fishing tackle box, with smoking supplies for residents and hand out cigarettes to each resident and to light each resident's cigarette. The Administrator and Assistant Director of Nursing were also present. Residents E and K left their oxygen tanks and tubing in the dining room, prior to exiting outside to smoke. Resident D's clinical record was reviewed on 10-16-17 at 9:52 a.m. His [DIAGNOSES REDACTED]. His most recent Minimum Data Set (MDS) assessment, dated 9-29-17, indicated he was severely cognitively intact. His most recent Safe Smoking Evaluation, dated 2-28-17, revealed he was deemed a safe smoker by the facility's interdisciplinary team. The recapitulation orders for Resident D for October, 2017, did not include physician orders [REDACTED]. Resident E's clinical record was reviewed on 10-12-17 at 7:45 p.m. Her [DIAGNOSES REDACTED]. Observations on 10-12-17 at 8:03 p.m., and 10-14-17 at 2:16 p.m., revealed she was taking part in a designated smoking activity without her supplemental oxygen in place. Her most recent MDS assessment, dated 8-23-17, indicated she was moderately cognitively impaired. Her most recent Safe Smoking Evaluation, dated 10-6-17, revealed she was deemed a safe smoker by the facility's interdisciplinary team. The 10-2017 recapitulation orders for Resident E indicated she is to receive supplemental oxygen at 2 liters per minute via a nasal cannula continuously and without orders to allow for the resident to remove the supplemental oxygen for elective designated smoking periods. The clinical record of Resident H was reviewed on 10-16-17 at 12:50 p.m. His [DIAGNOSES REDACTED]. His most recent Minimum Data Set (MDS) assessment, dated 9-5-17, indicated he was moderately cognitively intact. His most recent Safe Smoking Evaluation, dated 8-29-17, revealed he was deemed a safe smoker by the facility's interdisciplinary team. The recapitulation orders for Resident H for October, 2017, did not include physician orders [REDACTED]. The clinical record of Resident J was reviewed on 10-17-17 at 9:47 a.m. Her [DIAGNOSES REDACTED]. Observations on 10-12-17 at 8:03 p.m., and 10-14-17 at 2:16 p.m., revealed she was taking part in a designated smoking activity without her supplemental oxygen in place. Her most recent MDS assessment, dated 9-12-17, indicated she was moderately cognitively impaired. Her most recent Safe Smoking Evaluation, dated 8-17-17, revealed she was deemed a safe smoker by the facility's interdisciplinary team. Resident K's clinical record was reviewed on 10-16-17 at 10:20 a.m. Her [DIAGNOSES REDACTED]. The 10-2017, recapitulation orders for Resident K indicated she is to receive supplemental oxygen at 4 liters per minute via a nasal cannula continuously and without orders to allow for the resident to remove the supplemental oxygen for elective designated smoking periods. Observations on 10-12-17 at 8:03 p.m., and 10-14-17 at 2:16 p.m., revealed she was taking part in a designated smoking activity without her supplemental oxygen in place. Her most recent MDS assessment, dated 9-26-17, indicated she was cognitively intact. Her most recent Safe Smoker Evaluation, dated 9-14-17, revealed she was deemed a safe smoker by the facility's interdisciplinary team. The clinical record of Resident L was reviewed on 10-17-17 at 10:18 a.m. His [DIAGNOSES REDACTED]. Observations on 10-12-17 at 8:03 p.m., and 10-14-17 at 2:16 p.m., revealed he was taking part in a designated smoking activity without her supplemental oxygen in place. His most recent MDS assessment, dated 9-8-17, indicated he was moderately cognitively intact. His most recent Safe Smoking Evaluation, dated 6-7-17, revealed he was deemed a safe smoker by the facility's interdisciplinary team. The recapitulation orders for Resident L for October, 2017, did not include physician orders [REDACTED]. The clinical record of Resident M was reviewed on 10-16-17 at 12:00 p.m. Her [DIAGNOSES REDACTED]. Observations on 10-12-17 at 8:03 p.m., and 10-14-17 at 2:16 p.m., revealed she was taking part in a designated smoking activity. Her most recent MDS assessment, dated 9-20-17, indicated she was cognitively intact. The recapitulation orders for Resident M for October, 2017, did not include physician orders [REDACTED]. Review of the clinical record failed to locate any copy of a Safe Smoking Evaluation. Resident N's clinical record was reviewed on 10-16-17 at 11:39 a.m. Her [DIAGNOSES REDACTED]. Her most recent MDS assessment, dated 8-1-17, indicated she was cognitively intact. The 10-2017, recapitulation orders for Resident N indicated she is to receive supplemental oxygen at 3 liters per minute via a nasal cannula and without orders to allow for the resident to remove the supplemental oxygen for elective designated smoking periods. Observations on 10-12-17 at 8:03 p.m., and 10-14-17 at 2:16 p.m., revealed she was taking part in a designated smoking activity without her supplemental oxygen in place. Her most recent Safe Smoker Evaluation, dated 8-10-17, revealed she was deemed a safe smoker by the facility's interdisciplinary team. The clinical record of Resident P was reviewed on 10-16-17 at 9:48 a.m. Her [DIAGNOSES REDACTED]. Observations on 10-12-17 at 8:03 p.m., and 10-14-17 at 2:16 p.m., revealed she was taking part in a designated smoking activity. The recapitulation orders for Resident P for October, 2017, did not include physician orders [REDACTED]. Her most recent Safe Smoker Evaluation, dated 10-2-17, revealed she was deemed a safe smoker by the facility's interdisciplinary team. The clinical record of Resident Q was reviewed on 10-16-17 at 11:30 a.m. Her [DIAGNOSES REDACTED]. Observations on 10-12-17 at 8:03 p.m., and 10-14-17 at 2:16 p.m., revealed she was taking part in a designated smoking activity. Her most recent MDS assessment, dated 9-11-17, indicated she was cognitively intact. The recapitulation orders for Resident Q for October, 2017, did not include physician orders [REDACTED]. Her most recent Safe Smoker Evaluation, dated 7-19-17, revealed she was deemed a safe smoker by the facility's interdisciplinary team. The clinical record of Resident R was reviewed on 10-17-17 at 10:03 a.m. Her [DIAGNOSES REDACTED]. Observations on 10-12-17 at 8:03 p.m., and 10-14-17 at 2:16 p.m., revealed she was taking part in a designated smoking activity. Her most recent MDS assessment, dated 7-19-17, indicated she was cognitively intact. The recapitulation orders for Resident R for October, 2017, did not include physician orders [REDACTED]. Her most recent Safe Smoker Evaluation, dated 7-12-17, revealed she was deemed a safe smoker by the facility's interdisciplinary team. The clinical record of Resident S was reviewed on 10-17-17 at 10:00 a.m. Her [DIAGNOSES REDACTED]. Observations on 10-12-17 at 8:03 p.m., and 10-14-17 at 2:16 p.m., revealed she was taking part in a designated smoking activity. Her most recent MDS assessment, dated 9-1-17, indicated she was cognitively intact. The recapitulation orders for Resident S for October, 2017, did not include physician orders [REDACTED]. Her most recent Safe Smoker Evaluation, dated 6-12-17, revealed she was deemed a safe smoker by the facility's interdisciplinary team. The clinical record of Resident T was reviewed on 10-16-17 at 11:06 a.m. His [DIAGNOSES REDACTED]. Observations on 10-12-17 at 8:03 p.m., and 10-14-17 at 2:16 p.m., revealed he was taking part in a designated smoking activity. His admission MDS assessment, dated 8-14-17, indicated he was moderately cognitively impaired. This MDS assessment documented he did not use tobacco. The recapitulation orders for Resident T for October, 2017, did not include physician orders [REDACTED]. A review of an assessment dated [DATE], specified he was oriented to smoke breaks. A Safe Smoking Evaluation form was located in the clinical record, but was blank, except for the resident's name, room number and physician's name. The clinical record of Resident U was reviewed on 10-16-17 at 12:20 p.m. His [DIAGNOSES REDACTED]. Observations on 10-12-17 at 8:03 p.m., and 10-14-17 at 2:16 p.m., revealed he was taking part in a designated smoking activity. His most recent MDS assessment, dated 9-10-17, indicated he was cognitively intact. The recapitulation orders for Resident U for October, 2017, did not include physician orders [REDACTED]. His most recent Safe Smoker Evaluation, dated 3-21-17, revealed he was deemed a safe smoker by the facility's interdisciplinary team. The clinical record of Resident V was reviewed on 10-17-17 at 10:08 a.m. His [DIAGNOSES REDACTED]. Observations on 10-12-17 at 8:03 p.m., and 10-14-17 at 2:16 p.m., revealed he was taking part in a designated smoking activity. His most recent MDS assessment, dated 7-4-17, indicated he was moderately cognitively impaired. The recapitulation orders for Resident V for October, 2017, did not include physician orders [REDACTED]. His most recent Safe Smoker Evaluation, dated 7-28-17, revealed he was deemed a safe smoker by the facility's interdisciplinary team. On 10-13-17 at 10:55 a.m., the DON provided a copy of a policy entitled, Residents Safe Smoking Policy. This policy had a revision date of 11-29-12 and was indicated to be the current policy utilized by the facility. This policy specified, The facility shall establish and maintain safe resident smoking practices. 1. Residents shall be permitted to smoke in designated areas only. In compliance with Hancock County Code of Ordinance 91.51, smoking shall not be permitted inside the healthcare facility and will be prohibited within 25 feet of the facility entrance, exit, and open windows. 2. Smoking restrictions shall be strictly enforced in all nonsmoking areas. 3. The designated smoking area is outside of the facility and provides covered shelter .6. If the resident uses tobacco, an assessment will be completed to determine if the resident is a safe smoker. The Safe Smoking Evaluation will be completed on admission, quarterly and with significant changes. 7. All residents will be supervised while smoking. Smoking will be permitted during the designated smoke break times: 9:00 a.m., 11:00 a.m., 1:30 p.m., 4:30 p.m., and 6:30 p.m. 8. Any smoking-related privileges, restrictions, and concerns shall be noted on the care plan, and all personnel caring for the residents shall be alerted to these issues. 9. For the safety of all residents, no resident may keep any types of smoking articles including cigarettes, tobacco, etc., except when they are under direct supervision . On 10-13-17 at 10:55 a.m., the DON provided a copy of educational material he described as currently being provided to staff. This document was entitled, Dangers of Smoking While Using Oxygen. It was designated to have been obtained from the LiveStrong.com web site and was indicated to have last been updated on 8-14-17. This document indicated, Supplemental oxygen .poses safety risks when used while smoking. Normal air contains 21 percent oxygen, while supplemental oxygen can contain up to 100 percent oxygen. Although oxygen itself is not flammable, it creates an environment in which fires can easily ignite and burn quickly. You should never smoke inside a home when supplemental oxygen is in use. Smoking while on oxygen increases the risk of fire. Once ignited, fires burn hotter and more rapidly in oxygen-rich surroundings. This leads to larger fires that are harder to extinguish and more difficult to escape. Sparks created from striking a match or lighter are enough to ignite a fire while oxygen is in use. Fires endanger the lives of people who are on oxygen, others in the home or surrounding area and emergency personnel who respond to the fire. After oxygen is turned off, the increased oxygen levels still linger on the hair, skin and clothing of anyone receiving oxygen therapy. This creates a danger of serious burns on the head and face if smoking materials are brought toward the mouth and burns on the remainder of the body if clothing ignites . The Immediate Jeopardy was removed on 10-16-17 when the facility began utilizing two staff members to supervise residents during designated smoking times, educated staff and residents on the facility's smoking policies and the safe use of oxygen with smoking, but the noncompliance remained at the lower scope and severity of pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all employees had not been inserviced. 2. The clinical record for Resident H was reviewed on 10/16/17 at 12:50 p.m. The [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS) assessment, dated 9/5/17, noted a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. An incident report from the Indiana State Department of Health survey report system, dated 9/28/17 at 5:30 p.m., indicated Resident H eloped from the facility. The Administrator left the facility at approximately 5:30 p.m., and found Resident H at a stop light that was a half a mile away from the facility. Resident H stated at that time he was going to the Verizon store to purchase an iPhone. It was found that the electrical connection (plug) to the alarm system attached to a door (system to alert/alarm if a resident with a wanderguard is going through or close to an exit corridor) was not making contact, but not unplugged enough for anyone to notice. They believed Resident H threw a chair towards a door that resulted the misconnection that failed to activate the alarm when Resident H went out the door with his personal wondergaurd. An interview with Resident H, on 10/16/17 at 2:00 p.m., indicated he asked the nursing staff if they could take him to the Verizon store that day and they kept blowing him off. He indicated he disabled the alarm system in attempt to walk to this store to obtain a cell phone. The nursing staff didn't even know that he had left the facility. He indicated the weather was nice on that day. An interview with the Administrator, on 10/16/17 at 2:17 p.m., indicated she was heading home and saw Resident H at the stop light, headed east, about a half a mile away from the facility. Resident H wanted to go to the Verizon store and buy a cell phone. A progress note, dated 9/28/17 at 12:15 p.m., indicated the following, .Res (Resident H) is very anxious up at nurses med (medication) cart. Stating I want to go to target (sic) so that I can get a new phone The progress note was signed by Licensed Practical Nurse (LPN) 9. An interview with LPN 9, on 10/16/17 at 4:10 p.m., indicated Resident H had been asking to go to the Verizon store to obtain a new cell phone. She said they couldn't take him. She did not observe Resident H throw a chair at a door. A policy titled Elopement Prevention, Identification and Management, revised 1/6/16, was provided by the DON on 10/16/17 at 12:12 p.m. The policy indicated the following, .Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for [REDACTED]. A resident who leaves a safe area may be at risk of (or has the potential to experience) heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. Facility policies that clearly define the mechanisms and procedures for monitoring and managing residents at risk for elopement can help to minimize the risk of a resident leaving a safe area without authorization and/or appropriate supervision. In addition, the resident at risk should have interventions in their comprehensive plan of care to address the potential for elopement. Furthermore, a facility's disaster and emergency preparedness plan should include a plan to locate a missing resident 3. The clinical record for Resident B was reviewed on 10/17/17 at 10:44 a.m. The [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS) Assessment, dated 5/12/17, indicated Resident B was an extensive assist with one staff person for transfers and limited assist with one staff person for ambulation. A Interdisciplinary Progress Note, dated 5/4/17 at 4:20 p.m., indicated the following, .While transporting res (resident) to (name of hospital) via facility van, res (resident) fell in the van while turning to leave facility. W/C (wheelchair) was strapped down, wheels locked; but as van slowed down to turn, res (resident) slid off the w/c (wheelchair) onto her knees .Staff retrained by maintenance director on strapping w/c (wheelchair) to van (symbol for and) using seat belt A document titled Van in-service was provided by the Director of Nursing (DON) on 10/17/17 at 3:46 p.m. The document indicated the following, .Res (resident) has to have seat belt across, from the top of the van, and buckled to the vans' floor .Ensure all W/C (wheelchair) straps are secured to non moveable parts of a wheelchair and that they are tight and locks are pushed in till click sound, doub(TRUNCATED)