Every finding on record at Aperion Care Hanover

Based on observation and interview, the facility failed to store medications appropriately for 3 of 4 Medication Carts and 1 of 2 Medication Rooms reviewed. (Wing 4, Wing 3/Cart 3, Wing 2/Cart 1, and Wing 3 Medication Room). Findings include:1.On 04/09/2026 at 10:44 A.M., the Wing 4 Medication Cart was observed with RN 2, and contained the following: -A Novolog insulin pen, that was in the top drawer, for Resident 71 had 150 units of insulin left in it. The bag that the insulin pen was in had a written date of 03/05. The insulin pen had a number 3 written on it, with the rest of the numbers smeared and unreadable, -A full, undated, Insulin Glargine insulin pen, that was in the top drawer, for Resident 67. The RN indicated she had just opened the pen that morning, -An undated, Fiasp insulin pen, that was in the top drawer, for Resident 67 that had 50 units left in it, -A Humalog insulin pen, that was in the top drawer, for Resident 14 that was less than a 1/4 full and dated 03/07, and -In the second drawer there were two loose small oval pills and two loose small white round pills. The RN indicated insulin was good for 30 days once it was taken out of the refrigerator. 2. On 04/09/2026 at 10:59 A.M., the Wing 3/Cart 3 Medication Cart was observed with Licensed Practical Nurse (LPN) 3 and contained the following: -In the second drawer there was a loose small blue round pill, an oval pill, and a small round white pill. The nurse indicated the pills were Sinemet, Namenda, and Lasix, and -In the top, right drawer an unopened Lantus insulin pen for Resident 2, and an undated vial of Humulin insulin that had approximately 1/4 left in it for Resident 64. 3. On 04/09/2026 at 11:09 A.M., Wing 2/Cart 1 was observed with LPN 4, and contained the following: -A loose, unknown, small tan pill in the second drawer. During an interview, on 04/14/2026 at 2:53 P.M., the Director of Nursing (DON) indicated insulin was good for 30 days after it had been opened. Insulins should be dated when opened. If the insulin was unopened it should remain in the refrigerator. During an interview, on 04/16/2026 at 1:20 P.M., RN 5 indicated med carts should be clean, free of trash, and medications should not be loose in the drawers. The current, undated, facility policy titled, Storage of Medications was provided by the Administrator on 04/15/2026 at 12:32 P.M. The policy indicated, .Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier.Outdated, contaminated, or deteriorated medications.are immediately removed from inventory, disposes of according to procedures for medication disposal and reordered from the pharmacy, if a current order exists.Medication storage areas are kept clean, well-lit, and free of clutter. A Novolog Insert, with a revision date of 02/2023 was provided by the Administrator on 04/15/2026 at 1:17 P.M. The insert indicated, .Throw away all opened Novolog.after 28 days even if they still have insulin in them. A Lantus insert was provided by the Administrator on 04/15/2026 at 1:17 P.M. The insert indicated, .Not in-use (unopened) Room Temperature.28 days. A Fiasp insert was provided by the Administrator on 04/15/2026 at 1:17 P.M. The insert indicated, .Do not use.past the expiration date printed on the label or 28 days after you start using the pen. A Humalog insert was provided by the Administrator on 04/15/2026 at 1:17 P.M. The insert indicated, .Storage and Handling.In-use.Room Temperature.28 days. A Humulin insert was provided by the Administrator on 04/15/2026 at 1:17 P.M. The insert indicated, .Storage.In-Use.Opened.31 days. 4. The Wing 3 Medication Room was observed on 04/15/2026 at 11:40 A.M., with RN 5. A bottle of tuberculin serum that was half full, in a refrigerator lacked an opened date. There were two half dollar size spots of an unknown brownish substance on the bottom shelf and two quarter size spots of an unknown brownish substance on the top shelf of the medication refrigerator. RN 5 indicated the tuberculin serum should have had an opened date on the bottle. She had no idea what the brownish substance was, and the medication refrigerator should be kept clean. The tuberculin serum package directions for storage indicated, .vials in use more than 30 days should be discarded . The current, undated, facility policy titled, Storage of Medications was provided by the Administrator on 04/15/2026 at 12:32 P.M. The policy indicated, .Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier.Outdated, contaminated, or deteriorated medications.are immediately removed from inventory, disposes of according to procedures for medication disposal and reordered from the pharmacy, if a current order exists.Medication storage areas are kept clean, well-lit, and free of clutter. 410 IAC (Indiana Administrative Code) 16.2-3.1-25(o)

Based on record review and interview, the facility failed to follow physician's orders related to hold parameters for medications and follow manufacturer's guidelines for administering insulin for 3 of 21 residents reviewed for Quality of Care. (Residents 20, 14, and 67) Findings include:1.The clinical record for Resident 20 was reviewed on 04/13/2026 at 2:20 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 01/05/2026, indicated the resident was cognitively intact. The resident's diagnosis included, but was not limited to, hypertension. A current physician's order, with a start date of 11/24/2025, indicated the resident was to receive Carvedilol, a cardiac medication, 3.125 milligrams (mg) two times a day for hypertension. The medication was to be held, not given, if the systolic blood pressure (the top number, measures the maximum pressure in your arteries when your heart contracts and pumps blood) was less than 120. The resident's April 2026 Electronic Medication Administration Record (EMAR) was reviewed and indicated the resident had received the medication when the resident's systolic blood pressure was less than 120 on the following dates and times: - On 04/02/2026 at 7:00 A.M., when the resident's systolic blood pressure was 112, the resident received the Carvedilol medication. - On 04/02/2026 at 7:00 P.M., when the resident's systolic blood pressure was 118, the resident received the Carvedilol medication. - On 04/03/2026 at 7:00 A.M., when the resident's systolic blood pressure was 118, the resident received the Carvedilol medication. - On 04/04/2026 at 7:00 A.M., when the resident's systolic blood pressure was 112, the resident received the Carvedilol medication. - On 04/05/2026 at 7:00 A.M., when the resident's systolic blood pressure was 116, the resident received the Carvedilol medication. - On 04/06/2026 at 7:00 A.M., when the resident's systolic blood pressure was 110, the resident received the Carvedilol medication. - On 04/06/2026 at 7:00 P.M., when the resident's systolic blood pressure was 118, the resident received the Carvedilol medication. - On 04/07/2026 at 7:00 A.M., when the resident's systolic blood pressure was 116, the resident received the Carvedilol medication. - On 04/07/2026 at 7:00 P.M., when the resident's systolic blood pressure was 116, the resident received the Carvedilol medication. - On 04/09/2026 at 7:00 P.M., when the resident's systolic blood pressure was 118, the resident received the Carvedilol medication. - On 04/10/2026 at 7:00 P.M., when the resident's systolic blood pressure was 118, the resident received the Carvedilol medication. - On 04/12/2026 at 7:00 A.M., when the resident's systolic blood pressure was 118, the resident received the Carvedilol medication. - On 04/13/2026 at 7:00 A.M., when the resident's systolic blood pressure was 118, the resident received the Carvedilol medication. - On 04/14/2026 at 7:00 P.M., when the resident's systolic blood pressure was 117, the resident received the Carvedilol medication. - On 04/15/2026 at 7:00 A.M., when the resident's systolic blood pressure was 112, the resident received the Carvedilol medication. - On 04/16/2026 at 7:00 A.M., when the resident's systolic blood pressure was 112, the resident received the Carvedilol medication. 2a. The clinical record for Resident 14 was reviewed on 04/13/2026 at 10:53 A.M. A Quarterly MDS assessment, dated 02/24/2026, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, heart failure (chronic, serious condition where the heart muscle cannot pump blood efficiently enough to meet the body's needs for oxygen and nutrients), hypertension, and diabetes. A physician's order, dated 01/19/2026 through 04/09/2026, indicated the resident was to receive Insulin Glargine, 12 units subcutaneously, twice a day. The medication was to be held of the resident's blood glucose level was less than 110. The February, March, and April 2026 EMAR was reviewed and indicated the resident had received the medication when the resident's blood glucose levels were less than 110 on the following dates and times: - On 02/08/2026 at 7:00 A.M., when the resident's blood glucose level was 70, the resident received the Glargine.- On 02/13/2026 at 7:00 A.M., when the resident's blood glucose level was 92, the resident received the Glargine.- On 02/16/2026 at 7:00 A.M., when the resident's blood glucose level was 65, the resident received the Glargine.- On 02/21/2026 at 7:00 A.M., when the resident's blood glucose level was 94, the resident received the Glargine.- On 02/22/2026 at 7:00 A.M., when the resident's blood glucose level was 62, the resident received the Glargine.- On 02/26/2026 at 7:00 A.M., when the resident's blood glucose level was 62, the resident received the Glargine. - On 03/04/2026 at 7:00 A.M., when the resident's blood glucose level was 104, the resident received the Glargine.- On 03/06/2026 at 7:00 A.M., when the resident's blood glucose level was 70, the resident received the Glargine.- On 03/07/2026 at 7:00 A.M., when the resident's blood glucose level was 89, the resident received the Glargine.- On 03/08/2026 at 7:00 A.M., when the resident's blood glucose level was 84, the resident received the Glargine.- On 03/11/2026 at 7:00 A.M., when the resident's blood glucose level was 68, the resident received the Glargine.- On 03/12/2026 at 7:00 A.M., when the resident's blood glucose level was 62. the resident received the Glargine.- On 03/17/2026 at 7:00 A.M., when the resident's blood glucose level was 105, the resident received the Glargine.- On 03/20/2026 at 7:00 A.M., when the resident's blood glucose level was 68, the resident received the Glargine.- On 03/22/2026 at 7:00 P.M., when the resident's blood glucose level was 109, the resident received the Glargine. - On 03/31/2026 at 7:00 A.M., when the resident's blood glucose level was 74, the resident received the Glargine. 2b. A physician's order, dated 11/25/2025 through 04/09/2026, indicated the resident was to receive Midodrine (medication used to treat symptomatic low blood pressures) 2.5 mg, three times a day. The staff were to hold the medication if the residents systolic blood pressure was greater than 130. The February, March, and April 2026 EMAR indicated the resident had received the medication when the residents systolic blood pressure was greater than 130 on the following dates and times: - On 02/04/2026 at 7:00 P.M., when the resident's systolic blood pressure was 143, the resident received the Midodrine medication. - On 02/09/2026 at 1:00 P.M., when the resident's systolic blood pressure was 143, the resident received the Midodrine medication. - On 02/10/2026 at 1:00 P.M., when the resident's systolic blood pressure was 144, the resident received the Midodrine medication. - On 02/14/2026 at 1:00 P.M., when the resident's systolic blood pressure was 146, the resident received the Midodrine medication. - On 02/21/2026 at 7:00 P.M., when the resident's systolic blood pressure was 139, the resident received the Midodrine medication. - On 02/22/2026 at 1:00 P.M., when the resident's systolic blood pressure was 131, the resident received the Midodrine medication. - On 02/25/2026 at 1:00 P.M., when the resident's systolic blood pressure was 131, the resident received the Midodrine medication. - On 03/07/2026 at 7:00 A.M., when the resident's systolic blood pressure was 133, the resident received the Midodrine medication. - On 03/16/2026 at 7:00 A.M., when the resident's systolic blood pressure was 131, the resident received the Midodrine medication. - On 03/26/2026 at 7:00 P.M., when the resident's systolic blood pressure was 144 the resident received the Midodrine medication. - On 04/03/2026 at 7:00 P.M., when the resident's systolic blood pressure was 136, the resident received the Midodrine medication. - On 04/04/2026 at 7:00 A.M., when the resident's systolic blood pressure was 132, the resident received the Midodrine medication. During an interview, on 04/13/2026 at 1:36 P.M., RN 2 indicated if a resident's medications had hold parameters, then she would obtain the resident's vital signs before giving the medication. If the vitals did not fall within the parameters of giving the medication, then she would not administer the medication and document it in a progress note that the medication was not given. During an interview, on 04/14/2026 at 2:53 P.M., the DON indicated if a medication had hold parameters, then the nurse would get the resident's vital signs and if they were outside the parameters then the medication would not have been administered. If the medication was not administered, then there would be a progress note and documentation in the EMAR as not given. The current, undated, facility policy titled, Medication Administration General Guidelines was provided by the Administrator on 04/14/2026 at 4:33 P.M. The policy indicated, .Medications are administered as prescribed in accordance with good nursing principles and practices. 3. During a medication administration observation, on 04/15/2026 at 11:50 A.M., Licensed Practical Nurse (LPN) 7 removed Resident 67's Fiasp insulin pen from the top drawer of the medication cart. She cleaned the hub of the pen, placed a needle on the end of the pen, turned the dial to 10 units, and walked to the resident's room. The nurse indicated she was unaware insulin pens needed to be primed, she had never been taught to prime the pens. The Fiasp insulin pen package insert was provided by the Director of Nursing on 04/15/2026 at 3:35 P.M. The steps for administering indicated, .Priming your FIASP .Pen .Turn the dose selector to select 2 units .Hold the Pen with the needle pointing up. Tap the top of the Pen gently a few times to let any air bubbles rise to the top .Hold the Pen with the needle pointing up. Press and hold the dose button until the dose counter shows 0 .A drop of insulin should be seen at the needle tip . 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on record review, observation, and interview, the facility failed to implement fall interventions for 3 of 4 residents reviewed for Implementation of Care Plans. (Residents 6, 12, and 20)Findings include: 1. Resident 6's clinical record was reviewed on 04/13/2026 at 2:32 P.M. A Significant Change Minimum Data Set (MDS) assessment, dated 02/08/2026, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, a fracture of the first cervical vertebra (a bone that forms the neck region of the spine), stroke (a medical emergency that occurs when blood flow to part of the brain is blocked that can cause neurological deficits), and repeated falls. The resident's range of motion in one of his arms was impaired and he used a wheelchair. The resident experienced a fall without injury and a fall with a major injury since the last assessment. The resident's Risk for Falls Care Plan was initiated on 09/05/2025, and included but was not limited to, to following interventions: - An intervention, initiated on 10/17/2025, to place Call, Do Not Fall signage in the resident's room. The resident was observed in bed in his room on 04/09/2026 at 11:12 A.M. The resident was wearing a neck brace and a splint on his right hand. There were no signs posted in the resident's room. During an observation, on 04/13/2026 at 10:27 A.M., the resident was in his room in bed. There were no signs posted in the resident's room. During an observation, on 04/13/2026 at 1:45 P.M., the resident was in his room in bed. There were no signs posted in the resident's room. During an interview, on 04/14/2026 at 10:04 A.M., Licensed Practical Nurse (LPN) 3 indicated she was familiar with the resident. He had experienced several falls. He had fractured a bone in his neck and a bone in his right hand when he fell in February and fractured his left hip after a fall less than two weeks ago. When asked why she thought he fell so frequently, the LPN indicated the resident often forgot to use his call light. He doesn't realize he is getting weaker and forgets to use his call light. During an observation with LPN 3, on 04/14/2026 at 10:05 A.M., the resident was in his room in bed. LPN 3 looked around and indicated there were no signs posted in the resident's room. During an observation on 04/14/2026 at 2:14 P.M., the resident was in his room in bed. There were no signs posted in the resident's room. During an observation on 04/15/2026 at 10:23 A.M., the resident was in his room in bed. There were no signs posted in the resident's room. 2.During an observation, on 04/13/2026 at 11:45 A.M., Resident 12 was sitting at a table in the Wing 2 Dining Room. The resident stood up from his wheelchair and walked to the nurse's station and asked for a drink/snack. Licensed Practical Nurse 4 assisted the resident back to his wheelchair. There were no alarms in place to the resident's wheelchair. During an observation and interview, on 04/13/2026 at 12:13 P.M., Resident 12 was sitting in the Wing 2 Dining Room in his wheelchair. There was no chair alarm present. CNA 8 indicated the resident had a few falls recently. He had a pressure alarm to his bed. The resident liked to get up and run around. They usually had to ask him to sit back down because that was when he would fall. The resident's interventions for falls were placed on the pocket sheets that the C NAs carried on them every day. She thought the resident's chair alarm was discontinued when he went from a Broda chair to a regular wheelchair. During an interview and record review, on 04/13/2026 at 12:27 P.M., CNA 8 indicated and showed that the resident had an intervention on the pocket sheet for a chair alarm. The resident didn't have a chair alarm in place at that time, and she would have to go dig it out of the room as she was unsure where it was located. The clinical record for Resident 12 was reviewed on 04/14/2026 at 9:47 A.M. A Quarterly MDS assessment, dated 03/21/2026, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, Huntington's (neurodegenerative disorder) disease and other fracture. The resident had falls prior to the assessment. An open-ended physician's order, with start date of 11/17/2025, indicated the resident was to have a Chair Pressure Alarm (CPA), at all times for safety. 3. The clinical record for Resident 20 was reviewed on 04/13/2026 at 2:20 P.M. A Quarterly MDS assessment, dated 01/05/2026, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, rib fractures, dementia, seizure disorder, anxiety, repeated falls, and insomnia. The resident had two or more falls since the last assessment with no injury, and two or more falls since the last assessment with minor injuries. The previous assessment was a Significant Change MDS assessment dated [DATE]. The resident's Risk for Falls Care Plan indicated they had poor balance and an unsteady gait. Interventions included, but were not limited to, the following: -Signage placed in several places in resident's room stating, Call for help do not fall, initiated on 04/06/2024, and -Colored tape to the resident's walker, initiated on 10/12/2025. During an observation and interview, on 04/10/2026 at 1:37 P.M., Resident 20 was sitting in her recliner in her room. The backs of the resident's hands were bruised, and she had adhesive strips on her left hand. She was not sure how she had injured her hand. She had recently started on a new medication, and it made her kind of, woozy. She thought she may have injured them one day when she had been in her doorway and slid down the door frame. The resident had a walker next to her recliner. There were no signs posted in her room or colored tape on her walker. The resident indicated she did not use her walker to go to the bathroom because the bathroom was just next door to her room. During an observation, on 04/10/2026 at 2:57 P.M., there were no signs posted in the resident's room or colored tape on her walker. During an observation, on 04/13/2026 at 10:09 A.M., there were no signs posted in the resident's room or colored tape on her walker. The resident was sitting in her recliner. During an observation, on 04/13/2026 at 1:59 P.M., there were no signs posted in the resident's room or colored tape on her walker. The resident was sitting in her recliner. The Certified Nurse Aide (CNA) pocket sheet for Wing 1, the Dementia Unit, was provided by CNA 6 on 04/14/2026 at 9:43 A.M. CNA 6 indicated the pocket sheet was how she knew what the Care Plan interventions were for each resident. During an observation of Resident 20's room with CNA 6, on 04/14/2026 at 9:46 A.M., the CNA indicated she had no idea about the signs, but a staff member had put bright tape on the resident's walker at one time. The CNA asked the resident if she had taken the bright tape off her walker and the resident indicated, No. There were no signs posted in the room and there was no colored tape on the resident's walker. The current Fall Prevention Program policy, with an effective date of 11/28/2012, was provided by ##. The policy indicated, .The Fall Prevention Program includes .Care plan incorporates .Addresses each fall .Interventions are changed with each fall, as appropriate .Preventative measures . 410 IAC (Indiana Administrative Code) 16.2-3.1-35(g)(2)

Based on record review and interview, the facility failed to document a resident's medication administration for 1 of 21 residents record reviewed. (Resident 14)Findings include:The clinical record for Resident 14 was reviewed on 04/13/2026 at 10:53 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 02/24/2026, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, heart failure (the heart muscle cannot pump enough blood to meet the body's needs for oxygen and nutrients) and hypertension (chronic high blood pressure).An open-ended physician's order, with a start date of 04/10/2026, indicated the resident was to be given Veletri (a prescription medication delivered continuously via a small, portable pump for treating severe pulmonary arterial hypertension) Intravenous Solution Reconstituted. The resident was to receive 3.7 milliliters per hour in the evening for pulmonary hypertension. The April 2026 Electronic Medication Administration Record lacked documentation that the medication was administered on 04/10/2026, 04/11/2026, and 04/12/2026. During an interview, on 04/15/2026 at 1:41 P.M., Licensed Practical Nurse (LPN) 7 indicated the resident had a cardiac pump for pulmonary hypertension. The resident's medication would get changed out every day.During an interview, on 04/13/2026 at 1:36 P.M., RN 2 indicated medications were always signed out in the residents EMAR. There should never be blanks in the EMAR. The current, undated, facility policy titled, Medication Administration General Guidelines was provided by the Administrator on 04/14/2026 at 4:33 P.M. The policy indicated, .The individual who administers the medication dose records the administration on the resident's MAR [Medication Administration Record] directly after the medication is given.In no case should the individual who administered the medications report-off duty without first recording the administration of any medication.410 IAC (Indiana Administrative Code) 16.2-3.1-50(a)(1)

Based on observation, interview, and record review, the facility failed to verify physician orders and accurately transcribe physician orders for 2 of 21 residents reviewed for pharmacy services. (Resident 21 and 14) Findings include:1. During a medication administration observation and interview on 04/15/2026 at 9:31 A.M., Licensed Practical Nurse (LPN) 7 prepared Resident 21's medications. The resident had an order on the Electronic Medication Administration Record (EMAR) for Critical Procure Supplement for wound healing. The order did not have an amount to administer. The LPN indicated the order didn't indicate how much to administer and she would just give the resident 5 cubic centimeters (cc). The nurse poured 5 cc into a medication cup and took the resident's medications into his room. The resident refused the supplement. During an interview, on 9:59 A.M., the Minimum Data Set (MDS) Coordinator indicated if a resident had an order for a liquid supplement, then it should have the amount to be given in the order. Every resident was different based on weight and comorbidities. If an order didn't have an amount to give, then she would call the physician to clarify the order. She reviewed the order for Resident 21 at that time and indicated there should have been an amount to administer. The nurse should have clarified the order. 2a. The clinical record for Resident 14 was reviewed on 04/13/2026 at 10:53 A.M. A Quarterly MDS assessment, dated 02/24/2026, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, heart failure, and hypertension (high blood pressure).A Hospital Discharge Record, dated 04/09/2026, indicated the resident had the following physician's orders:- Midodrine 2.5 milligrams (mg) every eight hours, and - Vancomycin 125 mg, take 1 capsule four times a day for 14 days, three times a day for seven days, two times a day for seven days, daily for seven days, and once a week for seven weeks. The resident's facility physician's orders and April 2026 EMAR indicted the resident had the following orders transcribed after admission to the facility on [DATE]:- Midodrine 2.5 mg with a start date of 04/09/2026 through 04/12/2026, the staff were to give 0.25 mg every eight hours for hypertension, - Vancomycin 125 mg, dated 04/09/2026 through 04/13/2026, take one capsule four times a day for 14 days, -Vancomycin 125 mg, dated 04/10/2026 through 04/13/2026, take one capsule once a day for seven days. During an interview, on 4/15/26 at 8:55 A.M., the Director of Nursing (DON) indicated the resident had duplicate Vancomycin orders and she shouldn't have. During an interview, on 04/13/2026 at 1:36 P.M., RN 2 indicated when a resident received new orders or was admitted from the hospital, the nurse would transcribe the orders and a second nurse wound review and confirm them.During an interview, on 04/14/2026 at 2:53 P.M., the DON indicated the resident's midodrine order was for 2.5 mg. The 0.25 mg part of the order was entered in error. The medication order was corrected. The resident had only received the 2.5 mg.During an interview, on 04/15/2026 at 3:20 P.M., LPN 7 indicated the resident didn't receive duplicate doses of the Vancomycin when she had duplicate orders and the resident had only ever received 2.5 mg of the Midodrine when the order indicated she was to be given 0.25 mg. The medication was reviewed in the medication cart and there were only medication cards from the pharmacy on 03/10/2026 and 04/10/2026 for 2.5 mg tablets. During an interview, on 04/16/2026 at 10:31 A.M., RN 5 indicated if a resident had a duplicate or incorrect order, she would contact the physician to get clarification of the order. 2b. An open-ended physician's order with a start date of 04/10/2026 indicated the resident was to be given Veletri (a prescription medication delivered continuously via a small, portable pump for treating severe pulmonary arterial hypertension) Intravenous Solution Reconstituted. The resident was to receive 3.7 milliliters per hour in the evening for pulmonary hypertension. During an interview, on 04/15/2026 at 1:41 P.M., LPN 7 indicated the resident had a cardio pump for hypertension. The resident medication cartridge would get changed out every 24 hours. The pump would let the staff know when it was empty. The time the medication was changed out varied, it wasn't at the exact same time every day. The only time to document the medication administration on the EMAR was in the evening. She did change the medication out that morning, but there was nowhere for her to document that the medication was administered that morning. During an interview, on 04/15/2026 at 1:48 P.M., the DON indicated the resident received 89 ml/hour of the Veletri medication. There was a 100 mls in the cartridge. The pump was set to deliver 89 mls/24 hours but would use all the medication in that cartridge so it didn't always get changed out at the same time every day. The nurse would document in the EMAR when the medication was changed out. She thought the resident had an as needed order for the nurses to document when it was changed out. It appeared that the as needed order was not entered into the computer when she came back from the hospital, and she only had the evening order. There should have been an as needed order in the clinical record. The current facility policy titled, Physician Orders-Entering and Processing, with a revision date of 01/31/2018, was provided by the Administrator on 04/15/2026 at 11:06 A.M. The policy indicated, .To provide general guidelines when receiving, entering, and confirming physician or prescriber's orders.Medication orders should include:.Dose.Notify the resident's physician.for verification if applicable.The current facility policy titled, Transcription of Physician Orders-Procedure, dated 11/03/2022, was provided by the Administrator on 04/15/2026 at 11:06 A.M. The policy indicated, .To establish the procedure by transcribing new physician orders.Transcription of physician orders: Carefully, review transfer record and discharge summary from the hospital or the transfer record.After each order is entered in the physician Order tab of the chart, check that all orders were entered correctly.The current, undated, facility policy titled, Medication Administration General Guidelines was provided by the Administrator on 04/14/2026 at 4:33 P.M. The policy indicated, .Medications are administered as prescribed in accordance with good nursing principles and practices.FIVE RIGHTS-.right dose.410 IAC (Indiana Administrative Code) 16.2-3.1-25(b)(9)410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on observation, interview, and record review, the facility failed to assess a resident for self-administering medications for 1 of 18 residents observed for medications left at the bedside. (Resident 8) Findings included:During an observation and interview, on 04/09/2026 at 12:12 P.M., Resident 8 was sitting in his recliner in his room. His over-bed table was next to the recliner and contained several personal items, including, but not limited to, a white tube of ointment with a yellow label that had the cap on in a skewed manner, and a five cubic centimeter syringe of clear fluid. The resident indicated the tube of ointment was numbing cream he applied to his skin a couple hours before he left for dialysis treatments. The syringe was normal saline he used to flush his eyes with because he had allergies. During an observation, on 04/13/2026 at 10:18 A.M., the resident was not in his room. The tube of ointment was uncapped and lying on the over-bed table. They syringe of clear fluid was also laying on the table. On 04/13/2026 at 11:46 A.M., the uncapped tube of ointment and the syringe were laying on the resident's over-bed table. The clinical record was reviewed on 04/13/2026 at 11:18 A.M. A Quarterly Minimum Data Set (MDS)assessment, dated 02/03/2026, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, end stage renal disease (kidney function declines to below 10 to 15 percent) and diabetes. The resident received dialysis treatments while a resident. The resident's record lacked a physician's order for the ointment and for the resident to be permitted to self-administer the medication. During an observation and interview, on 04/14/2026 at 10:21 A.M., the MDS Coordinator indicated the ointment was lidocaine (a numbing agent). The ointment and syringe were both on the resident's over-bed table. The MDS Coordinator indicated they should not be left at the bedside, and the resident should have a physician's order for them to be left at bedside. The current undated Medication Administration General Guidelines policy was provided by the Administrator on 04/14/2026 at 4:33 P.M. The policy indicated, .Residents are allowed to self-administer medications when specifically authorized by the attending physician . 410 IAC (Indiana Administrative Code) 16.2-3.1-11(a)

Based on interview and record review, the facility failed to notify the Ombudsman of residents that were discharged from the facility for 3 of 3 discharged residents' records reviewed. (Residents 81, 79, and 3) Findings include: 1. The clinical record for Resident 81 was reviewed on 04/10/2026 at 2:36 P.M. The resident was admitted to the facility on [DATE] after a lengthy hospital stay. A Nursing Home Discharge Minimum Data Set (MDS) assessment, dated 03/11/2026, indicated the resident discharged to home on [DATE], and was not anticipated to return to the facility. The Census section of the resident's Electronic Health Record (EHR) indicated the resident was discharged from the facility on 02/23/2026. During an interview, on 04/15/2026 at 11:09 A.M., the Social Services Director (SSD) indicated the resident went home with her spouse and declined home health services. She normally sent a list of discharged residents to the Ombudsman every month, but she missed sending the list of residents that discharged in February. 2. The clinical record for Resident 79 was reviewed on 04/10/2026 at 2:34 P.M. A Census Report indicated the resident was discharged on 01/20/2026 and the facility stopped billing on 01/21/2026. A Progress Note, dated 01/20/2026 at 3:40 P.M., indicated the resident was transported to the local emergency room. The clinical record lacked documentation that the Ombudsman was notified of the resident's discharge to the hospital. During an interview, on 04/16/2026 at 9:56 A.M., the SSD indicated she didn't have a way to show that she had notified the local Ombudsman of the resident's discharges. There was no way to show that she submitted it, and she didn't document it in the resident's record. 3. The clinical record for Resident 3 was reviewed on 04/10/2026 at 2:39 P.M. A Nursing Home Discharge MDS assessment, dated 02/05/2026, indicated the resident discharged to home and was not anticipated to return to the facility. During an interview, on 04/14/2026 at 11:36 A.M., the Assistant Director of Nursing (ADON) indicated the SSD notified the Ombudsman monthly related to discharged residents, usually at the first of the month. During an interview, on 04/14/2026 at 11:58 A.M., the SSD indicated she uploaded the discharge reports to the Ombudsman's site per the request of the Ombudsman. The Ombudsman had asked for monthly reports. SSD was taught to email the reports but then the SSD got the request to move the report to a State Ombudsman website. During an interview, on 04/14/2026 at 12:26 P.M., the SSD indicated she had just sent the list of discharged residents for February 2026. She had looked to see if she had sent it earlier and could not find it. She had been sick for a while around that time. The current Notice of Transfer and Discharge policy, with a reviewed date of 05/08/2023, was provided by the Administrator on 04/15/2026 at 12:32 P.M. The policy indicated, .The facility will send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. This may be done by submitting a monthly list of discharges to the Ombudsman . 410 IAC (Indiana Administrative Code) 16.2-3.1-12(a)(6)(A)IV

Based on record review, observation, and interview, the facility failed to identify a Deep Tissue Pressure Injury in a timely manner for 1 of 2 residents reviewed for pressure ulcers. (Resident 67)Findings include:The clinical record for Resident 67 was reviewed on 04/13/2026 at 11:28 A.M. A Quarterly Minimum Data Set(MDS) assessment, dated 02/14/2026, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, respiratory failure (lungs cannot adequately oxygenate the blood or remove carbon dioxide), muscle wasting (decrease in muscle size, mass, and strength). The resident was extensively dependent on staff for assistance with mobility and was non-ambulatory (unable to walk, restricted movement, bedfast) The resident was at risk for developing a pressure ulcer. During an observation and interview, on 04/14/2026 at 9:17 A.M., the facility wound nurse and the Wound Doctor removed a soft protective boot and sock from the resident's left foot. The Wound Doctor indicated the wound was a deep tissue injury (DTI, Persistent non-blanchable deep red, maroon or purple discoloration Intact skin) that now measured 0.8 centimeters (CM) x (by) 0.2 cm. An ultrasonic water treatment had been used on the wound bed. The wound was in the healing process with decreased size and improved appearance. The Skin Monitoring: Comprehensive CNA (Certified Nurse Aide) Shower Review records were provided by the Director of Nursing (DON) on 04/15/2026 at 3:34 P.M., and included the following:- A record, dated 03/03/2026, was blank and did not indicate there were any new skin areas identified,- A record, dated 03/05/2026, was blank and did not indicate there were any new skin areas identified, - A record, dated 03/09/2026, indicated the resident's heels were soft. Nothing was documented regarding the left outer foot. A Preventative Interventions Worksheet, dated 03/03/2026, included a Braden Scale risk assessment (an assessment used for predicting a resident's risk for acquiring pressure wounds) which indicated the resident was at a very high risk for developing a pressure wound. A Wound ASSESSMENT DETAILS REPORT, dated 03/11/2026 at 2:22 P.M., indicated the resident had a facility acquired DTI, identified on 03/10/2026. A Facility Acquired/Worsening Wound Investigation Report, dated 03/17/2026, indicated the resident had an in-house acquired wound identified on 03/11/2026. The new interventions put in place after the identification of the wound, included but were not limited to, off-loading devices. The report lacked any documentation the wound was unavoidable. During an interview on 04/15/2026 at 2:54 P.M., the facility Wound Nurse indicated the facility should have had wound preventative measures in place from the time the resident returned from the hospital on [DATE] to the time the wound was identified on 03/10/2026. The facility failed to provide a policy related to pressure wounds. 410 IAC (Indiana Authorization Code) 16.2-3.1-40(a)(1)

Based on record review and interview, the facility failed to follow pharmacy recommendations related to completing an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident receiving an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 4) Findings include:The clinical record for Resident 4 was reviewed on 04/15/2026 at 10:04 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 03/04/2026, indicated the resident was moderately cognitively impaired. The resident's diagnosis included, but was not limited to, psychotic disorder. The resident received an antipsychotic medication at the time of the assessment. The resident's most recent AIMS assessment was completed on 07/30/2025. A Consultant Pharmacist Recommendations to Nursing record, dated 01/26/2026, indicated the resident received Risperidone, an antipsychotic medication requiring adverse effect monitoring via an AIMS assessment. The most recent AIMS was completed on 07/30/2025. It was recommended an AIMS be performed within 30 days of initiation of the medication and repeated every six months or with any dose increase while the resident continued antipsychotic therapy. The medication had been increased on 12/31/2025. During an interview, on 04/15/2026 at 10:04 A.M., the Director of Nursing (DON) indicated the resident should have had an AIMS assessment completed following the recommendation from the pharmacy and it was not completed. 410 IAC (Indiana Administrative Code) 16.2-3.1-25(i)

Based on interview and record review, the facility failed to ensure a resident's whole emotional and mental well-being was closely monitored during a followed accelerated behavior to support and prevent further behaviors for 1 of 3 residents reviewed for behavior health services. (Resident D) Findings include:The clinical record for Resident D was reviewed on 03/12/2026 at 02:40 P.M. An Annual Minimum Data Set (MDS) assessment, dated 02/23/2026, indicated the resident was unable to complete the cognition interview. The resident's diagnoses included, but were not limited to, anxiety, depression, and Huntington's disease (progressive brain disorder). He experienced disorganized thinking (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject) behavior continually. A current Care Plan, with the start date 02/04/2026, indicated Resident D had the potential to be physically aggressive hitting, kicking, punching, choking staff and other residents related to impulse control disorder. The interventions included, but were not limited to, dated 02/04/2026, Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. A Nurses Note, dated 03/07/2026 at 7:02 A.M., indicated it was reported that Resident D had been pacing up and down the hallway of the unit, and opening and shutting the door to his room. He had his TV at maximum volume, and it was disrupting other residents. Resident D was upset that his door was closed, and increased behaviors were noted after that. At approximately 6:15 A.M. the on-duty nurse asked Resident D if his door could be closed and the resident stated no. Communication was sent to the Assistant Director of Nursing notifying them of the behavior observed by the resident, and management voiced understanding. Resident D then exited his room and walked towards the nurses' station with his hands behind his back. Another resident was noted to be sitting in his wheelchair next to the nurses' station. Resident D then punched the resident in the wheelchair next to the nurses' station with a closed fist in the face. Resident D knocked the male resident out of his wheelchair backwards and began kicking the other male resident. The staff separated the residents. Resident D cussed and threatened staff members while lunging at them. The resident attempted to hit the on-duty nurse. An Aggressive Behavior Assessment, dated 03/07/2025, indicated Resident D had a history or recent episode of aggressive/agitated behavior and/or non-compliance with medications, treatment, regimen, resisting care a substantial amount. During an interview, on 03/12/2026 at 9:06 A.M., Licensed Practical Nurse (LPN) 2 indicated she was working on 03/07/2026 and witnessed the resident-to-resident altercation with Resident D. In report that morning she was told Resident D had been pacing that night and he had refused to turn down his TV volume since midnight. They had asked to close his door and he had gotten upset. He then exited his room at around 6:20 A.M. and walked towards the nurses' station. He would usually ask for his medication or a drink of ice water, so I turned around towards the nurse's cart to get ready for his request. Once he got to the nurse's station he turned and punched a male resident sitting in his wheelchair next to the nurses' station in the head. During an interview, on 03/12/2026 at 3:41 P.M., the Director of Nursing (DON) indicated Resident D had strong behaviors. He would get agitated and would walk up and down the hallway. He didn't show many signs before he had a negative behavior. A current facility policy titled Behavioral Health Services with a revision date 10/24/2022, was provided by the Administrator on 03/12/2026 at 3:41 P.M. The Policy indicated, .To establish a system for identifying behaviors and implementing appropriate interventions consistent with the individualized plan of care and to ensure that each resident receives appropriate treatment and services to attain the highest practicable mental and psychosocial well-being .If uncontrolled anger, aggression or anxiety cannot be redirected, i.e. the resident is in danger of harming self or others . 410 IAC (Indiana Administrative Code) 16.2-3.1-45(a)(2)

Based on interview, observation, and record review, the facility failed to provide person centered activities that meet the resident's interests and supported the physical, mental, and psychosocial well-being of a resident for 1 of 3 residents reviewed for activities. (Resident B). Findings included:The clinical record for Resident B was reviewed on 03/12/2026 at 11:11 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 02/19/2026, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, attention-deficit hyperactivity disorder (persistent, hyperactivity and impulsivity that interfere with daily functioning), depression, and Huntington's disease (progressive brain disorder). The resident's mood assessment indicated he had little interest or pleasure in doing things nearly every day. A current Care Plan, with the start date of 01/02/2025, indicated Resident B had the potential for altered activity pattern related to resident preferences. The resident will be able to attend group activities of his interest and express enjoyment/dissatisfaction in his participation in the group. The staff were to encourage his participation in group activities and respect his right to decline all initiations. The goal, with a revision date of 03/31/2025 and target date of 02/17/2026, indicated Resident B would be open to invitations to group activities of his interests such as sport related groups, science lab, and various table activities. The interventions included, but were not limited to: dated 01/02/2025, explain the importance of social interactions, leisure activity time, invite the resident to activities that promote additional intake of food and fluids, and ensure that all snacks and beverages offered comply with any diet and fluid restrictions. During an interview, on 03/12/2026 at 9:45 A.M., Certified Nurse Aide (CNA) 3 indicated Resident B had become obsessed with attention, and he would get more worked up with behaviors than he used to. With his age and diagnosis, he would get bored very easily. He wanted to call family members repeatedly and would get upset when there was no answer. He started to cry a lot recently. He used to participate in activities, but now only participated in church and singing activities. There were no personal centered activities for him that kept him engaged. During an interview, on 03/12/2026 at 1:30 P.M., Activities Staff 4 indicated they have not figured out how to get Resident B more involved with activities. He used to participate a lot in activities. The first activity scheduled was at 9:30 A.M. and that's when the resident's smoke break was, so the resident would not participate in the activity. There have been constant behaviors with him at activities and at smoke breaks. He would get mad easily. If he didn't like the activity he would say he was bored and walked away. Since November 2025 the resident had steadily declined in being involved in activities. During an observation, on 03/12/2026 at 9:48 A.M., there were two residents in the front of the Wing 2 dining room participating in the scheduled 9:30 A.M. activity titled Whole Brain. An activities staff member was reading a document for the residents. Resident B was observed sitting on the opposite side of the dining room at a table eating and not involved in the activity. During an observation, on 03/12/2026 at 1:25 P.M., six residents were in the sunroom with an activities staff member putting lotion on one resident's hands. Resident B was not observed in the area. The Activity Calendar had the following activities planned for 03/12/2026: at 9:30 A.M., Whole Brain Exercise; at 10:00 A.M., Chronicles, at 10:30 A.M., Hydration/Chats, at 1:00 P.M., Spa, at 2:00 P.M., Men's only Group, at 3:00 P.M., Pizza Toss; and at 5:00 P.M., Movie on Channel 2. A Nurses Note, dated 03/08/2026 at 11:10 A.M., indicated Resident B walked around the nurse's station with unsteady gait and refused to sit in his wheelchair he was unable to be redirected. He yelled and attempted to hit staff. Then demanded staff call his family for him. The current facility policy, titled Activities Program with a revision date of 11/07/2019, was provided by the Administrator on 03/12/2026 at 3:41 P.M. The policy indicated, Identify and involve each resident in an ongoing program of activities that is designed to appeal to his or her interests and needs .Provide for residents needing specialized or extended programs to enhance their overall daily routine and activity pursuit needs . This citation relates to Intake 2747968. 410 IAC (Indiana Administrative Code) 16.2-3.1-33 (a)

Based on interview and observation, the facility failed to provide a safe and homelike environment for 2 of 4 residents reviewed. (Residents C and E)Findings include:1.During an interview, on 8/29/2025 at 11:20 A.M., Resident C indicated her room had flooded four different times since she came to the facility three months ago. One morning she woke up to two inches of water in her room that continued out into the hallway. The rooms on either side of her were also flooded. When there was heavy rainfall, the water came in through the heating and cooling unit. When it started raining heavy staff would come in and put towels under the unit. It flooded about a month ago, and they moved Resident C and her roommate into a different room for the night. The following day they had to move back into their room. A different time it flooded Resident C had to sit out in the hallway for an hour while they cleaned it all up. She now puts all of her things in waterproof bags, because anything on the floor would get ruined. The room smelled sour for days after it floods. She had asked if she could get a new room before, but was told no. The clinical record for Resident C was reviewed on 8/29/25 at 11:18 A.M. An admission Minimum Data Set (MDS) assessment, dated 6/2/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, anxiety, hypertension, and depression. During an observation and interview, on 8/29/25 at 12:54 P.M., room [ROOM NUMBER]'s heating and cooling unit showed visible light from the outside around the unit. The wall around the unit was soft and spongy to the touch. The Maintenance Supervisor indicated he just replaced all the units down that hallway over the last six months. A lot of the units had pans that were leaking. He had drilled holes in the backs of the units to allow water to drain.During an observation, on 8/29/25 at 11: 25 A.M., room [ROOM NUMBER] had signs of water damage. The drywall was buckling to the left of the heating and cooling unit. During an observation, on 8/29/25 at 11:48 A.M., room [ROOM NUMBER] had signs of water damage around the heating and cooling unit. The paint and drywall was peeling and gapping with a white-water stain mark on the floor below the left corner of the unit.2.During an interview, on 8/29/25 at 11:57 A.M., Resident E indicated they previously lived on the skilled side of the facility. She did experience flooding in her room while living in room [ROOM NUMBER]. The water from the flooding ruined all of her cross-stitch supplies. She had to throw it all away, and the facility never replaced it. She ended up just buying new supplies herself. The clinical record for Resident E was reviewed on 8/29/25 at 12:05 P.M. An admission Minimum Data Set (MDS) assessment, dated 3/4/25, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, anxiety, hypertension, and asthma.During an interview, on 8/29/25 at 10:34 A.M., the Maintenance Director indicated that the only flooding the facility had was in room [ROOM NUMBER], and during heavy rains water sometimes water would creep in under the doorway in the large dinning room or by the Director of Nursing's office. It was caused by a clogged drainpipe. He was unaware of any other issues in residents' rooms related to water leaks.The current facility policy, dated 3/15/17, titled, Resident Rights was provided by the Director of Nursing on 8/29/25 at 1:00 P.M. The Policy indicated, .You have the right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely .The following citation relates to Intake 2567302.3.1-19(f)(5)

Based on record review, and interview the facility failed to document medications being administered for 1 of 4 residents reviewed. (Resident D)Findings include:The clinical record for Resident D was reviewed on 8/29/25 at 12:38 P.M. An admission Minimum Data Set (MDS) assessment, dated 06/20/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, anemia, end-stage renal failure, and heart failure. A current open ended physician's order, with the start date of 7/14/25 at 5:00 P.M., indicated Resident D was to have his dialysis port on his abdomen soaked with a non woven sponge for five minutes before hooking up his dialysis catheter every 24 hours.The July 2025 and August 2025 Electronic Medication Administration Record (EMAR) indicated the following dates lacked documentation the resident received his dialysis port care: July 17, July 20, July 25, July 27, July 29, August 6, August 7, and August 24, 2025.The current undated facility policy, titled Medication Administration General Guidelines, was provided by the Director of Nursing on 8/29/25 at 2:19 P.M. The policy indicated, .The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medication report off-duty without first recording the administration of any medications . The resident's MAR is initialed by the person administering the medication, in the space provided under the date, and on the lines for that specific medication dose administration .This citation relates to Intake 2584623.

Based on observation, interview, and record review, the facility failed to ensure a resident was treated with respect and dignity for 1 of 4 residents reviewed. (Resident B) Findings include: During an interview, on 06/27/25 at 11:59 P.M., Resident D indicated that Certified Nursing Assistant (CNA) 2 yelled, Shut up at Resident B multiple times while trying to give the resident a shower a few weeks ago. Resident D explained that her room was next to the shower room, so she could hear her yelling so loud that it was echoing down the hallway. The clinical record for Resident D was reviewed on 06/27/25 11:51 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 05/26/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, depression and anxiety. During an interview and observation, on 06/27/25 at 08:27 A.M., Resident B indicated that staff were always nice to her, and nobody had ever verbally abused her at the facility. She had no concerns with care. The resident appeared well groomed and happy. The clinical record for Resident B was reviewed on 06/27/25 10:07 A.M. A Quarterly MDS assessment, dated 06/04/25, indicated the resident was mildly cognitively impaired. The resident's diagnosis included, but was not limited to, non-Alzheimer's dementia. She was dependent on one physical staff member for her activities of daily living related to showers. During an interview, on 06/27/25 at 12:22 P.M., Licensed Practical Nurse (LPN) 3 indicated that CNA 2 was getting loud with Resident B and kept telling the resident to be quiet. LPN 3 told her she needed to calm down or that she would have to leave and CNA 2 calmed down. During an interview, on 06/27/25 at 11:28 A.M., the DON indicated that she had received a report the morning following the incident that CNA 2 yelled at Resident B telling her that she did not need to go to the bathroom. The yelling continued down the hallway to the shower room. Upon investigation CNA 2 was terminated. A facility document titled Notification of Employee Termination, was provided by the Director of Nursing on 06/27/25 at 12:47 P.M. It indicated CNA 2 was terminated. The current facility policy titled Dignity, with a revision date of 04/23/18, was provided by the Director of Nursing on 06/27/25 at 12:40 P.M.,. The policy 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 .Staff shall carry out activities in a manner which assists the resident to maintain and enhance his/her self-esteem and self-worth . The deficient practice was corrected, on 06/25/25, after the facility assessed residents for abuse and dignity concerns, re-educated staff on resident rights abuse and dignity, and had a system in place to monitor for resident rights. 3.1-3(t)

Based on observation, record review, and interview, the facility failed to ensure an effective pest control was in place for residents' bathrooms and bedrooms related to gnats or drain flies. This deficient practice had the potential to affect 70 of 70 residents that resided in the facility. Findings include: During an observation of Wing 2, on 03/21/25 through 03/25/25, the following concerns were observed on the following dates and times: - On 03/21/25 at 10:25 A.M., the Wing 2 Shower Room had sticky floors; a strong urine odor; the toilet base had one inch by eight-inch band of black debris around toilet base; and a one-foot-long, a two-foot-long, and a three-foot-long stripe of black/brown residue around the tile areas in the shower stall. - On 03/21/25 at 10:33 A.M., the bathroom shared by Resident rooms [ROOM NUMBERS], had a swarm of gnats flying about the room and multiple gnats on the walls. - On 03/21/25 at 10:39 A.M., the bathroom shared by Resident rooms [ROOM NUMBERS], had several gnats flying about the room. Resident D indicated they have had a problem with gnats for a while. - On 03/24/25 at 10:24 A.M., the Resident room [ROOM NUMBER], had a few gnats flying about in the residents' bedroom. - On 03/24/25 at 3:17 P.M., the bathroom shared by Resident rooms [ROOM NUMBERS], had several gnats flying about the residents' bedroom area. Resident E indicated they have had a problem with gnats in their room and bathroom for a while. - On 03/24/25 at 10:24 A.M., in the Resident room [ROOM NUMBER], had a few gnats flying about in the residents' bedroom. - On 03/24/25 at 3:17 P.M., the bathroom shared by Resident rooms [ROOM NUMBERS] had several gnats flying about the residents' bedroom. Resident E indicated they have had a problem with gnats in their room and bathroom for a while. - On 03/25/25 at 10:14 A.M., the bathroom shared by Resident rooms [ROOM NUMBERS] had several gnats flying about the room and on the walls. - On 03/25/25 at 10:23 A.M., the bathroom shared by Resident rooms [ROOM NUMBERS] had several gnats flying about the room and on the walls. - On 03/25/25 at 10:30 A.M., on the walls in the hallways of Wing 2 there were several gnats observed on the walls. During an interview, on 03/27/25 at 10:11 A.M., the Maintenance Director indicated the facility had a Pest Control provider who came into the facility every two weeks. The pest control provider did not normally go into the residents' bedrooms or bathrooms. During an interview, on 03/27/25 at 10:12 A.M., the Housekeeping Supervisor indicated they had cleaning check-off lists for each unit. Staff were to check off items after they were completed. They also had a separate check off list for deep cleaning. On a deep clean they pulled everything out of the residents' room, cleaned the walls, the privacy curtain, the bedding, pulled out the beds, cleaned the bed frame, window blinds, the trim, and the bathrooms. Rooms were deep cleaned every couple of weeks and as needed. Some were done more often. She kept the deep clean check off lists. She kept the daily check-off lists for about 2 weeks. Blank checklists were provided by the Housekeeping Supervisor. She indicated she had just thrown them away and did not have any completed checklists for any of the units. None of the checklists included cleaning the walls of the shower rooms. The Pest Control visit records for the last 3 months were provided by the Maintenance Director on 03/27/25 at 11:50 A.M. Only one record, dated 03/18/25, included a service documented as One Shot. During an interview on 03/27/25 at 2:48 P.M., when asked for the building inspections for the interior and exterior of the building, the Maintenance Director indicated he walked through the building everyday but did not document his observations. During an interview on 03/27/25 at 2:50 P.M., the facility's pest control company indicated One Shot was their internal code for just a one-time service. They had used a product in the drains that would make it less hospitable for gnats and drain flies. They came out twice a month for routine services. They applied a general application for pests in the common areas and in the kitchen for preemptive maintenance and did not treat the residents' bathrooms or bedrooms. For the product they had put in the drains, they really did not have a time frame as to when the situation may alleviate itself because of other factors. 2. During an observation on 03/27/25 at 11:11 A.M., Resident B was outside in the courtyard in his wheelchair with a group of residents that were awaiting to smoke. While propelling himself, he fell forward, with the wheelchair still attached to his back because he used a seat belt for positioning and landed face down with his forehead touching the sidewalk. Another resident turned the resident to his side as no staff were within five feet of this resident. During an interview on 03/27/25 at 1:26 P.M., CNA 8 indicated they had put in a work order for the concrete chipping. No one was with the resident when he fell . They had put the work order in about two weeks ago because they noticed it was getting worse, and all the rain had not helped. The resident had a scrape on his forehead and a little bump on the back of his head from today's fall. The Progress Notes for Resident B were provided by the DON on 03/27/25 at 3:14 P.M. A note, dated 03/27/25 at 11:00 A.M., indicated the resident had an unwitnessed fall in the courtyard smoking area. The resident's wheelchair tipped over as he was propelling it on the concrete. The resident's statement indicated, I was coming to smoke and the chair tipped over because of the concrete. The resident received a scrape to the forehead and a small bump on the top of his head. The MAINTENANCE REQUEST forms were provided by the Administrator on 03/27/25 at 1:50 P.M., and included, but was not limited to, the following: - A request, from CNA 9, dated 03/12/25, indicating the sidewalk had a big chunk out of it, and could you please look at it and see if something could be done. The current undated Housekeeping Service Policy was provided by the Corporate Clinical Nurse Consultant on 03/27/25 at 1:45 P.M. The policy indicated, .Purpose .To ensure that the facility, equipment, furnishings [sic] and resident rooms are maintained in a sanitary manner; to provide a comfortable environment, and to prevent the development and transmission of infection .maintain a clean, odor free, .orderly environment .which meet .the .residents right for a safe, clean, comfortable homelike environment . The current undated Preventative Maintenance and Inspections policy was provided by the DON on 03/27/25 at 2:40 P.M. The policy indicated, .Inspection checklists are developed for at least .The building .Exterior inspection will be conducted and documented weekly .Interior inspection will be conducted and documented weekly .Condition of flooring .Cement cracks .Each resident room will be inspected and documented monthly . The current Falls policy, with a reviewed date of 01/01/15, was provided by the DON on 03/27/25 at 2:40 P.M. The policy indicated, .Licensed nurse should conduct assessment immediately, including events leading up to the fall to determine when possible and causative factors . This citation relates to Complaints IN00455300 and IN00455916. 3.1-19(f)(4)

Based on observation and interview, the facility failed to follow appropriate guidelines related to the use of hairnets in the kitchen for 3 of 3 kitchen observations. (Dietary Manager, Cooks 4 and 5, and the Corporate Dietary Consultant) Findings include: 1. During a tour of the kitchen, on 03/20/25 at 11:01 A.M., the Dietary Manager (DM) had three inches of hair outside of her hairnet on each side and the back of her head while she was in the food preparation area. During an observation, on 03/26/25 at 11:54 A.M., the DM had three inches of hair exposed outside the hairnet while in the food preparation area. During a kitchen observation, on 03/27/25 at 11:42 A.M., [NAME] 4 had six inches of hair exposed outside her hairnet on the right side of her face, [NAME] 5 had two inches of hair exposed outside the hairnet around her face, the DM had three inches of hair exposed outside the hairnet on both sides of face and on the back of her neck, and the Corporate Dietary Consultant had three inches of bangs and two inches of hair exposed outside the hairnet on both sides of her face while in the food preparation area. During an interview, on 03/27/25 at 11:56 A.M., the DM indicated hairnets should cover all the hair. If hair cannot be contained with one hair net, two hairnets should be used. The current Hair Restraints policy, dated 2020, was provided by the Director of Nursing on 03/27/25 at 3:15 P.M. The policy indicated, .Staff shall wear hair restraints in all food production, dishwashing, and serving areas. 3.1-21(i)(3)

Based on observation and interview, the facility failed to have the State survey results available to view for 2 of 6 days during the survey. Findings include: During an observation, on 03/25/25 at 3:24 P.M., a laminated piece of paper on a corkboard outside the Administrator's office indicated the survey results were in a white binder in the living room. The living room and front entrance were observed, and no white binder or survey results were visible. During an observation, on 03/26/25 at 11:21 A.M., the living room and front entrance lacked visible survey results. During an observation, on 03/26/25 at 1:49 P.M., the living room and front entrance lacked visible survey results. During an interview, on 03/26/25 at 1:52 P.M., the Minimum Data Set (MDS) Coordinator indicated the State survey results were sitting in a pile in the Administrator's office and were not accessible for visitors to view without having to ask for them. They should be available for them to view without asking the staff. During an interview, on 03/27/25 at 10:02 A.M., the Administrator indicated the facility did not have a policy for State survey results being accessible to view, they would just follow the regulation. 3.1-3(b)(1)

Based on observation, interview, and record review, the facility failed to provide a clean and safe environment related to a dirty shower room and safe walkways for 2 of 4 facility areas reviewed. (Wing 2 and the outside courtyard) Findings include: 1. During an observation of Wing 2, on 03/21/25 through 03/25/25, the following concerns were observed on the following dates and times: - On 03/21/25 at 10:25 A.M., the Shower Room had sticky floors; a strong urine odor; the toilet base had a one inch by eight-inch band of black debris around toilet base; and a one-foot-long, a two-foot-long, and a three-foot-long stripe of black/brown residue around the tile areas in the shower stall. - On 03/21/25 at 10:33 A.M., the bathroom shared by Resident rooms [ROOM NUMBERS], had a baseball size shallow pit in the bathroom floor where tiles were missing. A resident in room [ROOM NUMBER] was observed to be independent with toileting and unsteady on his feet. - On 03/24/25 at 10:26 A.M., the Shower Room had sticky floors; the toilet base had one inch by eight-inch band of black debris around toilet base; and a one-foot-long, a two-foot-long, and a three-foot-long stripe of black/brown residue around the tile areas in the shower stall. - On 03/24/25 at 3:17 P.M., the bathroom shared by Resident rooms [ROOM NUMBERS], had a strong urine odor. - On 03/25/25 at 10:23 A.M., the bathroom shared by Resident rooms [ROOM NUMBERS], had a baseball size shallow pit in the bathroom floor where tiles were missing. - On 03/25/25 at 10:25 A.M., Resident room [ROOM NUMBER]'s bathroom door had brown stains and chunks of brown debris on the doorknob to the bathroom. During an interview, on 03/27/25 at 10:25 A.M., Licensed Practical Nurse (LPN) 7 indicated there was a resident who resided in room [ROOM NUMBER] who was able to use the bathroom without staffs' assistance. During an anonymous interview, from 03/20/25 through 03/27/25, a staff member indicated a group of volunteers had complained, while on Wing 2, the floors were filthy with food particles; spilled fluid;, and a swarm of gnats. A volunteer even started cleaning the floor because the spills were so bad. The nursing staff would not clean anything up, they left it for Housekeeping. Wing 2 was always a mess. During an interview, on 03/27/25 at 10:12 A.M., the Housekeeping Supervisor indicated they had cleaning check-off lists for each unit. Staff were to check off items after they were completed. They also had a separate check off list for deep cleaning. On a deep clean they pulled everything out of the residents' room, cleaned the walls, the privacy curtain, the bedding, pulled out the beds, cleaned the bed frame, window blinds, the trim, and the bathrooms. Rooms were deep cleaned every couple of weeks and as needed. Some were done more often. She kept the deep clean check off lists. She kept the daily check-off lists for about two weeks. Blank checklists were provided by the Housekeeping Supervisor. She indicated she did not have any completed checklists for any of the units since she had just thrown them away. None of the checklists included cleaning the walls of the shower rooms. During an interview, on 03/27/25 at 2:48 P.M., when asked for the building inspections for the interior and exterior of the building, the Maintenance Director indicated he walked through the building everyday but did not document his observations. 2. During an observation, on 03/27/25 at 11:11 A.M., Resident B was outside in the courtyard in his wheelchair with a group of residents that were awaiting to smoke. While propelling himself, he fell forward, with the wheelchair still attached to his back because he used a seat belt for positioning and landed face down with his forehead touching the sidewalk. Another resident turned the resident to his side as no staff were within five feet of this resident. During an interview, on 03/27/25 at 1:26 P.M., CNA 8 indicated they had put in a work order for the concrete chipping. No one was with the resident when he fell . They had put the work order in about two weeks ago because they noticed it was getting worse, and all the rain had not helped. The resident had a scrape on his forehead and a little bump on the back of his head from today's fall. The Progress Notes for Resident B were provided by the DON on 03/27/25 at 3:14 P.M. A note, dated 03/27/25 at 11:00 A.M., indicated the resident had an unwitnessed fall in the courtyard smoking area. The resident's wheelchair tipped over as he was propelling it on the concrete. The resident's statement indicated, I was coming to smoke and the chair tipped over because of the concrete. The resident received a scrape to the forehead and a small bump on the top of his head. The MAINTENANCE REQUEST forms were provided by the Administrator on 03/27/25 at 1:50 P.M. A request, from CNA 9, dated 03/12/25, indicating the sidewalk had a big chunk out of it, and could you please look at it and see if something could be done. The current undated Housekeeping Service Policy was provided by the Corporate Clinical Nurse Consultant on 03/27/25 at 1:45 P.M. The policy indicated, .Purpose .To ensure that the facility, equipment, furnishings [sic] and resident rooms are maintained in a sanitary manner; to provide a comfortable environment, and to prevent the development and transmission of infection .maintain a clean, odor free, .orderly environment .which meet .the .residents right for a safe, clean, comfortable homelike environment . The current undated Preventative Maintenance and Inspections policy was provided by the DON on 03/27/25 at 2:40 P.M. The policy indicated, .Inspection checklists are developed for at least .The building .Exterior inspection will be conducted and documented weekly .Interior inspection will be conducted and documented weekly .Condition of flooring .Cement cracks .Each resident room will be inspected and documented monthly . The current Falls policy, with a reviewed date of 01/01/15, was provided by the DON on 03/27/25 at 2:40 P.M. The policy indicated, .Licensed nurse should conduct assessment immediately, including events leading up to the fall to determine when possible and causative factors . This citation relates to Complaints IN00455300 and IN00455916. 3.1-19(a)(4) 3.1-19(f)(5)

Based on observation and interview, the facility failed to store medications appropriately for 1 of 2 medication storage rooms (Wing 2 Medication Storage Room) and 3 of 4 medication carts observed (Wing 2 Medication Cart and Wing 3 Medication Carts). Findings include: During an observation, on 03/21/25 at 10:16 A.M., the Wing 2 Medication Storage Room had three unopened bags of g-tube feeding formula that were not in a box that were sitting on the bare floor and six unopened boxes sitting on the bare floor. The Director of Nursing (DON) indicated the boxes were supplies. During an observation, on 03/21/25 at 10:19 A.M., a Wing 2 Medication Cart contained a loose round tan pill inside a drawer. Licensed Practical Nurse (LPN) 7 removed the pill and disposed of it at that time. During an observation and interview, on 03/21/25 at 10:43 A.M., a Wing 3 Medication Cart contained the following loose pills inside the drawers: - a white round pill, LPN 10 indicated it was a Tylenol, - an oval pill, LPN 10 indicated was a coenzyme, - a small white pill, LPN 10 indicated was risperidone, and - a small yellow/tan colored pill, LPN indicated was baclofen. LPN 10 removed all the loose pills from the cart and placed them in a medication cup. During an observation and interview, on 03/21/25 at 10:48 A.M., a Wing 3 Medication Cart contained a loose white round pill, lots of small papers, and what appeared to powdered pill substances in all the corners of the drawers, LPN 3 indicated the loose pill was a trazodone, the nurses were responsible for cleaning out the medication carts, that cart was pretty dirty. She would clean it out that day. The current, undated, facility policy titled, Medication Storage was provided by the Administrator on 03/27/25 at 10:02 A.M. The policy indicated, .Medications and biologicals are stored safely, securely, and properly, following the manufacturer's recommendations or those of the supplier .Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures and humidity . 3.1-25(o)

Based on record review and interview, the facility failed to administer prescribed medications related to insulin administration for 1 of 19 residents reviewed for Quality of Care. (Resident 12) Findings include: The clinical record for Resident 12 was reviewed on 03/27/25 at 10:45 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 02/07/25, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, diabetes, hypertension, dementia, and paranoid schizophrenia. The January 2025 Electronic Medication Administration Record/Electronic Treatment Administration Record (EMAR/ETAR) was provided by the Director of Nursing (DON) on 03/27/25 at 11:37 A.M. The physician's order, with a start date of 11/13/24 and a discontinued date of 01/14/25, indicated the resident was to receive Humalog (insulin) 12 units, to be administered after meals. The January 2025 Electronic Medication Administration Record/Electronic Treatment Administration Record (EMAR/ETAR) for Resident 12 indicated the resident's Humalog was scheduled for 9:00 A.M., 1:00 P.M., and 7:00 P.M. The record lacked documentation (was left blank) the resident received the prescribed insulin on the following dates and times: January 3, at 7:00 P.M., January 4, at 7:00 P.M., and January 5, at 7:00 P.M. The resident's Blood Glucose Fingerstick Monitoring record was reviewed and indication the following: on January 3, at 7:00 P.M., the resident blood sugar value was 390; on January 4, at 7:00 P.M., the resident's blood sugar value was 143; and on January 5, at 7:00 P.M., the resident's blood sugar value was 280. The Progress Notes for January 2025 were provided by the DON on 03/27/25 at 11:37 A.M. The record lacked documentation as to why the medication was not given. The current Diabetes Care Plan, with an initiated date of 08/27/24, indicated the staff were to administer the resident's diabetes medication as ordered by the doctor. During an interview, on 03/26/25 at 1:33 P.M., RN 6 indicated if a resident refused a medication or procedure, staff were to mark it as refused on the EMAR/ETAR and they also documented in the Progress Notes. The EMAR ETAR should not have blanks on it. The current, undated, facility policy titled, Medication Administration General Guidelines, was provided by the MDS Coordinator on 03/27/25 at 1:15 P.M. The policy indicated, .Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so .If a dose of regularly scheduled medications is withheld, refused, not available, or given at a time other than the scheduled time .An explanatory note is entered .If 3 consecutive doses of a vital medication are withheld, refused, or not available the physician is notified. Nursing documents the notification and physician response . 3.1-37(a)

Based on interview and record review, the facility failed to ensure resident to resident abuse did not occur related to sexual abuse resulting in a severely cognitive resident and a cognitive resident found in an unsupervised sexual situation for 2 of 5 residents reviewed for abuse. (Resident C and Resident D) The immediate jeopardy began on 8/24/23, when the facility failed to prevent resident to resident sexual abuse when a cognitively alert male resident was found with a severely cognitively impaired female resident in an inappropriate sexual position. The DON, ADON, MDSC, and the consultant were notified of the immediate jeopardy on 9/22/23 at 2:55 p.m. The Immediate Jeopardy was removed on 9/27/23, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. The clinical record for Resident C was reviewed on 9/21/23 at 12:57 p.m. A Quarterly MDS (Minimum Data Set) assessment, dated 7/3/23, indicated the resident was severely cognitively impaired and required supervision for locomotion (walking from one location to another). Her diagnoses included, but were not limited to: Huntington's disease, chorea (neurological disorder), psychosis, bipolar disorder, schizophrenia, violent behavior, and dementia. A review of the EMAR (Electronic Medical Record) on 9/22/23 at 2:19 p.m., lacked a consent from the POA (Power of Attorney) for the resident to have any sexual activities. The Care Plan, dated 2/5/22, indicated the resident had the potential for resident-to-resident abuse related to Huntington's disease, impulsiveness, psychosis, bipolar disorder, schizophrenia, dementia, and wandering into other residents' room. The interventions were to follow up with the social service director or designee or psychiatric services. Staff were to investigate the actual or suspected resident to resident abuse per the facility policy. They were to monitor residents involved in an actual or suspected resident to resident abuse per the facility policy. Staff were to notify the administrator, director of nursing, the physician, the POA, or Guardian immediately upon actual or suspected resident-to-resident abuse and they were to separate the residents involved in resident-to-resident abuse as soon as resident-to-resident abuse was reported or witnessed. A Behavior Note, dated 7/20/23, indicated Resident C had a behavior of going into the hallway naked. The reason for the behavior was marked unknown. A Progress Note, dated 8/24/23 at 5:50 p.m., indicated a CNA (Certified Nurse Aide) reported that a resident went into the central bathroom to use the toilet. After the resident had her pants pulled down, a male resident entered the bathroom and pulled the curtain behind him and pulled down his pants and turned to face the female resident. The CNAs went into the bathroom to clean up the area and wash their hands when they noticed two sets of feet behind the curtain. The female's skin was checked immediately; and no issues were noted. The residents were separated, and SSD (Social Service Director) was called to speak to the male resident. The physician was notified of the incident. The staff called the resident's POA and left a voicemail to return a call. A Progress Note, dated 9/7/23 at 3:48 p.m., indicated the resident was pulling her hair out and scratching her face excessively. She recently had visitors and the behaviors began following the recent visit. During an observation on 9/27/23 at 4:09 p.m., Resident C was standing by the common bathroom door. There were no staff visible from where the resident was standing. At 4:11 p.m., the nurse walked from behind the medication cart and was on the phone. She would have been able to see the resident if she looked to her right. 2. The clinical record for Resident D was reviewed on 9/21/23 at 11:21 a.m. A Quarterly MDS (minimum data set) assessment, dated 8/29/23, indicated the resident was cognitively intact and required supervision for locomotion. His diagnoses included but were not limited to, Huntington's, mood affective disorder, anxiety, and attention deficit hyperactivity disorder. The Behavior Management Record for Resident D from June, July, August, and September indicated the following: - On July 5, 6, 20, 27, 29, August 3, 5, 6, 9, and 11, 2023, the resident was using vulgar/explicit language around or towards another resident. - On August 3, 2023, the resident knowingly entered the bathroom shower room with a half-naked female resident. - On August 11, 2023, the resident indicated he was in a relationship with a certain staff member. - On August 15 and 16, 2023, the resident knowingly went into the bathroom with a female resident exposed. - On August 26, 2023, the resident was following residents. - On August 27, 2023, the resident was sleeping in another resident's bed. The Behavior Note, dated 8/11/23 at 7:27 p.m., indicated Resident D was making fun of other residents and indicated he was dating another female. The Behavior Note, dated 8/12/23 at 11:30 a.m., indicated the writer was on the unit taking an item to another resident. On their way to the door to go back to Wing 1, Resident D stopped her and stated, Hey .wait! I have a girlfriend. He then proceeded to say, it was a staff member from activities. She loves me, and she kissed me. The writer explained to resident that this was serious and inappropriate. He then said, Oh hey! I was just kidding. Can't you take a joke? She is not my girlfriend, and she did not kiss me. I was just kidding. Nurse on call notified of resident's statement. The Behavior Note, dated 8/12/23 at 1:00 p.m., indicated after lunch service this writer spoke with Resident D regarding the incident earlier in the shift when he told another staff member that he had been kissed by another staff member even though he insisted that he was only joking when I said that. This writer explained that it was inappropriate to make untrue statements about staff members. That false accusations and statements made against other residents or staff are not just joking around. The comments are inappropriate and will not be tolerated. His privileges to attend activities with only one staff member present will not occur to protect staff from false accusations. He verbalized understanding. He apologized for making up untrue statements about other residents and staff members. This conversation with the resident was witnessed by two other staff members. The SSD Note, dated 8/14/23 at 1:30 p.m., indicated the SSD spoke with the resident regarding the behaviors he had been exhibiting. SSD spoke with resident regarding the seriousness of false accusations and reminded him that unless something was true, he should not say it even in a joking manner. A Progress Note, dated 8/24/23 at 6:04 p.m., indicated the resident followed a female resident into the central bathroom and pulled the curtain behind himself and the female resident. He pulled his pants down and turned to face the female resident. The two CNAs (Certified Nurse Aide) went into the bathroom to clean and wash their hands when they noticed two sets of feet behind the curtain. When they opened the curtain both residents had their pants pulled down. The staff immediately separated the male and female resident and did a skin check. There were no issues observed. The MD and POA were notified. The resident was put on 15-minute checks until further notice. A Progress Note, dated 8/24/23 at 4:18 p.m., indicated the SSD spoke with the resident regarding inappropriate sexual behavior towards another resident. The resident stated that he knew what he had done was wrong. The SSD told the resident that he was not to be in the bathroom with any other resident at any time. The resident stated he understood. A Progress Note, dated 9/12/23 at 4:27 p.m., indicated the resident continued on 15-minute checks The resident stated numerous times that he watched porn all the time. A Progress Note, dated 9/13/23 at 10:52 a.m., indicated the resident was seen by staff being sexually inappropriate toward another staff member. The Care Plan, dated 6/5/23, indicated the resident had exhibited sexually inappropriate behaviors of inappropriate comments to staff, about staff, and other residents. The interventions were for staff to encourage the resident to express his feelings. Staff were to explain to the resident that behavior was not appropriate. They were to let the resident know what kind of behavior was expected and what will be tolerated. The staff were to notify the MD as needed. Staff were to talk to the resident about the feelings and rights of others and about who are exposed to his acting out. The Care plan, dated 6/7/23, indicated the resident exhibited sexually inappropriate behavior. The interventions indicated staff were to administer the resident's medications as ordered. Staff were to document all behaviors and reassure the resident it was okay to talk of feelings or thoughts. He was educated that inappropriate behaviors were not acceptable. The staff were to report any sexual inappropriate behavior immediately per facility policy. Review of the resident's EMAR on 9/22/23 at 2:19 p.m., indicated the resident lacked a care plan or updated care plan related to the resident's sexual encounter on 8/24/23. During an interview on 9/21/23 at 10:10 a.m., the ADON (Assistant Director of Nursing) indicated there was a reportable on Resident D and Resident C. Two CNAs went into the central bathroom to wash their hands. The CNAs walked into the bathroom/shower room and turned to their right, to the sink. There was a mirror above the sink and the mirror showed a reflection of the toilet stall across from the sink. The bathroom stall had a curtain pulled and the CNAs saw a set of feet and a pair of pants on the floor under the curtain. They noticed a second pair of feet and the CNA opened the curtain. Resident D had his pants down with no brief or underwear on. He was standing with his feet slightly apart and facing Resident C. The staff members separated the residents and reported the incident. The ADON assessed both residents and Resident D was interviewed. When he was asked what he intended to do, he said he did not know, because he got caught. Resident C did not talk much in context, and she did not interview Resident C, but she did not seem distressed. Resident D resided on the end of the hallway where it was all men. During an interview on 9/21/23 10:22 a.m., CNA 2 indicated when she and CNA 3 went into the central bathroom to wash their hands, they turned around and the curtain was pulled in front of the toilet stall. She noticed Resident C's pants down and asked if she needed help. The resident did not speak, but she then noticed a second pair of feet. Resident C was standing with her back to the curtain and Resident D was standing in front of the toilet. Resident C's pants were down, and she still had a brief in place. Resident D's pants and underwear were down, and he was sexually fully aroused. When Resident D was asked what he was doing, he said he did not know because he got caught. The residents were immediately separated, and the incident was reported to the nurse. During an interview on 9/25/23 at 9:33 a.m., CNA 3 indicated when she and CNA 2 went into the central bathroom to wash their hands, CNA 2 noticed Resident C's feet behind the curtain, she did not usually pull the curtain when she went into the bathroom stall, but the curtain was pulled. CNA 2 asked her if she needed help and stuck her head in the curtain and there stood Resident D. He had his pants to his ankles, hands on his hip, leaned back, and had a fully aroused p**is. Resident C had her pants to her ankles, but still had her brief on. We immediately separated them and reported it. Over half of the Wing 2 residents required feeding assistance, and if they have someone with behaviors, then they would have to stop feeding to deal with the behaviors. There needs to be activities on the unit. They do not usually have any real activities over there. During an interview on 9/25/23 at 10:19 a.m., The Regional Consultant indicated the facility did not have a working camera system in the building. The cameras were not hooked up to anything. The prior owner took the system boxes when the new company bought the building prior to this incident. During an interview on 9/25/23 at 10:23 a.m., CNA 2 indicated she was not sure of the actual time they found Resident D and Resident C in the bathroom. She was not sure of the last time they were seen on Wing 2 before they found them together in the bathroom. LPN (Licensed Practical Nurse) 4 was working on Wing 2 and had a meeting. The ADON was covering on the wing for the LPN and had left the floor when we found the two residents together (Resident D and Resident C). She had immediately tried to notify administration, and the BOM (Business Office Manager) called wanting to find out what was needed, and we told her we had a situation. After a couple of minutes, the ADON returned, and we notified her. During an interview 9/25/23 at 10:32 a.m., LPN 4 indicated she had a meeting with the Corporate Staff 5 to talk about the unit. Staff on the Huntington's unit were just stretched, too, thin. She had been reporting to corporate for months about the need for more help. The incident with Resident D and Resident C had to occur around 4:00 p.m. She did not recall seeing either resident out in the hallway, but it would have not been unusual to not see them. When the two CNAs would take the residents out to smoke. two staff for safety reasons, that would normally leave one staff on the unit to monitor all the residents during the smoke break. The only activities normally on the unit were papers dropped off for the residents to color or cross word puzzles. During an interview on 9/24/23 at 8:15 a.m., CNA 6 indicated she was the only CNA working on Wing 2 with the nurse since 8:00 a.m. This was her first time working on the unit. She indicated there was no way she could care, monitor, and feed all the residents with just her and the one nurse. During an interview on 9/24/23 at 8:20 a.m., RN 7 indicated yesterday from 4:00 p.m. till 5:00 p.m., she was the only staff member working on Wing 2. Resident D was walking out into the hallway multiple times, and she could not get him to stay in his room. During a confidential interview between 9/21/23 and 9/25/23, a staff member indicated there were multiple residents who required assistance with eating. Working with 4 staff for 28 resident was very rough. The weekends were the worst. When staff were feeding a resident and had to stop to monitor another resident or assist another resident, the resident they were assisting to eat would get very upset. During a confidential group interview between 9/21/23 and 9/25/23, three staff members indicated there was not enough staff to meet the residents' needs on Wing 2. There were multiple residents that required feeding assistance and had behaviors. The Huntington's unit (Wing 2), did not have consistent activities or appropriate activities for the age range of residents. When a resident was on 15-minute checks, they tried to keep them in a common area, but this did not work. The weekend shifts are the worst. If there were more staff and better activities it would be possible to mitigate some of the aggressive behaviors. Cross Reference F740. On 9/21/23 at 9:55 a.m., the Regional Consultant provided a current copy of the policy titled Abuse and Neglect, and a revision date of 8/1/23. It included, but was not limited to, Policy .Each resident has the right to be free from abuse . The current facility policy titled Behavior Management with a revised date of December 2015, was provided by the Administrator on 09/27/23. The policy indicated, .All Licensed Nurses, CMT/QMAs, and C.N.A.s are responsible for documentation on the Behavior Monitoring Form and identifying interventions initiated to redirect behaviors . The Immediate Jeopardy that began on 8/24/23, was removed on 9/27/23, when the facility conducted the following: All residents' cognitive ability to consent to sexual activity was reviewed. The residents' care plan will be updated to reflect the determination. All facility staff were in-serviced on the Facility abuse policy with a focus on the residents' mental capacity related to sexual interactions and abuse prevention with Huntington/behaviors, Huntington disease education and understanding, and sexual abuse. The Social Service Director was in-serviced on reviewing behavior logs daily at morning meetings. The Immediate Jeopardy was removed on 9/27/23, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy because the Administrator or Designee will audit to ensure the appropriate care plans and or action was taken for ability to consent to sexual activity and will do walking round on the unit daily, varying shifts, to observe and verify adequate supervision being provided. This Federal tag relates to Complaint IN00417850 3.1-27(a)(1)

Based on interview and record review, the facility failed to identify, monitor, and provide needed care and services to prevent dehydration, weight loss, and physician notification resulting in hospitalization for 1 of 9 residents reviewed for Quality of Care. (Resident B). Findings include: The clinical record for Resident B was reviewed on [DATE] at 3:18 p.m. The resident's diagnoses included, but were not limited to, dementia with behavior, edema, and hypertension. A Physician's Order, dated [DATE], indicated the resident was prescribed Lasix 40 mg (milligrams) twice daily. The Admission MDS (Minimum Data Set) assessment, dated [DATE], indicated the resident was severely cognitively impaired. She required one staff member's supervision for mobility and transfer, and a one staff member's extensive assistance for ADLs (Activities of Daily Living). She was occasionally incontinent of bladder and always continent of bowel. The Discharge MDS assessment, dated [DATE], indicated the resident required extensive assistance of one staff member for mobility, transfer, and ADLs. She was always incontinent of bladder and bowel. A Physician's Order, dated [DATE], indicated the resident was prescribed Remeron 7.5 mg at bedtime for weight loss/appetite stimulation. A Physician's Order, dated [DATE], indicated Resident B was to have 800 ml (milliliter) to 1000 ml of fluids every day and evening shift for hydration monitoring. Staff were to observe the resident for signs or symptoms of decreased fluid intake, and to notify the physician and Registered Dietitian (RD) if deceased fluid intake was observed. The resident was to have a total of 1600 ml to 2000 ml per day. On [DATE] 12:12 p.m. MDS Nurse provided the December Fluids Report for Resident B. The report indicated the resident received a total of fluid intake on the following days: On [DATE], the resident received 600 ml of fluids. On [DATE], the resident received 480 ml of fluids. On [DATE], the resident received 1080 ml of fluids. On [DATE], the resident received 480 ml of fluids. On [DATE], the resident received 740 ml of fluids. On [DATE], the resident received 960 ml of fluids. On [DATE], the resident received 900 ml of fluids. The MARs (Medication Administration Records), dated [DATE], indicated the resident received Lasix 40 mg twice a day every day from [DATE] through [DATE]. The January Fluids Report for Resident B indicated the resident received a total of fluid intake on the following days: On [DATE], the resident received 720 ml of fluids. On [DATE], the resident received 720 ml of fluids. On [DATE], the resident received 720 ml of fluids. On [DATE], the resident received 480 ml of fluids. On [DATE], the resident received 960 ml of fluids. On [DATE], the resident received 840 ml of fluids. On [DATE], the resident received 480 ml of flluids. On [DATE] and [DATE], the resident received 840 ml of fluids. On [DATE] and [DATE], the resident received 480 ml of fluids. On [DATE], the resident received 180 ml of fluids. On [DATE], the resident received 0.0 ml of fluids. The MARs, dated [DATE], indicated the resident received Lasix 40 mg twice a day every day from [DATE] through [DATE] and one dose on [DATE]. On [DATE] at 1:50 p.m. the DON provided a Weights and Vitals Summary for Resident B. The resident's weight was as followed: On [DATE], the resident weighed 154 pounds. On [DATE], the resident weighed 143 pounds. On [DATE], the resident weighed 138 pounds. On [DATE], the resident weighed 131 pounds. A Progress Note, dated [DATE] at 10:09 a.m., indicated the resident's UA (urinalysis) and CXR (x-ray) results were received. The UA showed no growth in 48 hours. The CXR showed no acute cardiopulmonary disease seen. The physician was notified of results. A Care Plan, dated [DATE], indicated the resident had an alteration in neurological status related to dementia. The interventions included, but were not limited to: Give medications as ordered. Monitor/document for side effects and effectiveness. Monitor intake to assure an adequate fluid intake to prevent dehydration. Monitor/document/report to physician as needed signs/symptoms, or any changes in level of consciousness. A Care Plan, dated [DATE], indicated the resident had an ADL Self Care Performance Deficit related to confusion and dementia. The interventions included, but were not limited to; monitor/document/report to physician as needed any changes or declines in function. A Care Plan, dated [DATE], indicated the resident was anticipated to have weight loss related to dementia, edema, refusing meals, snacks, and fluids. The intervention included, but were not limited to, house supplement with meals, Remeron 7.5 mg at bedtime. Staff were to monitor and record food intake at each meal. A Care Plan, dated [DATE], indicated the resident has nutritional problem or potential nutritional problem related to Dementia. The interventions included, but were not limited to: Provide and serve diet as ordered. Provide and serve supplements as ordered. Staff were to monitor the resident's intake and record every meal. The Registered Dietitian (RD) was to evaluate and make diet change recommendations as needed. A Progress Note, dated [DATE] at 8:34 p.m., indicated the resident had not been eating her meals and she looked lethargic. The resident's vital signs were as followed: Blood Pressure (BP) ,d+[DATE], Pulse (P) 80, Temperature 97.8, Respirations 15, and Oxygen Saturation 95% (percent). She took her five o'clock medications but would not take her seven o'clock medications. When the nurse said her name, she had opened her eyes and nodded her head. When she was asked if she was okay. She closed her eyes and went back to sleep. Staff will continue to monitor. A Progress Note, dated [DATE] at 3:21 p.m., indicated the physician was notified the resident was lethargic, and not eating or taking fluids well. The physician ordered for lab work and urinalysis received and noted. On [DATE] at 3:04 p.m., a Lab Report for Resident B was provided by the DON. The report, dated [DATE], indicated the resident's blood sugar level (Glucose) was high at 196; BUN (blood urea nitrogen) was high at 33 (an elevated BUN can be due to dehydration, urinary tract obstruction, or congestive heart failure); and Creatinine was high at 1.39. The resident did not have a history of high blood sugar levels. A Progress Note, dated [DATE] at 9:21 a.m., indicated the resident's weight was down 5.0 pounds in one week. Resident refusing meals and snacks. Resident refused 21 Meals in 28 Days. A Progress Note, dated [DATE] at 11:19 a.m. indicate, The resident's sill refused some meals but not as bad as it had been. Will continue weekly weights and to follow weekly. A Progress Note, dated [DATE] at 1:27 p.m., indicated the nurse was called to the unit to assist with Resident B. The resident was noted to be in bed with a 102.4 fever, her heart rate was thready with a pulse between ,d+[DATE], her respirations were 43 and fast pace, her blood pressure was ,d+[DATE], her oxygen saturation was 67 % on room air. Oxygen was applied, and her saturation remained low at 72 % on 2 liter. The physician was called, and new orders were received to send to the emergency room . An emergency room Report, dated [DATE], indicated the resident was admitted with urosepsis and severe dehydration. A hospital Death Summary, dated [DATE], indicated the resident was admitted on [DATE] secondary to urinary tract infection, septic shock requiring pressor support, acute renal failure, acute respiratory failure, and pneumonia. The patient worsened on [DATE]. Became unresponsive on [DATE]. The patient passed on [DATE]. During an interview on [DATE] at 10:51 a.m., LPN (Licensed Practical Nurse) 2 indicated if a resident was declining, she would call the POA, talk with the DON, and the physician. She would attempt to get the resident to eat and drink; she would provide oral care. To monitor for dehydration, she would look for signs and symptoms such as: dry mouth, tenting skin, dry lips and eyes, and dark urine. During an interview on [DATE] at 12:58 p.m., LPN 6 indicated if a resident refused to drink fluids she would offer an alternative liquid, monitor vitals, assess by look for signs and symptoms of dehydration. If they continued to refuse fluids, she would continue to monitor, and she would contact the physician. During an interview on [DATE] at 1:07 p.m., LPN 7 indicated if a resident was refusing to drink, she would encourage them to drink, and then notify the Administrator, DON, and physician. During an interview on [DATE] at 1:50 p.m., the DON indicated she could not locate any other vitals for Resident B of her blood pressure or pulse from [DATE] to [DATE] (except for the progress note, dated [DATE]). At 2:55 p.m., the DON indicated Resident B's hydration report was her total intake to include all fluids from meals, medication pass, and through out the day. During an interview on [DATE] at 3:01 p.m., the Registered Dietitian indicated if a resident did not have an order for fluid restriction, did not have an order for fluid intake, and was not care planned for fluids the general rule would be to take the resident's weight divide by 2.2 and then multiply by 30 ml and that would tell you the amount of fluids they should consume per day. The current facility policy titled Weight/Hydration Management and dated [DATE], was provided by the Interim Administrator on [DATE] at 1:04 p.m. The Policy indicated, .Resident's nutritional status will be monitored on a regular basis .Nutritional status, including weight, is influenced by calories, protein, and fluid .Clarification .Parameters of nutritional status: Refers to factors (e.g., weight, food/fluid intake, and pertinent laboratory values) that reflect the resident's nutritional status .Sufficient fluid: the amount of fluid needed to prevent dehydration . A general guideline for determining baseline daily fluids needs is to multiply the resident's body in kg (kilograms) times 30 ml (2.2 lbs = 1 kg) . The current facility policy titled Notification of Change and dated ,d+[DATE], was provided by the DON on [DATE] at 4:55 p.m. The Policy indicated, .Purpose: to keep .physician aware of changes which directly affect the care and welfare of the resident .Policy: Facility personnel shall immediately .consult with resident's physician; . a significant change in the resident's physical .status, (i.e., a deterioration in health .life threatening condition) . This Federal tag relates to Complaints IN00391313. 3XXX,d+[DATE]

Based on observation, interview, and record review, the facility failed to ensure preventative interventions (transporting residents in a facility vehicle and following the appropriate user instructions for the facility's latching/seat belt device system) were in place for 1 of 3 residents reviewed for accidents (Resident B) Resident B fell from a chair during transport and sustained fractures. The Immediate Jeopardy began on (MONTH) 7, 2020, when the facility failed to ensure facility staff transported a resident on the facility bus in a secured manner. The resident was transported in the facility bus on a motorized scooter that was not secured. This resulted in the resident falling out of the scooter during transport and she received tibia and fibula fractures. The Health Facility Administrator was notified of the Immediate Jeopardy on 1/14/20 at 5:48 p.m. Findings include: During an interview on 1/13/20 at 10:38 a.m., CNA (Certified Nursing Aide) 2/Bus Driver indicated she was returning with Resident B to the facility from a doctors' appointment. When she left she had not strapped the resident's electric scooter down, because she was not sure how to secure the chair. The CNA did not place the facility bus seat belt on the resident nor was the resident wearing her scooter seat belt. As she approached an intersection the traffic light turned yellow and a car made a right hand turn in front of her and she had to put on the brakes to avoid a collision. The resident slid out of the scooter and on to the floor. I drove to the facility and the nurses came out to assess the resident who was on the floor. The resident was admitted to the hospital with [REDACTED]. During an observation of the facility bus on 1/13/20 at 10:50 a.m., with CNA 2 and the Maintenance Supervisor, the bus apparatus for latching observed was a four point lock down system. CNA 2 indicated the proper procedure for securing a wheelchair to the bus floor was securing all four points of the frame by the wheels. Residents were to be secured prior to transport with a safety belt from the back of the bus. She had not secured Resident B's scooter to the bus because she did not know how and the resident was not wearing the bus seat belt nor the scooter seat belt. The clinical record reviewed for Resident B was completed on 1/13/20 at 10:30 a.m. The resident's [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) assessment, dated 12/30/19, indicated the resident was moderately cognitively impaired. A progress note, dated 1/7/20 at 2:00 p.m., indicated LPN (Licensed Practical Nurse) 3 received a phone call from CNA 2 at 1:17 p.m., stating that while returning to the facility, she had to hit the brakes hard and Resident B fell out of her chair and was laying on the floor in the van. LPN 3 and RN 4 went out to the van and found Resident B laying on the floor. The resident was complaining of pain in her left leg. Nurse 3 obtained vital signs and EMS (Emergency Medical Services) was called to come and transport the resident to the hospital. An Accident and Incident Report, dated 1/7/20 at 1:45 p.m., was provided by the Administrator on 1/13/20 at 10:50 a.m. The report indicated the driver of the bus hit the brakes to avoid a collision and the resident fell forward out of the electric scooter landing on the floor on her side, then rolled over to her back on the floor. The resident complained of a lot of pain in her left foot. The potential cause of the resident's fall was related to the resident not being properly secured. A Medical Imaging Report, dated 1/7/20 at 3:45 p.m., was provided by the Administrator on 1/13/20 at 10:50 a.m., indicated 3 views of the left ankle revealed comminuted mildly displaced fracture distal tibia with butterfly fragment, fracture was angulated anteriorly, and a displaced oblique fracture distal fibula as well as angulated laterally. On 1/14/20 at 4:20 p.m., the Social Services Director provided a copy of the Nursing Home to Hospital Transfer Form which indicated the Reason for Transfer was Resident B fell out of her power chair in the facility van. The Administrator provided a current copy of the Owner's Manual on 1/14/20 at 11:57 a.m., which indicated Motor Vehicle Transport Pride recommends that you do not remain seated in your power chair while traveling in a motor vehicle. Positioning Belts: WARNING! If you require a positioning belt to safely operate your power chair, make sure it is fastened securely in order to reduce the possibility of a fall from the power chair. WARNING! The positioning belt is not designed for use as a seat belt in a motor vehicle. Nor is your power chair suitable for use as a seat in any vehicle. Anyone traveling in a vehicle should be properly belted into seats approved by the vehicle manufacturer. On 1/14/20 at 2:15 p.m. the Administrator provided a copy of the Transportation Aide Job Description, dated 1/8/20 and signed by CNA 2. The Job Description .Reasoning Ability: ability to apply common sense understanding to carry out instructions furnished in written, oral or diagram form .Essential Functions and Responsibilities: .Aware of safety procedures related to transporting of residents . On 1/14/20 at 2:15 p.m. the Administrator provided a copy of the Employee Corrective Action dated 1/13/20. The reason for the warning: did not ensure that during transport resident was buckled before driving. Employee was suspended for four days and will report to his/her supervisor to resume duties on 1/13/20. On 1/14/20 at 4:02 p.m., CNA 2 indicated she did not know there were some wheelchairs not suitable for resident transport on the facility bus. She did know there was one wheelchair that was too large to fit on the bus. During an interview on 1/14/20 at 5:05 p.m., the Administrator indicated she was unaware there were certain wheelchairs that were not safe to use for resident transport on the bus. The facility bus Owner's Manuel indicated, .Be Responsible for Safe Transportation .Our goal is to help you as a driver and owner achieve the highest practical level of safety not only for your passengers but also for the people around and near the vehicle .It is the Owner's/Driver's responsibility to use the bus for its intended design purpose. It is also the owner's/ driver's responsibility to observe and comply with the proper operating practices and safety regulations that are in the supplied manuals as well as comply with local, state and federal laws .It is the Driver's responsibility to understand the operation of the complete bus. Failure to follow the proper procedures could affect the performance on the bus and/or affect the safety of the passengers. It is important that you familiarize yourself with all[NAME]River Bus body features along with the chassis and other components. The immediate jeopardy that began on 1/7/20 was removed on 1/16/19, when the facility re-educated on proper safety checks to ensure residents are strapped safely in the vehicle, on transporting residents in manufactured approved chairs for transport (including Broda chairs), required to complete Transportation Job description as well as orientation checklist prior to employee being eligible to transport residents, ensure that if a wheelchair is being used, to follow the manufacturer guidelines prior to transporting, will have two designated wheelchairs approved for transport that must stay on the bus for transportation (two different sizes), any resident unable to meet the requirements for transport will be transported by EMS or other approved means, and Administrator and/or Designee will be responsible to sign off on all Orientation check lists prior to any employee transporting residents. But, noncompliance remained at a lower scope and severity of actual harm that is not immediate jeopardy because the facility needed to continue to monitor residents during transportation for safe procedures and ensure facility staff are receiving continued education on safe transportation procedures. This Federal tag related to Complaint IN 668 3.1-45(a)(2)

Based on record review and interview, the facility failed to provide adequate supervision to prevent the elopement of a cognitively impaired resident, with a recent history of exit seeking behaviors, whose whereabouts were unknown until the resident was observed by a staff member that was off facility property for 1 of 3 residents reviewed for accidents/supervision (Resident 43). The facility also failed to accurately and completely investigate falls and obtain neurological assessments of residents following falls for 2 of 3 residents reviewed for accident/hazards (Residents 36, 60) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 12/07/19, when the facility failed to adequately supervise a cognitively impaired resident with a recent history of exit seeking behaviors. This deficient practice resulted in the resident's elopement from the facility, and his whereabouts were unknown until he was spotted off campus by facility staff. The Administrator was notified of the Immediate Jeopardy on 12/10/19 at 05:20 P.M. Findings include: 1. An Incident Note, dated 11/24/2019 at 10:34 [NAME]M., indicated the resident was seen by the Activities Director to exit the building at the end of the hall, directly behind a visitor who had exited. Staff immediately went outside, and the resident walked quickly to the right of building and was by the edge of the parking lot by the road. Staff called the resident's name, and he did stop walking. He was easily redirected to come back inside. He stated he just wanted to go on a walk. Staff explained that exiting the building without letting staff know, especially going toward the highway was not safe. A Health Status Note, dated 11/27/2019 at 6:50 P.M., indicated the resident had been ambulating around the unit to the dining room that day. There were no issues with exit seeking today. The 15 minute checks continued with resident cooperation. A Health Status Note, dated 12/02/2019 at 7:03 P.M., indicated the resident had been ambulating around the facility with a wide but steady gait. The resident remained on monitoring for a possible elopement risk. The resident stated he did not want to run away from facility, but was just trying to take walk. A Health Status Note, dated 12/05/2019 at 6:37 P.M., indicated the resident had no exit seeking behaviors noted on that shift. A Health Status Note, dated 12/07/2019 at 2:09 [NAME]M., indicated the resident had no exit seeking episodes on that shift. 15 minute checks continued. Staff would continue to monitor the resident. A Health Status Note, dated 12/07/2019 at 10:30 [NAME]M., indicated the DON (Director of Nursing) had been notified by staff that the resident had left building. The physician and Administrator had been notified of the resident leaving without signing out. Upon the DON's arrival to facility, the resident was in his room. He stated he was going to see his family member and did not sign out. The resident's family member was notified of resident wanting to visit him, and he stated he was not home at this time. The resident was informed that his family member was not home. The resident expressed his wishes to leave the facility to live with family. The facility would continue to reach out to family to assist with placement per the resident's request. An Incident Note, dated 12/07/2019 at 10:37 [NAME]M., indicated the resident seen by staff approximately half a mile from facility walking along the road. The staff member called the facility, and immediately 2 staff members left the faciity on foot to speak with resident. The resident willingly came back to facility via a staff member's vehicle. The resident stated he went out the front door after pushing several buttons. In fact, the front door was not locked. Staff immediately began monitoring the resident 1 on 1 and the DON was notified of the incident. During an interview on 12/10/19 at 2:36 P.M., the DON and Administrator indicated on 12/07/19, the resident had wanted to go and see his family member. The family hadn't come to the facility to get him, so he decided to walk. The resident was found walking on a State highway towards a neighboring city, near a stop sign. CNA (Certified Nurse Aide) 2 was on her lunch break and called the facility and told the nurse that the resident was out of the building. CNA 2 stopped and the resident willingly got into her vehicle and was brought back to the facility. The resident had been on 15 minute checks prior to this incident as a nursing measure. The DON had just wanted the staff to continue to check on the resident because of a prior incident 2 to 3 weeks ago when the activities aide had witnessed the resident follow some visitors out of the building. The resident was an elopement risk since admission. The resident knew he needed to wait for his family to come and get him and did not want to wait any longer. After the incident, they offered for the resident to live on the locked dementia unit so the resident would remember to ask for assistance before he left. The resident did not have orders to leave the facility on his own. The resident had walked out the front door as it was not a locked door at the time. The front door was now locked at all times as an intervention. During an interview on 12/10/19 at 4:08 P.M., the DON indicated the resident did not have an order to leave the facility unsupervised now or at the time he left the building on 12/07/19. At this time she would not let him leave the building unsupervised. If he wanted to go somewhere, someone would need to sign him out if he wanted to leave the facility. During an interview on 12/11/19 at 9:47 [NAME]M., RN 3 indicated on the morning of 12/07/19 at 10:13 [NAME]M., she answered the phone at the nurses' station and was notified by CNA 2 that Resident 43 was out of the facility, and was observed walking down the road. She did not believe CNA 2 at first, because she had just seen the resident in the facility. She saw him visiting with another resident when she gave the other resident some medication at 10:02 [NAME]M. CNAs 4 and 5 overheard the phone call and left the building to go find the resident. The phone call got disconnected, but CNA 2 called back and said she was with the resident. RN 3 told CNA 2 that CNA 4 and CNA 5 were coming to get the resident. CNA 4 had returned to the facility to get her car to drive to where the resident was, but CNA 5 continued on foot to reach the resident. CNA 2 told RN 3 that the resident was in her car and she was bringing him back to the facility. The resident and all the CNAs returned to the building together and she assessed the resident at that time. The resident was okay, he had no injuries. RN 3 assumed the resident left through the smoking area doors. He told her he just pushed some buttons on the key pad at the front door and the door opened. RN 3 sent an aide to check the front door and found it to be unlocked. RN 3 indicated the front door used to be locked all the time, then it was supposed to be left unlocked during certain hours of the day. She wasn't sure if it was supposed to lock automatically at certain times. She called maintenance to see about the door, and called the DON to tell her what had happened. The resident was already on 15 minute checks because he had been witnessed following a visitor out the door a few weeks prior to 12/07/19. When the resident came back to the facility, the immediate intervention was to keep eyes on the resident at all times. During an interview on 12/11/19 at 10:01 [NAME]M., CNA 2 indicated on the morning of 12/07/19, she observed Resident 43 when she was assisting another resident into the main dining room. When CNA 2 was heading out of the building to take her break at 10:05 [NAME]M., she saw the resident heading up the hall towards the nurses' station. She was sure of the time, because she kept track of her breaks. CNA 2 went to the bank, and then went through the drive through of a fast food restaurant. She observed the resident walking down the road on the same side as the facility, headed towards the intersection, near a local bank. CNA 2 called the facility to let them know as she was turning around go get him. By the time she got to the resident, he had turned left at the intersection and was heading down another street. When she got to the resident he was breathing heavy, he had been walking at a pretty fast pace. She told him it was a little too cold to be out walking. The resident agreed, and got into her car. The resident was wearing blue jeans, a long sleeve shirt, a coat, and a ball cap. On the way back to the facility, they stopped and picked up CNA 5, and they all returned to the facility. CNA 5 brought the resident back to RN 3. The weather outside, on 12/07/19 at 10 [NAME]M., was 45 degrees Fahrenheit. The clinical record for Resident 43 was reviewed on 12/11/19 at 11:32 [NAME]M. An Admission MDS (Minimum Data Set) assessment, dated 09/21/19, indicated the resident was severely cognitively impaired. [DIAGNOSES REDACTED]. An Elopement Risk assessment dated [DATE] and 10/15/19, indicated the resident was at risk for elopement. The complete Care Plan for the resident was provided by the DON on 12/10/19 at 5:33 P.M. A Care Plan titled Resident is at risk for elopement, and dated 09/26/19, was reviewed. Goals included, but were not limited to, .Resident will be secure from elopement and will not exit facility thru next review with a start date of 09/26/19 and target date of 03/06/20. Interventions included, but were not limited to, .Respect residents right to make decisions and allow the resident to roam thru out facility freely . The current facility policy titled Elopement Prevention, Identification and Management with a revision date of 01/06/16, was provided by the MDS Coordinator on 12/11/19 at 12:39 P.M. The policy indicated, .Purpose: It is the policy of this facility to ensure that each resident receives adequate supervision and assistive devices to prevent elopements and that all personnel will report and investigate all reports of missing residents .Definitions to clarify terms related to providing supervision and other interventions to prevent accidents: .Elopement occurs when a resident leaves the premises or a safe area without authorization .and/or any necessary supervision to do so . The Immediate Jeopardy that began on 12/07/19 was removed on 12/11/19 at 2:00 P.M., when the facility completed audits of all residents for elopement risk, and inservices to educated staff on the facility elopement policy. 2. The clinical record for Resident 36 was reviewed on 12/12/19 at 3:12 P.M. A Quarterly MDS assessment, dated 10/17/19, indicated the resident was moderately cognitively impaired. The resident required extensive staff assistance with all ADLs (Activities of Daily Living), and used a wheelchair. [DIAGNOSES REDACTED]. The resident had experienced no falls since the last assessment, and utilized bed, chair, and floor mat alarms daily. An Accident Investigation report, dated 10/21/19, indicated the resident was found lying on her stomach on the floor in her room. A small red mark on the resident's left cheek was observed, and was thought to be a rug burn. The resident indicated she had crawled out of bed, and denied further injury. The facility could provide no record of neurological assessments for the unwitnessed fall the resident sustained [REDACTED]. An Accident Investigation report, dated 10/31/19, indicated the resident was found alone, sitting on the floor in the bathroom. The resident was assessed, and there were no injuries noted. The facility could provide no record of neurological assessments for the unwitnessed fall the resident sustained [REDACTED]. An Accident Investigation report, dated 11/21/19, indicated the resident was found sitting beside her bed, with a skin tear noted by staff. There were no other injuries noted. The facility could provide no record of neurological assessments for the unwitnessed fall the resident sustained [REDACTED]. 3. The clinical record for Resident 60 was reviewed on 12/12/19 at 2:52 P.M. A Quarterly MDS assessment, dated 11/12/19, indicated the resident was severely cognitively impaired. The resident required limited staff assistance with bed mobility, transferring, and walking; extensive staff assistance for dressing, toileting, and personal hygiene; and supervision for eating and locomotion on and off the unit. [DIAGNOSES REDACTED]. The resident had experienced two or more falls without injury, and one fall with an injury that was not major, since the last assessment. The resident utilized a chair alarm daily. An Accident Investigation Report, dated 10/23/19 at 8:40 [NAME]M., indicated the resident was in his room and attempted to self transfer from standing with a walker to sitting in a wheelchair. The resident missed his wheelchair and landed on his bottom on the floor. The resident denied any injury. The resident was assisted up from the floor by two staff members. The resident did not hit his head, no neurological checks were required, and no injuries were noted. The form lacked documentation that indicated the whether or not the fall was witnessed, an immediate action or intervention, and was not signed. The was nothing documented on the attached Post Fall Investigation form. An Accident Investigation Report, dated 10/23/19 at 1:00 P.M., indicated the resident was sitting in the dining room after a meal and attempted to get up unassisted to walk with his walker and fell , landing on his bottom. There were no injuries noted. The form lacked documentation of an immediate action or intervention, and there was nothing documented on the attached Post Fall Investigation form. An Accident Investigation Report, dated 11/05/19 at 10:35 [NAME]M., indicated the resident was found sitting on the floor in from of his wheelchair in his room. The resident stated he was trying to sit in his wheelchair after getting up from bed. There were no injuries noted. The form lacked documentation of an immediate action or intervention. The facility could provide no record of neurological assessments for the unwitnessed fall the resident sustained [REDACTED]. A Health Status Note, dated 11/5/19 at 1:40 P.M., indicated the resident was noted to be yelling from his room at approximately 11:15 [NAME]M. Upon entering the room, the resident was found sitting on the floor in front of his wheelchair. The resident stated he was getting in his chair from his bed and missed his chair. The resident denied injury, and there was no injury noted. The resident's family was notified at 1:30 P.M. of both falls. There was not an Accident Investigation Report for the second fall the resident sustained [REDACTED]. During an interview on 12/16/19 at 11:45 [NAME]M., the DON indicated if a resident had a unwitnessed fall or a fall with a head injury, neurological checks should be initiated. Nursing staff should start an investigation to determine what happened; determine factors to consider that could have contributed to the fall. The immediate action or intervention should be documented for every fall on either the initial Accident Investigation Form, or the Post Fall Investigation Form. The current facility policy, titled Fall Emergency, First Aid', dated 10/2014, was provided by the DON on 12/17/19 at 11:54 [NAME]M. The policy indicated, .Complete Accident/Incident Report per policy . The current facility policy, titled Neurological Assessment, dated 10/2014, was provided by the DON on 12/17/19 at 11:54 [NAME]M. The policy indicated, .Neurological assessment, is to be completed in all cases of head injury to the resident (when suspected or known) . 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure staff to resident sexual abuse did not occur for 1 of 3 residents reviewed for abuse. (Resident B) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 12/1/18 at 10:34 p.m. when the facility failed to ensure staff to resident sexual abuse did not occur. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 12/4/18 at 3:08 p.m. Findings include: The clinical record for Resident B was reviewed on 12/4/18 at 12:27 p.m. [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) Admission assessment, dated 11/6/18, indicated the resident's cognition was moderately impaired. The shower sheet, dated 11/28/18, indicated the resident had no skin issues. The incident report, dated 12/2/18 at 1:00 a.m., indicated CNA (Certified Nursing Aide) 4 witnessed CNA 5 standing in between Resident B's legs with his pants down and bare buttocks exposed. The nurse's note, dated 12/1/18 at 11:30 p.m., indicated the Director of Nursing (DON) arrived at the facility and, at 11:40 p.m., assessed Resident B's perineum area (the area between the vulva and anus on a woman). The anal and perineum presented with redness. Resident B stated He went in the back and then in the front. During an interview on 12/4/18 at 1:17 p.m., CNA 4 indicated, around 10:30 p.m. on 12/1/18, she was off work and had been at the store across from the facility. CNA 4 lived near the facility, and as she walked outside along the side of the building where wing 2 was located, she looked and saw a room light on with the blind opened. CNA 4 looked closer, and CNA 5 was in the room with his pants down and a leg on each side of him. CNA 5 moved as he assisted the person up off of the bed, and CNA 4 saw the person was Resident B. CNA 4 became overwhelmed, ran home, and called the Administrator. During an interview on 12/4/18 at 11:10 a.m., the DON indicated when she arrived at the facility on 12/1/18 she asked Resident B if anyone touched her. Resident B patted her hand down around her perineum area. The DON asked Resident B if he put his penis in her and Resident B responded yes. While doing a head to toe assessment, Resident B told the DON he went in the back. Resident B's rectal area and vaginal area looked traumatized with [MEDICAL CONDITION] (swelling) present. During an interview on 12/4/18 at 11:10 a.m., the Administrator indicated she spoke with the SANE (Sexual Assault Nurse Examiner) nurse from the hospital on [DATE], who indicated Resident B had bruising on the urethra and a possible tear on the outside of the anal area. The Administrator then spoke to Officer 8 who informed her that CNA 5, at first, denied all allegations. When Officer 8 told CNA 5 they could have evidence, CNA 5 said all he did was ejaculate. When Officer 8 asked CNA 5 why he would do that, CNA 5 responded because he could and it was something to do. During an interview on 12/4/18 at 3:15 p.m., the Administrator indicated CNA 5 was the only employee working the dementia unit at the time the incident occurred. During an interview on 12/5/18 at 11:01 a.m., Officer 8 indicated he had spoken to CNA 5 on 12/2/18 around 1:00 a.m. CNA 5 at first denied any sexual encounters but then said he had masturbated in room [ROOM NUMBER]. During an interview on 12/5/18 at 11:05 p.m., LPN (Licensed Practical Nurse) 7 indicated on 12/1/18, sometime around 11:00 p.m., the Administrator called and requested CNA 5 be escorted out. LPN 7 raced to the dementia unit and saw CNA 5 quickly exiting out of a room at the end of the hall. CNA 5 asked LPN 7 what was going on and looked surprised to see her. LPN 7 told CNA 5 there had been an emergency, as she was unaware of what had happened between CNA 5 and Resident B. LPN 7 escorted CNA 5 out of the building. The written statement, dated 12/7/18 and untimed, indicated CNA 4 told LPN 7 she had been at the store to purchase decorations for the facility. CNA 4 left the store and was walking along the side of the building where Wing 2 was located. CNA 4 saw a window blind was open, observed CNA 5 with his pants pulled down raping (Resident B), and saw Resident B's tan socks straight up in the air. Upon finding out what had happened, LPN 7 went back to Wing 2 and found Resident B wandering in the hallway near the room where the incident occurred. She was wearing tan socks. During an interview on 12/6/18 at 8:10 p.m., RN (Registered Nurse) 3 indicated the day after the incident, Resident B was very quiet, sat still, and kept saying nasty, nasty. The emergency department history and physical, dated 12/2/18, indicated the resident had significant dementia and was sent from a nursing home after a staff member was discovered allegedly sexually assaulting the patient. The pelvic exam, per the SANE, included superficial tears at introitus (entrance into a canal or hollow organ - the vaginal introitus is the opening that leads to the vaginal canal) and ecchymosis (a discoloration of the skin resulting from bleeding underneath, typically caused by bruising) with additional [DIAGNOSES REDACTED]. On 12/4/18 at 11:20 a.m., the Administrator provided a current copy of the document titled Abuse Prohibition, Reporting and Investigation, dated (MONTH) 2014. It included, but was not limited to, Policy .This facility will not permit residents to be subjected to abuse by anyone, including employees The Immediate Jeopardy that began on 12/1/18 was removed on 12/7/18 when the facility completed staff education on abuse identification and prevention; resident interviews were completed; abuse policy posted and distributed to the residents; resident council meeting; hourly rounds completed to monitor staff and resident interaction on the secure unit; and management education on signs/symptoms of staff burnout. The Immediate Jeopardy was removed on 12/7/18 but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy because not all management been educated on signs/symptoms of staff burnout and adequate supervisor one hour rounds. This Federal tag relates to Complaint IN 743 3.1-27(a)(1)

Based on record review and interview, the facility failed to immediately initiate CPR (Cardiopulmonary Resuscitation) for a resident who was found, unresponsive, whose code status was unclear, and to promptly notify the physician of the resident's change in condition. This deficient practice affected 1 of 1 residents reviewed for death and 1 of 31 residents reviewed for Advance Directives. (Resident 56) The immediate jeopardy began on [DATE] when the facility failed to immediately initiate CPR to a resident with an unclear code status that was found unresponsive. The AIT (Administrator in Training) was notified of the immediate jeopardy on [DATE] at 3:18 P.M. The immediate jeopardy was removed on [DATE], but the non-compliance remained at the lower scope and severity level of 2, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: During the initial process of record review on [DATE], it was discovered that the most recent order recapitulations (a monthly review of the resident's current orders) available for review in the resident's charts were for the month of (MONTH) (YEAR). The recapitulations of the physician's orders [REDACTED]. The AIT indicated the staff would work on gathering the orders for the specific residents the surveyors requested to review, and would provide them as soon as possible. The above requested orders were provided by the DON on [DATE] at 2:09 P.M., and were reviewed at that time. During an interview on [DATE] at 10:44 A.M., the AIT indicated the previous DON had been in charge of everything related to nursing services, including handling the monthly reviews of the resident's current orders, skin assessments, and pharmacy recommendations. The previous DON had kept these documents in her office. The previous DON had fallen behind in her work but did not alert administration or ask for assistance with her duties, so it wasn't until recently that the AIT found out things hadn't been taken care of. The AIT indicated the previous DON (who is now a floor nurse) told her She had been working all these shifts, she was tired, and she just got behind. The AIT indicated they did hire a new DON, and were working on getting things caught up. During an interview on [DATE] at 11:05 A.M., the Corporate Nurse Consultant indicated the monthly orders for all residents had been checked and verified for the months of (MONTH) (YEAR) and (MONTH) (YEAR), but they hadn't been filed into the appropriate charts. Up until recently, the previous DON had the monthly orders and pharmacy reviews in her office. The orders had been checked and verified but weren't filed appropriately. The reason these things weren't done was a staffing issue, but they were working on getting everything back into the charts so the resident's charts were current. Resident 56's clinical record was reviewed on [DATE] at 10:28 A.M. The resident was found to be without cognitive impairment. [DIAGNOSES REDACTED]. The most recent review of Resident 56's orders listed the resident's code status as Full Code. The order recapitulation for the month of (MONTH) (YEAR) was signed by the physician on [DATE]. Resident 56's current care plans included, but were not limited to, a care plan for Code Status, Full Code. The dates documented on the left side of the care plan indicated the care plan had been reviewed on [DATE], [DATE], [DATE], and [DATE]. Interventions included, but were not limited to, Identify the resident's chart as FULL CODE, All staff will be made aware of the resident's choice of FULL CODE, and In the event of cardiopulmonary arrest, initiate CPR, summon an ambulance, advise the physician (and) legal representative and transport to emergency room for treatment. There were no other care plans that indicated the resident had changed his code status. Review of a telephone order in a clear plastic sleeve in the resident's chart dated [DATE] indicated Pt (patient) requests No Code status. There was a signature of the nurse that received the order, but the order was not signed by the physician. Review of a form titled Requested Health Care Decisions in a clear plastic sleeve in the resident's chart dated [DATE] indicated the resident did not want to have CPR performed as a life saving measure (i.e. Do Not Resuscitate No Code). This form was signed by the resident and a facility representative. There was no documentation on the form of the date the physician was notified. Review of a nursing progress note, dated [DATE] at 6:30 P.M., indicated staff went into the resident's room after a CNA (Certified Nurse Aide) reported the resident was unresponsive. The progress note indicated staff attempted to wake the resident and that he was ashen, cool to the touch, and unresponsive. Staff attempted to rouse resident verbally and with a cool wash cloth. Blood pressure was unobtainable; respiration and heart beat were absent. Review of a nursing progress note, dated [DATE] at 6:45 P.M., indicated all attempts to rouse patient exhausted, res (resident) has expired. Review of a nursing progress note, dated [DATE] at 6:55 P.M., indicated staff attempted to call the resident's family member and left messages for family to call the facility. Review of a nursing progress note, dated [DATE] at 7:00 P.M., indicated staff placed a call to the mortuary to advise of Resident 56's death. Review of a nursing progress note, dated [DATE] at 7:10 P.M., indicated staff notified the DON (Director of Nursing), and that the DON indicated she would notify the doctor. Review of a nursing progress note, dated [DATE] at 8:00 P.M., indicate the mortuary arrived to pick up the resident. Review of a nursing progress note, dated [DATE] at 9:00 P.M., indicated the resident's family member contacted the facility and was advised of the resident's passing. During an interview on [DATE] 10:12 A.M., the DON indicated there was information in each resident's chart regarding a resident's code status. If a patient was to fall ill, the nurses were to look for the signed code status. She would look for a signed order in the front of the chart. Resident 56 had an order dated [DATE] that indicated he requested to be a DNR (Do Not Resuscitate). The monthly reviewed physician orders [REDACTED]. Staff never updated the orders to reflect a DNR status. During an interview on [DATE] at 10:37 A.M., RN (Registered Nurse) 10 indicated she was familiar with Resident 56 and she regularly worked the hall where he resided. She was not sure but thought he was a No Code. To find a resident's code status she would look in the MAR (Medication Administration Record) or the resident's chart. She would check the clear plastic sleeve in front of the chart. You could check the monthly reviewed physician orders [REDACTED]. Review of Resident 56's most recent MAR, dated [DATE] through [DATE], listed the resident's code status as FULL CODE. During an interview on [DATE] at 03:01 P.M., LPN (Licensed Practical Nurse) 7 indicated when she first went into Resident 56's room he didn't respond to her verbally and she thought that was odd. She touched him and he was cold. She assessed him; he had no pulse, no blood pressure, and was unresponsive. She did not initiate chest compressions at any time. She did not check the chart to verify his code status. She had determined the resident had already expired. During an interview on [DATE] at 12:32 P.M., RN 9 indicated a resident's code status should be documented in the front of the chart. If she came upon a resident that was unresponsive, she would check for a pulse, have someone check the chart for code status, and if the resident was a full code, she would start CPR and call EMS (Emergency Medical Services). During an interview on [DATE] at 01:56 P.M., the DON indicated Resident 56's telephone order denoting a request for a change in code status should have been faxed to the pharmacy so the code status would be changed on the monthly printout of the resident's current orders. The telephone order was incomplete because it was not signed by the physician and the Requested Healthcare Decisions form was incomplete because there was no documentation that indicated the physician was notified. The resident's care plans should have been updated to reflect the resident's change in code status from Full Code to DNR and they were not. The DON indicated she reviewed the resident's chart and did not find any documentation that indicated the MD was notified of the resident's change in condition. There was no documentation of a physician's orders [REDACTED]. The current facility policy titled Acute Condition Changes-Clinical Protocol, with a revision date of (MONTH) 2009, was provided by the DON on [DATE] at 12:41 P.M. and was reviewed at that time. The policy indicated.The nursing staff will contact the Physician based on the urgency of the situation. For emergencies, they will call or page the Physician and request a prompt response (within approximately one-half hour or less). The current facility policy titled Advance Directives, dated ,[DATE], was provided by the AIT on [DATE] at 2:56 P.M. and was reviewed at that time. The policy indicated .The facility shall comply with state law as it relates to Advance Directives . The current facility policy titled Cardiopulmonary Resuscitation, with a revision date of ,[DATE], was provided by the AIT on [DATE] at 2:07 P.M. and was reviewed at that time. The policy indicated, .Facility staff shall provide basic life support and CPR: When cardiac or respiratory arrest occurs for residents who do not show obvious clinical signs of irreversible death and: .Who do not have a valid DNR order .If the nurse observes the resident is unresponsive but the resident's body temperature is not cold, cyanosis (bluish discoloration of the skin and mucous membranes) is not present and liver mortis (venous pooling of blood in dependent body parts) is not present, the nurse shall immediately assess circulatory and respiratory function and proceed to administer CPR, requesting emergency medical services. The Immediate Jeopardy that began on [DATE] was removed on [DATE] at 2:59 P.M., when the facility completed audits on all charts to ensure the resident's signed code status' were correct with the current physician's orders [REDACTED]. status. IDT (Interdisciplinary Team) staff were educated on the process of updating and changing code status. Staff had been educated on prompt notification of a resident that was found non-responsive. The non-compliance remained at the lower scope and severity level of 2, no actual harm with potential for more than minimal harm that is not immediate jeopardy because not all staff had completed education on after hours code status changes and change of condition/physician notification. 3XXX,[DATE](f)(5)

Based on observation, interview, and record review, the facility failed to adequately supervise residents who resided on a locked Alzheimer's Unit and had to be moved to an unsecured unit/wing. This deficient practice had the potential to affect 12 of 30 residents residing on Wing 4. (Residents 05, 07, 11, 22, 24, 26, 30, 39, 42, 44, 51, and 54) The Immediate Jeopardy began on 01/17/18 at 9:30 A.M., when there were no designated staff continually monitoring the three exit doors on Wing 4. The Administrator in Training, Corporate Clinical Compliance, Consultant, and the Director of Nursing were notified of the Immediate Jeopardy at 11:50 A.M. on 01/17/18. The Immediate Jeopardy was removed on 1/19/18, but the non-compliance remained at the lower scope and severity level of 2 of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Findings include: During an interview, on 01/16/18 at 10:54 A.M., the SSD (Social Service Director) indicated on 01/15/18 around 2:30 P.M., there was a leak in the sprinkler system in the locked Alzheimer's Unit. All residents were removed from the unit prior to the ceiling collapse. The residents were moved to an unsecured unit, Wing 4. During an interview, on 01/16/18 at 11:10 A.M., the AIT (Administrator in Training) indicated the sprinkler incident was reported to the State that morning on 01/16/18 due to facility Internet not working on 01/15/18. Staff were checking all wings for fire. On 01/15/18 the AIT spoke with the night shift nurses on Wings 3 and 4. The nurses were conducting resident head counts every 15 minutes for the residents transferred to Wing 4 and would be continued until the residents were able to return to the locked Alzheimer's Unit. Staff were sitting by the exit doors of Wing 4 from 12 A.M., to 6 A.M., on 01/16/18. During an observation, on 01/16/18 at 02:47 P.M., Resident 26 exited the unsecured temporary Alzheimer's Unit (Wing 4), opening the door. The clip alarm that was attached to the door did not activate. The resident was able to open the door and walk under the clip alarm system to leave the Unit unnoticed by staff. Following the resident off of Wing 4 at 02:50 P.M., he turned right down a hallway, went to the original locked Alzheimer's Unit, stood outside the door and looked at a note that was posted to the door. The resident turned around, went to the kitchen doors, look at a note on the kitchen door, then turned and walked back down the hallway. The resident walked to Wing 3 where CNA (Certified Nurse Aide) 5 redirected and escorted the resident back to Wing 4 and to his room at 02:52 P.M. During an observation, on 01/16/18 at 03:01 P.M., Resident 26 exited the unsecured temporary Alzheimer's Unit (Wing 4), opening the door. The clip alarm that was attached to the door did not activate. The resident was able to open the door and walk under the clip alarm system to leave the Unit unnoticed by staff. The resident walked down the hallway and around the corner towards Wing 3. The Activities Director was walking towards the resident and redirected and escorted the resident back to Wing 4 at 3:03 P.M. The AIT, walking from the kitchen, met the resident and the Activities Director at the doors to Wing 4 and inquired of staff, How did this happen? During an interview, on 01/16/18 at 03:44 P.M., the AIT indicated she was aware Resident 26 was found wandering in another wing of the facility. Because the unit where the water damage occurred was the locked Dementia Unit, they had to move those residents to Wing 4 and put personal alarms on the two fire doors to alert staff if the doors were opened. Currently, Resident 26 was receiving one on one care. Going forward, staff will be stationed on the doors at all times. They will continue to do 15 minute head checks and fire checks. They will provide documentation of monitoring. During an observation, on 01/17/18 at 09:21 A.M., Resident 26 was in his room with the door closed, with no staff members present and his roommate had a visitor. There were no designated staff continually monitoring the exit doors from Wing 4. The designated chair was empty. Staff were at the nurses' station assisting other residents. During an interview, on 01/17/18 at 09:31 A.M., the AIT indicated the facility was hoping to get the Alzheimer's Unit repaired in 3 weeks or less. The facility currently had staffing issues and were trying to fill staff positions on the schedule. They were also trying to get volunteers to come sit at the doors on Wing 4, and hoping to get 24 hours around the clock door coverage. An observation of Wing 4 was conducted on 01/17/18 at 09:59 A.M., DA (Dietary Aide) 4 was noted to be sitting in a chair in the middle of the hall monitoring the doors to the unit. The DM (Dietary Manager) alerted DA 4 that Resident 26, whose room was on the opposite end of the hallway, was walking alone and half way down the hall near the doors in the middle of the hallway that exited to another unit. The DM and DA 4 proceeded down the hall toward the resident. An observation of Wing 4 was conducted on 01/17/18 at 10:05 A.M. The designated chair for the continuous door observation was empty. The DA was observed talking to a resident in room [ROOM NUMBER]. The DA was inside the room and had her back to the door. The DA returned to her posted chair at 10:08 A.M. During an observation of the locked Alzheimer's Unit, on 01/17/18 at 2:48 P.M., indicated a large open area covering one third of the central hallway with bare rafters, and capped wires hanging down. The main building entrance doors located down the hall, outside of the Wing 4 fire door, were unlocked for exiting or entering the building. The record for Resident 05 was reviewed on 01/17/18 at 3:00 P.M. [DIAGNOSES REDACTED]. The Annual MDS (Minimum Data Set) assessment, dated 10/10/17 indicated the resident was severely cognitively impaired and independently mobile. The resident was care planned for a secure unit related to dementia and at risk for elopement. The record for Resident 07 was reviewed on 01/17/18 at 3:02 P.M. [DIAGNOSES REDACTED]. The Annual MDS assessment, dated 10/11/17 indicated the resident was independently mobile. The resident was care planned for a secure unit related to dementia, disorganized thinking, and behaviors of pacing/rummaging. The record for Resident 11 was reviewed on 01/17/18 at 3:05 P.M. [DIAGNOSES REDACTED]. The Quarterly MDS assessment, dated 10/18/17 indicated the resident was moderately cognitively impaired and independently mobile. The resident was care planned for a secure unit related to dementia. The record for Resident 22 was reviewed on 01/17/18 at 3:10 P.M. [DIAGNOSES REDACTED]. The Significant Change MDS assessment, dated 11/13/17 indicated the resident was severely cognitively impaired and independently mobile. The resident was care planned for a secure unit related to dementia, at risk for elopement, and wondering. The record for Resident 24 was reviewed on 01/17/18 at 3:15 P.M. [DIAGNOSES REDACTED]. The Quarterly MDS assessment, dated 11/16/17 indicated the resident was severely cognitively impaired. The resident was care planned for a secure unit related to dementia, elopement, and wondering. The record for Resident 26 was reviewed on 01/17/18 at 3:20 P.M. [DIAGNOSES REDACTED]. The Quarterly MDS assessment, dated 11/17/17 indicated the resident was severely cognitively impaired and independently mobile. The resident was care planned for wondering and at risk for elopement. The record for Resident 30 was reviewed on 01/17/18 at 3:25 P.M. [DIAGNOSES REDACTED]. The Quarterly MDS assessment, dated 11/23/17 indicated the resident was severely cognitively impaired. The resident was care planned for a secure unit related to dementia, at risk for elopement, and wondering. The record for Resident 39 was reviewed on 01/17/18 at 3:30 P.M. [DIAGNOSES REDACTED]. The Quarterly MDS assessment, dated 12/01/17 indicated the resident was independently mobile. The resident was care planned for a secure unit related to dementia. The record for Resident 42 was reviewed on 01/17/18 at 3:35 P.M. [DIAGNOSES REDACTED]. The Quarterly MDS assessment, dated 12/08/17 indicated the resident was moderately cognitively impaired and independently mobile. The resident was care planned for a secure unit related to dementia, wondering, and at risk for elopement. The record for Resident 44 was reviewed on 01/17/18 at 3:40 P.M. [DIAGNOSES REDACTED]. The Quarterly MDS assessment, dated 12/13/17 indicated the resident was severely cognitively impaired and independently mobile. The resident was care planned for a secure unit related to dementia, wandering, and exit seeking. The record for Resident 51 was reviewed on 01/17/18 at 3:45 P.M. [DIAGNOSES REDACTED]. The Quarterly MDS assessment, dated 12/29/17 indicated the resident was independently mobile. The resident was care planned for a secure unit related to dementia and a history of exit seeking. The record for Resident 54 was reviewed on 01/17/18 at 3:50 P.M. [DIAGNOSES REDACTED]. The Quarterly MDS assessment, dated 12/14/17 indicated the resident was independently mobile. The resident was care planned for a secure unit related to dementia, wandering, restlessness, and at risk for elopement. The current facility policy titled Abuse and Neglect, with a revision date of (MONTH) 2007, was provided on 01/16/18 and was reviewed at that time. The policy indicated, .Along with other staff and management, the Medical Director will help identify situations that might constitute or could be construed as neglect: for example, .inappropriate management of problematic behavior .The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect . The current facility policy titled Elopement (Missing/Wandering Residents), dated (MONTH) 2014, was provided on 01/24/18 at 4:06 P.M. and was reviewed at that time. The policy indicated, .ensure a secure environment for residents at risk for elopement . The Immediate Jeopardy that began on 01/17/18 at 09:30 A.M. was removed on 01/19/18 at 04:10 P.M. when the facility inserviced staff from all departments on 01/17/18 on the expectations when assigned to being a door monitor on Wing 4 (temporary residence for residents from secured unit) .15 minute checks were in place for all residents that previously resided on the secured unit, a binder had been placed at the nurse's station on Wing 4 with pictures of all the residents that previously resided on the secure unit so all staff will know who the residents from the secured wing were. The non-compliance remained at the lower scope and severity level of 2, no actual harm with the potential for more than minimal harm that is not immediate jeopardy because the facility was attempting to find a vendor to place key pads on both sides of the two fire doors on Wing 4 to secure the area without the need for a constant door monitor. 3.1-45(a)(2)