Every finding on record at Arbor Grove Village

Based on observation and interview, the facility failed to provide a homelike environment related to hot water temperatures. This deficient practice had the potential to effect 75 of 75 residents residing in the facility. Findings include:During an observation, on 04/20/2026 at 9:51 A.M., in room [ROOM NUMBER] the bathroom sink water was tested for water temperature. The water in the residents bathroom sink was immediately too hot to place your hands under the water without discomfort or redness. During an observation, on 04/20/2026 at 9:54 A.M., in room [ROOM NUMBER] the bathroom sink water was tested for water temperature. The water in the residents bathroom sink was too hot to place your hands under the water without discomfort or redness.During an observation, on 04/20/2026 at 10:04 A.M., in room [ROOM NUMBER] and room [ROOM NUMBER] the shared a bathroom sink water was tested for water temperature. The water in the residents bathroom sink was too hot to place your hands under the water without discomfort or redness. During an observation, on 04/20/2026 at 10:06 A.M., in room [ROOM NUMBER] and room [ROOM NUMBER] the shared a bathroom sink water was tested for water temperature. The water in the residents bathroom sink was too hot to place your hands under the water without discomfort or redness. During an observation, on 04/20/2026 at 10:08 A.M., in room [ROOM NUMBER] and room [ROOM NUMBER] the shared a bathroom sink water was tested for water temperature. The water in the residents bathroom sink was too hot to place your hands under the water without discomfort or redness. During an observation, on 04/20/2026 at 10:09 A.M., in room [ROOM NUMBER] the bathroom sink water was tested for water temperature. The water in the residents bathroom sink was too hot to place your hands under the water without discomfort or redness. During an observation, with the Maintenance Director on 04/20/2026 from 10:13 A.M. through 10:34 A.M., the following was observed of water temperatures in the residents bathroom sinks:- At 10:13 A.M., in room [ROOM NUMBER] the hot water was turned on, and the hot water temperature was 132 degrees Fahrenheit, at 10:16 A.M. the water temperature was 110 degrees Fahrenheit, and at 10:17 A.M. the water was 117.3 degrees Fahrenheit, - At 10:20 A.M., room [ROOM NUMBER] the hot water was turned on, and the hot water temperature was 127 degrees Fahrenheit, at 10:23 A.M. the water temperature was 114.0 degrees Fahrenheit,- At 10:33 A.M., room [ROOM NUMBER] the hot water was turned on, and the water temperature was 123 degrees Fahrenheit, at 10:34 A.M., the water temperature was 120.9 degrees Fahrenheit. During an interview, on 04/20/2026 at 10:35 A.M., the Maintenance Director indicated he checked water temperatures once a week. He always let the water run for two to three minutes until the temperature was a steady temperature. The regulation range was 100 to 120 degrees Fahrenheit. At 10:45 A.M., the Maintenance Director indicated he was not sure why the water temperatures were fluctuating. He had to adjust them often and they had put in a new mixing valve recently. He was working with his boss but believed they need to be recalibrated. He had to keep a close watch on the temperatures. The temperature at the mixing valve was appropriate but it was hotter coming out of the lines and he was unsure why. During an interview, on 04/20/2026 at 10:53 A.M., the Administrator indicated no residents had been burned from hot water. She was not aware of residents knowing that they needed to let the water run for a few minutes before sticking their hands under the water. The staff assisted residents on the dementia unit with washing their hands, but they did have individual bathrooms in their rooms that they had access to. There were no signs hanging in the bathrooms alerting residents to wait a couple minutes before placing their hands in the water. The current facility policy tilted, Resident Rights, with a revision date of 08/2025, was provided by the Regional Director Clinical Services on 04/24/2026. The policy indicated, .Quality of Life and Safe Environment.A resident has a right to care in an environment that promotes maintenance or enhancement of each resident's quality of life. The resident has the right to be safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely.410 IAC (Indiana Administrative Code) 16.2-3.1-19(r)(1)410 IAC (Indiana Administrative Code) 16.2-3.1-19(r)(2)

Based on interview, record review, and observation, the facility failed to educate a resident and follow appropriate infection control guidelines related to urinary care for 4 of 4 residents reviewed for Urinary Tract Infections (UTIs) and indwelling urinary catheters. (Residents 5, 4, 27, and 56)Findings include:1. During an interview, on 04/20/2026 at 11:31 A.M., Resident 5 indicated she had recently been on an antibiotic for a UTI. It currently burned when she urinated and her urine was milky yellow in color. During an interview, on 04/22/2026 at 10:52 A.M., Licensed Practical Nurse (LPN) 4 indicated the resident required stand-by assistance of one staff member for toileting. The resident preferred to be independent with toileting. The staff had educated her on wiping from front to back. The clinical record was reviewed on 04/21/2026 at 3:04 P.M. A Significant Change Minimum Data Set (MDS) assessment, dated 02/10/2026, indicated the resident was cognitively intact. The resident required substantial assistance from staff members for hygiene and was frequently incontinent of bowel and bladder. The resident's diagnoses included, but were not limited to, diabetes (a chronic condition causing high blood sugar because the body cannot make or properly use insulin) and morbid obesity (a chronic disease defined by a Body Mass Index (BMI) of 40 or higher, or 35 or higher with significant obesity-related health complications). The Infection Control Tracking and Trending for Antibiotic Stewardship Records were reviewed on 04/22/2026 at 10:39 A.M. The records indicated Resident 5 had the following UTI symptoms and treatments: -On 04/05/2026, altered mental status, the urinalysis tested positive for the bacteria E. coli, and the resident was started on the antibiotic Fosfomycin on 04/08/2026, and -On 03/18/2026, burning, frequency, and increased incontinence, the urinalysis tested positive for the bacteria E. coli and pseudomonas. The resident was started on the antibiotic Fosfomycin on 03/22/2026. The resident's complete Care Plan, Progress Notes, and Infection Events were reviewed. The clinical record lacked documentation the resident had been educated on appropriate toileting procedures. During an interview, on 04/24/2026 at 1:27 P.M., the Director of Nursing (DON) indicated they were currently testing the resident for a UTI due to her recent fall. The resident toileted herself. They had no record of the resident being educated on the appropriate toileting procedures. The Interdisciplinary Team did not do a root cause analysis for infections. It was dependent on the resident. She was unaware of the frequency in which the facility assessed residents for performing Activities of Daily Living (ADLS). The Interdisciplinary Team (IDT) Comprehensive Care Plan Policy, with a revised date of 10/2025, was provided by the Administrator on 04/23/2026 at 3:41 P.M. The policy indicated, .It is the policy of this facility that each resident will have an interdisciplinary comprehensive person-centered care plan developed and implemented based on Resident Assessment Instrument (RAI) process. The care plan must include measurable goals and resident specific interventions based on resident needs and preferences to promote the resident's highest level of functioning including medical, nursing, mental, and psychosocial well-being . 2. During an interview, on 04/21/2026 at 9:42 A.M., Resident 4 indicated he had a lot of UTIs and his indwelling urinary catheter leaked at times. The indwelling urinary catheter care for Resident 4 was observed, on 04/23/2026 at 1:10 P.M., with CNA 3 and CNA 17. The staff took a towel and a clean pad in the room with them and donned a gown and gloves. CNA 17 prepared a clean plastic bag, wetted some washcloths, and placed them in the clean bag. CNA 3 touched the bed control device, assisted the resident with their disposable water cup, handed the cup to CNA 17, who placed it on the over-bed table. CNA 17 placed the resident's phone on the over-bed table, touched the bed control device, then picked up the clean brief. The staff continued to provide care to the resident's private areas without changing their gloves. The clinical record for Resident 4 was reviewed on 04/22/2026 at 3:44 P.M. An admission MDS assessment, dated 04/08/2026, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, end stage renal disease (permanent, stage 5 chronic kidney failure, where kidneys function below 10–15% and cannot support life, requiring regular dialysis or a kidney transplant) and obstructive uropathy (a structural or functional blockage of urine flow, leading to urine backflow, potential kidney swelling (hydronephrosis), and kidney damage). The resident had an indwelling urinary catheter and was frequently incontinent of bowel. The SURVEILLANCE LOG OF RESIDENT INFECTIONS AND ANTIBIOTIC USE record, for April 2026, indicated the resident was treated with the antibiotic Levofloxacin/ Macrobid for a UTI from 04/11/2026 to 04/20/2026. 3. During an interview, on 04/21/2026 at 9:19 A.M., Resident 27 indicated she was currently on an antibiotic for a UTI. She had UTIs frequently. She received bed baths. She did not use a bed pan; she usually just went in her brief. The incontinence care was observed, on 04/22/2026 at 3:13 P.M., with Certified Nurse Aide (CNA) 6 and CNA 7. The resident was in her room in bed. The CNAs entered the resident's room, donned gloves, took a package of cleaning wipes, pulled the resident's covers down, and removed her brief from the front of her body. CNA 6 wiped down the center of the resident's private area, from front to back and back to front, with one wipe and did not turn the wipe. CNA 6 got a clean wipe and wiped the creases of the resident's legs around the private area. The CNAs rolled the resident to her side, wiped her backside, and changed her brief. The staff did not try to separate the resident's legs to see the folds of the labia or ensure cleanliness. Incontinence care was observed, on 04/23/2026 at 1:47 P.M., with CNA 3 and Nurse Aide in Training (NAT) 8. The two staff members donned gloves. CNA 3 filled a plastic basin with water, touching the faucet with her gloved hands, and took the basin to the bedside. The CNA got a plastic garbage bag out of her pocket for the soiled linens then threw a dirty tissue of the resident's in the trash. The CNA removed the resident's bed linens, touched the privacy curtain, then removed the resident's brief from the front. The CNA wetted wash clothes in the wash pan, added soap, wiped from front to back, turning the washcloth, and pulling the labia apart. The CNA followed with a rinse cloth and a towel, then continued with cleaning the backside of the resident, changed her gloves, and applied a fresh brief. During an interview, on 04/23/2026 at 1:59 P.M., CNA 3 indicated, when providing incontinence care, staff were to gather supplies, put warm water in the plastic basin, and don gloves. When cleaning, go down the middle, from front to back, fold the washcloth for every crevice after each wipe. You should do the same with a rinse cloth and a towel. Staff should change gloves if they touch inanimate objects in the residents' rooms. This resident was able to move her legs apart. The clinical record for Resident 27 was reviewed on 04/23/2026 at 3:13 P.M. An Annual MDS assessment, dated 03/04/2026, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, hemiplegia (the severe or complete paralysis of one side of the body, caused by brain damage (often opposite the affected side) or spinal cord injury, frequently stemming from strokes, tumors, or congenital conditions) and irritable bowel (a common, chronic functional disorder of the large intestine causing abdominal pain, cramping, bloating, and diarrhea or constipation). The resident was always incontinent of bladder and bowel. The resident required substantial/maximal assistance of staff members for toileting hygiene. The physician's orders indicated the resident had received the antibiotic Bactrim 800-160 milligrams (mg) twice a day from 04/18/2026 to 04/21/2026, for a UTI. The Perineal Care policy, with a reviewed date of 03/2023, was provided by the Regional Director of Clinical Services on 04/24/2026 at 10:19 A.M. The policy indicated, .Don gloves .fill wash basin with warm water .Assist resident to spread legs and lift knees .Wet and soap folded wash cloth .Separate labia and wash urethral area first .Wash between and outside labia in downward strokes .Alternate from side to side wipe from front to back and from center of perineum outward .Use a clean area of the washcloth with each wipe. Do not rewipe area unless using a clean area of the washcloth . 4. During an observation, on 04/21/2026 at 1:51 P.M., Resident 56 was sitting in his recliner in his room. The resident's urinary catheter drainage bag was hanging on a trash can to the right side of the resident's recliner. During an observation, on 04/21/2026 at 2:14 P.M., Resident 56 was sitting in his recliner in his room. The resident's urinary catheter drainage bag was hanging on a trash can to the right side of the resident's recliner. During an interview, on 04/21/2026 at 2:34 P.M., the Director of Nursing (DON) indicated the resident's urinary catheter drainage bag should not have been hanging on the trash can. She moved the catheter bag at that time. During an interview, on 04/21/2026 at 2:36 P.M., QMA 13 indicated the resident was an assist of one staff with care. The resident was able to walk to the bathroom, but the staff would hang his urinary catheter drainage bag where it needed to be. During an interview, on 04/22/2026 at 10:22 A.M., QMA 16 indicated the resident needed assistance with care. He had a cream for his penis and had an indwelling urinary catheter. His penis had a split in it from where he had pulled on the catheter. During an observation and interview, on 04/23/2026 at 1:14 P.M., Resident 56 indicated his penis was split down from the catheter. He never messed with his catheter; the staff always messed with it. The resident's urinary catheter drainage bag was hanging from a trash can beside the recliner. The catheter bag had a dignity cover on the sides of the bag but it was opened on the bottom and the urine collection bag was resting on the floor. During an observation, on 04/23/2026 at 1:29 P.M., CNA's 14 and 15 provided urinary catheter care for Resident 56. The resident's penis had a tear to the bottom of the penis. There were no open wounds. The resident's incontinence brief had a moderate amount of green drainage. The CNA's indicated the resident had a lot of drainage. After the urinary catheter care was completed, CNA 14 placed the urinary catheter drainage bag on the trash can beside the resident's recliner. During an interview, on 04/23/2026 at 1:45 P.M., CNA 14 indicated the resident has had the green drainage for a couple of days. It was worse at that time. She always hung the urinary catheter drainage bag on the trash can because that was where the resident liked it. During an interview, on 04/23/2026 at 9:08 A.M., RN 11 indicated the resident came to the facility with his urinary catheter. The resident had an inflatable pump in his penis. The resident always complained of penis pain, but it would fluctuate. The resident's penis was not flaccid and always stayed a little erect. The resident had a penile tear that has since healed but would never grow back. The tear was from his long-term urinary catheter use. The resident had gone to a urology consult recently and believed he was going to get a suprapubic catheter; he was going to go back for a follow up appointment in a few days. The resident did have an infection recently and was on a couple of antibiotics. During an interview, on 04/23/2026 at 9:17 A.M., the Nurse Practitioner indicated if the resident had a tear to the penis, it was likely due to the catheter being pulled but she was unsure what had caused it. The clinical record for Resident 56 was reviewed on 04/22/2026 at 1:57 P.M. A Quarterly MDS assessment, dated 02/09/2026, indicated the resident was cognitively intact. The resident's diagnoses, included but were not limited to, vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, damaging tissue) and obstructive uropathy (a structural or functional blockage of urine flow, leading to urine backflow, potential kidney swelling (hydronephrosis), and kidney damage). A Hospital Discharge Record, dated 11/26/2025, indicated the resident would need to follow up with urology. The resident had no Urology Visit scheduled until April 2026. A Progress Note, dated 03/28/2026 at 3:53 P.M., indicated the resident had complaints of pain to the penis. Upon an assessment, the nurse noted there was increased edema to the shaft of the penis. The resident was noted with a tear to the penis related to the catheter. There was purulent (a thick, milky, or opaque fluid—often yellow, green, or brown—that oozes from a wound, signaling a potential bacterial infection) and bloody drainage noted to the brief. The drainage was malodorous (something having an unpleasant, foul, or offensive smell). The resident's catheter was replaced, the area was cleansed, and antibiotic ointment was applied. The physician was notified. A Progress Note, dated 03/28/2026 at 5:00 P.M., indicated a new order was received to culture the tear to the head of the penis. The staff were to cleanse the tear with soap and water, pat dry, and apply antibiotic ointment, everyday until the wound was healed. The resident was also to receive Keflex (an antibiotic) 500 milligrams (mg), twice a day, for seven days. A Progress Note, dated 04/02/2026 at 2:23 P.M., indicated the resident's culture results were received and indicated there was moderate growth of staph-aureus and heavy growth of proteus mirabilis. The physician was notified. A Progress Note, dated 04/03/2026 at 5:36 P.M., indicated a new physician's order was received for Clindamycin (an antibiotic) 300 mg, twice a day for seven days in addition to the Keflex. The EMAR indicated the resident was administered the medications per the physician orders. The Complete Care Plan was reviewed and included, but was not limited to, a care plan the resident required an indwelling urinary catheter related to Benign Prostatic Hyperplasia (a common condition in older men where the prostate gland becomes enlarged, causing uncomfortable urinary symptoms with lower urinary tract) and obstructive uropathy with a start date of 12/03/2025. The interventions included, but were not limited to the following: - the resident prefers to have catheter bag hanging on the trash can beside chair, with a start date of 04/21/2026 at 2:41 P.M., and- do not allow tubing or any part of the drainage system to touch the floor, with a start date of 12/03/2025. The Care Plan and clinical record lacked any indication the resident was educated on the risks of having the urinary catheter drainage bag hanging on the trash can or interventions related to the catheter drainage bag hanging on the trash can prior to the start of the survey. During an interview, on 04/23/2026 at 2:35 P.M., the Assistant Director of Nursing (ADON) indicated the resident admitted to the facility with a catheter. There was a weekend when the staff called her and indicated the resident had a laceration to his penis. It was a typical keratosis (a rare, benign (non-cancerous) skin growth appearing as tan, brown, or black waxy, stuck-on papules or plaques) the resident had for awhile that had become more inflamed. The resident would frequently adjust his urinary catheter himself. The staff should be monitoring the resident's skin while providing urinary catheter care completed every shift. The resident had his first urology visit last week. If the resident's hospital discharge paperwork indicated they needed to follow-up with urology, then they would call them within a week to get that scheduled. Urology was only for chronic catheter management and when a resident was discharging home from the hospital. During an interview, on 04/24/2026 at 3:07 P.M., the DON indicated the facility lacked a policy related to urinary catheter bags touching things. The resident was care planned for his urinary catheter bag to hang on the trash can. They added the intervention the day she saw the bag hanging on the trash can during the survey. The current facility policy titled, Infection Prevention and Control Program Policy, with a revision date of 05/2023, was provided by the Regional Director Clinical Services on 04/24/2026 at 10:19 A.M. The policy indicated, .The facility shall establish and maintain infection prevention and control program (IPCP) designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections. The IPCP is a comprehensive system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under contractual arrangement, is based on the facility assessment, and following accepted national standards. The IPCP includes Antibiotic Stewardship Program. 410 IAC (Indiana Administrative Code) 16.2-3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to assess a resident to self-administer medications for 2 of 19 residents reviewed for self-administration of medications. (Residents 34 and 73)Findings include:1. During an observation and interview, on 04/21/2026 at 9:07 A.M., Resident 34 was sitting in her chair, in her room. The resident had a medication cup full of medications sitting on her over the bed table. She indicated the medications were her morning medications. The staff would normally leave them on her table so she could take them with her breakfast or after she was done eating. During an observation and interview, on 04/23/2026 at 9:02 A.M., the resident was sitting in her chair in her room, there was a cup full of medication sitting on her over bed table. Licensed Practical Nurse (LPN) 9 indicated the resident's medications should not have been left at her bedside table. The resident should have had a physician's order for the medications and an assessment to self-administer medications. During an interview, on 04/23/2026 at 9:05 A.M., LPN 9 indicated the resident didn't have an order or an assessment to self-administer medications. The resident's medications should not have been sitting on her bedside table without a nurse in the room. The clinical record for Resident 34 was reviewed on 04/21/2026 at 2:11 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 02/17/2026, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, dementia (an umbrella term for progressive cognitive decline—including memory loss, language issues, and behavioral changes), anemia (a common blood condition characterized by a lack of healthy red blood cells or hemoglobin, leading to reduced oxygen transport), hypertension (high blood pressure), diabetes (high blood sugar), anxiety (a common, often chronic, mental health condition characterized by excessive, persistent worry and fear that interferes with daily life, often causing physical symptoms like heart palpitations, trembling, and nausea), and depression (a common, serious mood disorder characterized by persistent sadness, loss of interest in activities, fatigue, and cognitive difficulties, lasting at least two weeks). The Electronic Medication Administration Record (EMAR) indicated the resident had the following physician orders for morning medications: - Alprazolam (an antianxiety medication) 0.5 milligrams (mg), - Aripiprazole (an antipsychotic medication) 5 mg, - Aspirin 81 mg, - Calcitriol (vitamin D) 0.25 micrograms (mcg),- Cetirizine (an antihistamine) 10 mg, - Vitamin D3 125 mcg, - Daily Vitamin 400 mcg, - Diltiazem (blood pressure medication) 240 mg, - Metformin (a high blood sugar medication) 500 mg, - Metoprolol (a blood pressure medication) 50 mg, - Omeprazole (a heartburn medication) 40 mg, - Calcium Carbonate 500 mg, - PreserVision (an eye vitamin), - Sertraline (an antidepressant medication) 150 mg, and - Tamsulosin (a bladder medication) 0.4 mg. 2. During an observation and interview, on 04/20/2026 at 9:51 A.M., Resident 73 was sitting in his bed, in his room. The resident had a medication cup with a brown substance that contained white and pale colored flecks in it, sitting on his bedside table next to his breakfast tray. He indicated the medications cup contained his morning medication and chocolate pudding. He would take them when he was finished eating. During an observation and interview, on 04/20/2026 at 10:28 A.M., Resident 73 was sitting in his bed, in his room. The medication cup with a brown substance that contained white and pale colored flecks in it and his breakfast tray were no longer sitting on the bedside table. The resident indicated he finished his breakfast and had taken his medications. During an interview on 04/20/2026 at 10:50 A.M., LPN 2 indicated Resident 73 would not interrupt his meal to take his medications. He took his medications crushed in pudding or applesauce and took them after he had finished his meal. Medications should not be left at bedside, and residents should be watched until all medications were taken. The clinical record for Resident 73 was reviewed on 04/24/2026 at 10:46 A.M. An annual MDS assessment, dated 02/17/2026, indicated the resident was cognitively intact. The Resident's diagnoses included, but were not limited to, a seizure disorder, high blood pressure, and dementia. The clinical record lacked order or an assessment to self-administer medications. The current facility policy, titled Self-Administration of Medications, revised on 01/2015, was provided by the Administrator on 04/23/2026 at 4:16 P.M. The policy indicated, .If a resident desires to participate in self-administration, the interdisciplinary team will assess the competence of the resident to participate by completing the Self-Administration of Medication Assessment observation. 410 IAC (Indiana Administrative Code) 16.2-3.1-11(a)

Based on observation, interview, and record review, the facility failed to accommodate the needs of a resident related to call light availability for a resident with frequent falls for 1 of 19 residents reviewed for accommodations of needs. (Resident 9) Findings include: During an observation, on 04/20/2026 at 9:43 A.M., Resident 9 was asleep in bed in her room. No call lights were available for the resident. A touch pad call light and a push button call light were on the floor under the turn-off system hanging on the wall. Neither call light would be reachable by the resident. During an observation and interview, on 04/21/2026 at 2:54 P.M., the resident's room door was closed. A therapy associate in the hallway indicated Resident 9's roommate liked the room door to stay closed. If staff members left the door open, the roommate would get up and close it. During an observation, on 04/22/2026 at 11:02 A.M., the resident was sitting in her recliner in her room. Her head was tilted back and her eyes were closed. Her wheelchair was sitting in front of the recliner, and her feet were propped up on the seat of the wheelchair. A push-button call light was laying in the middle of the resident's bed, several feet away from the resident. During an observation and interview, on 04/24/2026 at 10:46 A.M., the resident was lying in bed in her room. Her call light was on the floor under the edge of the bed out of the resident's reach. Certified Nurse Aide (CNA) 10 indicated the call light must have fallen. During an interview, on 04/23/2026 at 3:29 P.M., the Physical Therapist indicated the resident fell frequently. The hardest part for her was getting out of bed in the morning, she required a lot of assistance. When she first stood up and walked, she was unsteady. Staff usually stood with her when she first would get up and walked with her down to the dining room. Throughout the day, the resident was more awake and she would get up and ambulate on her own with stand-by assistance. During an interview, on 04/24/2026 at 10:48 A.M., the Infection Preventionist indicated to ensure call lights were in reach for residents the staff would give the call light to the resident when they laid them down or when they were in their chairs. The clinical record was reviewed on 04/21/2026 at 2:24 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 02/10/2026, indicated Resident 9 was rarely understood. The resident's diagnosis included, but was not limited to, dementia (a progressive, irreversible syndrome characterized by a decline in cognitive function, memory, language, and behavior, beyond normal aging, caused by damaged brain cells). The resident needed assistance with hygiene and was incontinent of bowel and bladder. The resident had two or more falls with no injury and two or more falls with minor injuries since the last assessment. The resident's Risk for Falls Care Plan included, but was not limited to, and intervention, with an approach start date of 05/30/2023, to keep the resident's call light in reach.The Interdisciplinary Team (IDT) Comprehensive Care Plan Policy, with a revised date of 10/2025, was provided by the Administrator on 04/23/2026 at 3:41 P.M. The policy indicated, .It is the policy of this facility that each resident will have an interdisciplinary comprehensive person-centered care plan developed and implemented.The care plan must include measurable goals and resident specific interventions based on resident needs and preferences to promote the resident's highest level of functioning including medical, nursing, mental, and psychosocial well-being .Purpose .Create an organized, resident-centered review on a routine basis .provided to maintain or restore health and well-being .410 IAC (Indiana Administrative Code) 16.2-3.1-3(v)(1)

Based on interview and record review, the facility failed to develop or implement care planned interventions related to hearing aids and implanted medical devices for 2 of 21 residents reviewed for Care Plans. (Residents 48 and 56)Findings include:1. During an interview, on 04/21/2026 at 10:26 A.M., Resident 48 indicated she did have some hearing loss. She received hearing aids last year. She didn't wear them because she was not sure how to adjust them. On 04/22/2026 at 9:42 A.M., the resident was observed in bed in her room. She indicated she thought her hearing aids were on a shelf near her bed. The CNAs (Certified Nurse Aides) never asked her about them, she didn't think they even knew she had them. The resident's hearing aids were observed in a case on a shelf of the plastic storage unit. The case was plugged in and was covered in a thin layer of dust. During an interview, on 04/22/2026 at 9:48 A.M., CNA 3 indicated that if a resident had hearing aids, she would ask if they wanted to wear them as part of routine Activities of Daily Living (ADL) care. She would assist them with putting the hearing aids on and making sure they were in the correct ear and that they were functioning without issue. She routinely provided care for the resident. She had never assisted the resident with hearing aids; she didn't even know the resident had hearing aids. During an interview, on 04/22/2026 at 10:00 A.M., Licensed Practical Nurse (LPN) 19 indicated the resident didn't wear hearing aids. She thought she had her hearing tested recently, like in the last three or four months. The resident's clinical record was reviewed on 04/22/2026. A Quarterly Minimum Data Set (MDS) assessment, dated 04/01/2026, indicated the resident was cognitively intact. The resident had minimal hearing difficulty and did not wear hearing aids. A Progress Note, dated 08/22/2025 at 10:39 A.M., indicated the resident's hearing aids were delivered and adjusted for fit. A Progress Note, dated 01/07/2026 at 07:27 A.M., indicated the resident was seen by the audiologist on 01/06/2026. The hearing aids were to be cleaned after each use. The hearing aids should be kept on the charger when not in use. Please assist the resident by inserting the hearing aids in the morning and removing the hearing aids in the evening. Please charge the hearing aids for at least three hours every day before wearing. The resident was to wear the hearing aids daily. The resident's Communication Care Plan, with a start date of 03/17/2025, and a revision date of 04/07/2026, indicated the resident had hearing loss. The interventions included, but were not limited to: - An intervention, with a start date of 03/17/2025, indicated the staff were to check to ensure the resident's hearing aids are clean, functioning, and properly placed into both ears. During an interview, on 04/22/2026 at 9:48 A.M., CNA 3 indicated they had CNA papers that contained important information about each resident; things like how much assistance a resident would need when transferring, fall interventions, if they wore dentures or glasses, things like that. Everything on the CNA papers was part of the resident's Care Plan on the computer. The CNA paper for the resident indicated staff were to check that her hearing aid(s) were clean, functioning, and properly placed into both ear(s). They were to store the hearing aid(s) in the resident's room or in the nurse's cart. When the CNA opened the computer to review the resident's record, she did not see interventions related to the resident's hearing aids on the screen. She indicated everything on the CNA papers should be accessible on the computers the CNAs used to document care. During an interview, on 04/22/2026 at 10:30 A.M., CNA 3 indicated she was unaware that she could open a resident's Care Plan in the computer and review the resident specific interventions. 2. During an interview, on 04/23/2026 at 9:08 A.M., Registered Nurse (RN) 11 indicated the resident came to the facility with his urinary catheter. The resident had an inflatable pump in his penis. The resident always complained of penis pain, but it would fluctuate. The resident's penis was not flaccid and always stayed a little erect. The resident had a penile tear that has since healed but would never grow back. The tear was from his long-term urinary catheter use. The resident had gone to a urology consult recently and believed he was going to get a suprapubic catheter; he was going to go back for a follow up appointment in a few days. During an interview, on 04/23/2026 at 2:35 P.M., the Assisted Director of Nursing (ADON) indicated the resident admitted to the facility with a catheter. There was a weekend when the staff called her and indicated the resident had a laceration to his penis. It was a typical keratosis (a rare, benign [non-cancerous] skin growth appearing as tan, brown, or black waxy, stuck-on papules or plaques), that the resident always had that had become more inflamed. The resident would frequently adjust his urinary catheter himself. The staff should be monitoring the resident's skin while providing urinary catheter care that was completed every shift. The resident had his first urology visit last week. Historically the resident had a penile pump, but she had never seen it function. She believed it would have been documented on the admission assessment. The resident had told them about the implant on admission. She didn't think the facility had a policy to care plan a resident for a penile pump only for pacemakers and pain pumps. The clinical record for Resident 56 was reviewed on 04/22/2026 at 1:57 P.M. A Quarterly MDS assessment, dated 02/09/2026, indicated the resident was cognitively intact. The resident's diagnoses, included but were not limited to, vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, damaging tissue) and obstructive uropathy (a structural or functional blockage of urine flow, leading to urine backflow, potential kidney swelling (hydronephrosis), and kidney damage. The residents care plan lacked a care plan related to the penile pump. The current facility policy, titled IDT Comprehensive Care Plan Policy, revised on 10/2025, was provided by the Administrator on 04/23/2026 at 3:41 P.M. The policy indicated, .It is the policy of this facility that each resident will have an interdisciplinary care plan developed and implemented. 410 IAC (Indiana Administrative Code) 16.2-3.1-35(b)(1)

Based on observation, interview, and record review, the facility failed to update or revise residents' care plans related to hearing aids and preventative measures related to skin impairments for 2 of 21 residents reviewed for care plan revisions. (Residents 48 and 12)Findings include:1. During an interview, on 04/21/2026 at 10:26 A.M., Resident 48 indicated she did have some hearing loss. She got hearing aids last year. She didn't wear them because she was not sure how to adjust them.On 04/22/2026 at 9:42 A.M., the resident was observed in bed in her room. She indicated she thought her hearing aids were on a shelf near her bed. The CNAs (Certified Nurse Aides) never asked her about them, she didn't think they even knew she had them. The resident's hearing aids were observed in a case on a shelf of the plastic storage unit. The case was plugged in and was covered in a thin layer of dust. During an interview, on 04/22/2026 at 9:48 A.M., CNA 3 indicated that if a resident had hearing aids, she would ask if they wanted to wear them as part of routine Activities of Daily Living (ADL) care. She would assist them with putting the hearing aids on and making sure they were in the correct ear and that they were functioning without issue. If a resident refused to wear their hearing aids or was having a problem with their hearing aids, she would let the nurse know. She would not document anything about it but would tell the nurse and thought the nurse would document something in the resident's record. She routinely provided care for the resident. She had never assisted the resident with hearing aids; she didn't even know the resident had hearing aids. During an interview, on 04/22/2026 at 10:00 A.M., Licensed Practical Nurse (LPN) 19 indicated the resident didn't wear hearing aids. She thought she had her hearing tested recently, like in the last three or four months. If a resident had hearing aids and wasn't wearing them, she would document it in the resident's record. She would let the Social Services Director (SSD) know.The resident's record lacked documentation that she was not wearing her hearing aids.The resident's clinical record was reviewed on 04/22/2026. A Quarterly Minimum Data Set (MDS) assessment, dated 04/01/2026, indicated the resident was cognitively intact. The resident had minimal hearing difficulty and did not wear hearing aids.A Progress Note, dated 08/22/2025 at 10:39 A.M., indicated the resident's hearing aids were delivered and adjusted for fit.A Progress Note, dated 01/07/2026 at 07:27 A.M., indicated the resident was seen by the audiologist on 01/06/2026. The hearing aids were to be cleaned after each use. The hearing aids should be kept on the charger when not in use. Please assist the resident by inserting the hearing aids in the morning and removing the hearing aids in the evening. Please charge the hearing aids for at least 3 hours every day before wearing. The resident was to wear the hearing aids daily. An Audiologist Group Visit Note in the resident's Electronic Health Record (EHR) indicated a hearing aid check was performed on 01/06/2026. The progress notes section of the document indicated the hearing aids worked well. It was important to note that turning the volume up on one hearing aid would change the volume on both aids simultaneously. The hearing aids fit well and the resident was hearing well. The nurses were to insert and remove the hearing aids. The hearing aids were paired to the resident's cell phone so the resident could control the volume. The resident was very happy about that. The resident's Communication Care Plan, with a start date of 03/17/2025, and a revision date of 04/07/2026, indicated the resident had hearing loss. The interventions included, but were not limited to:- An intervention, with a start date of 03/17/2025, to check that hearing aids are clean, functioning, and properly placed into both ears, and- An intervention, with a start date of 03/17/2025, that if the resident refused to wear her hearing aids, explore the reason for refusal.During an interview, on 04/22/2026 at 10:09 A.M., the Social Service Director (SSD) indicated the resident had hearing aids. She was last seen by the audiologist on 07/16/2025. The resident never mentioned that she had any issues with the hearing aids. During an interview, on 04/22/2026 at 10:11 A.M., the Assistant Director of Nursing (ADON) indicated if a resident was refusing to wear their hearing aids they would look into it. They would open a Hot Charting Event in the resident's record where they would monitor the situation. They would document what was going on, what they tried to do to address the issue, and if the resident continued to refuse to wear them. They would update the resident's care plan to reflect the interventions and the resident's refusal. The resident's care plan lacked documentation it was revised related to the resident's non-use of or refusal to wear their hearing aids.During an interview, on 04/22/2026 at 10:30 A.M., LPN 19 indicated she went to the resident's room and assisted the resident with putting in her hearing aids. The resident immediately indicated the hearing aids needed to be adjusted. The LPN thought there should be a Hot Charting Event opened in the resident's record. The audiologist should have told them they adjusted the resident's hearing aids and that the resident could adjust them with her cell phone when they came in to see her in January. 2. During an interview, on 04/21/2026 at 9:37 A.M., Resident 12's family member indicated they were concerned about how the resident kept injuring her lower legs. She had experienced bruising and skin tears on her lower legs.The resident's clinical record was reviewed on 04/23/2026 at 9:52 A.M. A Significant Change MDS assessment, dated 12/22/2025, indicated the resident was severely cognitively impaired. The resident's diagnosis included, but was not limited to, dementia (a decline in mental ability severe enough to interfere with daily life, caused by physical changes in the brain). The resident had no skin impairments. The resident used a manual wheelchair and was able to propel herself short distances independently.A Progress Note, dated 02/14/2026 at 12:00 A.M., indicated the resident was found to have bruising on her left lower leg. The bruising was noted to align with the resident's wheelchair pedal. Staff were educated to ensure the resident's wheelchair pedals and the resident's legs were in the appropriate place.An Interdisciplinary Team (IDT) Progress Note, dated 02/16/2026, indicated the resident had bruising to her left leg. The root cause was determined to be that the resident moved her feet off the wheelchair foot pedals at times to propel herself without moving the pedals to the side. The new intervention was to remove the pedals from the chair.A Wound Review IDT Note, dated 03/23/2026 at 11:02 A.M., indicated the resident had a skin tear to the back of her left leg. The root cause was determined to be related to the resident hitting her legs on her wheelchair foot pedals. The new intervention was to remove the wheelchair foot pedals when not in use. A Wound Review IDT Note, dated 04/11/20260 at 4:12 A.M., indicated the resident had a skin tear on the back of her right leg. The root cause was determined to be related to mechanical trauma from hitting her legs on the wheelchair foot pedals. The new intervention was to apply support bandages/stockings to the resident's legs to protect her skin. The resident's Care Plans that were in place on 03/23/2026 and 04/11/2026 were reviewed on 04/23/2026 at 10:04 A.M. The Care Plans lacked indication they were updated to include the interventions to remove the resident's foot pedals from her wheelchair to help prevent injury to her legs.During an interview, on 04/24/2026 at 10:17 A.M., the Director of Nursing indicated during that time she thought hospice had provided a smaller wheelchair for the resident and that wheelchair would have come with foot pedals. Recently, the resident received a new, high-backed wheelchair and no longer propelled herself. The resident's Care Plan should have been updated to indicate the foot pedals should have been removed from the wheelchair if that was an implemented intervention to prevent injuries to the resident's legs. The current facility policy, titled IDT Comprehensive Care Plan Policy, revised on 10/2025, was provided by the Administrator on 04/23/2026 at 3:41 P.M. The policy indicated, .It is the policy of this facility that each resident will have an interdisciplinary care plan developed and implemented.Care plan problems, goals, and interventions must be reviewed and revised by the interdisciplinary team periodically. 410 IAC (Indiana Administrative Code) 16.2-3.1-35(b)(2)410 IAC (Indiana Administrative Code) 16.2-3.1-35(d)(2)(B)

Based on record review and interview, the facility failed to have ongoing communication and collaboration with the dialysis center regarding a residents prescribed medications during dialysis care days for 1 of 1 resident reviewed for dialysis services. (Resident 4) Findings include:The clinical record for Resident 4 was reviewed on 04/22/2026 at 3:44 P.M. An admission Minimum Data Set (MDS) assessment, dated 04/08/2026, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, end stage renal disease (permanent, stage 5 chronic kidney failure, where kidneys function below 10 to 15% and cannot support life, requiring regular dialysis or a kidney transplant), hypertension (high blood pressure), hypokalemia (a condition characterized by low blood potassium levels, essential for nerve, muscle, and heart function), atrial fibrillation (a common heart rhythm disorder characterized by rapid, chaotic electrical signals causing the upper chambers (atria) to quiver instead of beating effectively, resulting in an irregular, fast heartbeat), and depression (a common, serious mood disorder characterized by persistent sadness, loss of interest in activities, fatigue, and cognitive difficulties, lasting at least two weeks). The resident received dialysis treatments while a resident.The April 2026 Electronic Medication Administration Record (EMAR) indicated the resident did not receive the following medications on the following dates and times: - Amiodarone tablet; 200 milligrams (mg) once a day for a diagnosis of Atrial Fibrillation was not administered, on 04/03/2026 from 7:00 A.M. to 11:00 A.M. and on 04/06/2026 from 7:00 A.M. to 11:00 A.M., due to the resident not being available. - Carvedilol tablet; 3.125 mg twice a day for a diagnosis of hypertension was not administered, on 04/03/2026 from 7:00 A.M. to 11:00 A.M. and on 04/06/2026 from 7:00 A.M. to 11:00 A.M., due to the resident not being available. - Eliquis (apixaban) tablet; 5 mg twice a day for a diagnosis of Atrial Fibrillation was not administered, on 04/03/2026 from 7:00 A.M. to 11:00 A.M. and on 04/06/2026 from 7:00 A.M. to 11:00 A.M., due to the resident not available. - Potassium chloride tablet extended release; 10 Milliequivalents once a day for a diagnosis of hypokalemia was not administered, on 04/03/2026 from 7:00 A.M. to 11:00 A.M. and on 04/06/2026 from 7:00 A.M. to 11:00 A.M., due to the resident not being available. - Sertraline tablet; 25 mg once a day for a diagnosis of depression was not administered, on 04/03/2026 from 7:00 A.M. to 11:00 A.M. and on 04/06/2026 from 7:00 A.M. to 11:00 A.M., due to the resident not being available. - Velphoro (sucroferric oxyhydroxide) tablet, chewable; 500 mg three times a day for a diagnosis of End Stage Renal Disease was not administered, on 04/03/2026 at 7:00 A.M. and on 04/06/2026 at 7:00 A.M., due to the resident not being available. During an interview, on 04/23/2026 at 10:42 A.M., Licensed Practical Nurse (LPN) 19 indicated Resident 4 went out for dialysis treatments on Monday, Wednesday, and Friday. The resident received some medications multiple times throughout the day. The resident could get his medications before he left for dialysis or when he returned, it just depended on the nurse on duty. During an interview, on 04/24/2026 at 10:52 A.M., LPN 18 indicated for residents who left the facility for dialysis treatments, the staff managed their medications. It depended on how the medication was ordered. They just followed the physicians' orders on the EMAR. During an interview, on 04/24/2026 at 1:07 P.M., the Director of Nursing indicated Resident 4 had not received his Amiodarone medication on April 3 and on April 6, the resident was unavailable. The Amiodarone was prescribed for his Atrial Fibrillation. The nurse on duty did not give the resident his medications because he was out of the facility at dialysis. The DON indicated the facility did not have a policy that said when residents were out of the building when they should give a resident their medications. The current Dialysis Care policy, with a reviewed date of 11/2017, provided by the Regional Director of Clinical Services on 04/24/2026 at 10:19 A.M. The policy indicated, .to ensure that residents requiring dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care, and the residents' goals and preferences. The facility will assure that each resident receives care and services for the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice .410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on observation, interview, and record review, the facility failed to administer medications appropriately and have medications available for 2 of 22 residents reviewed for pharmacy services. (Residents 82 and 77)Findings include:1. During an observation, on 04/23/2026 at 9:00 A.M., Registered Nurse (RN) 11 provided a treatment to Resident 82. After the treatment was complete, there was a medication cup observed on the resident's over the bed table that contained two pink tablets. RN 11 gave the medications to the resident. During an interview, on 04/23/2026 at 11:42 A.M., RN 11 indicated the tablets she gave the resident in her room were antacids. There was a nurse in training, Licensed Practical Nurse (LPN) 12, that had prepared the medications and took them to the resident before she went into the resident's room to complete the treatment. She asked the nurse to wait to give her the medications until after she was done with her treatment. Usually, the nurse who prepared the medication was the nurse that would administer the medication. The clinical record for Resident 82 was reviewed on 04/22/2026 at 1:17 P.M. The resident admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to, stricture of artery (thick-walled, elastic blood vessel) and peripheral vascular disease (a slow, progressive circulation disorder involving narrowing, blockage, or spasms in blood vessels). The current facility policy titled, Medication Administration, with a revision date of 4/2025, was provided by the Administrator on 04/23/2026 at 4:16 P.M. The policy indicated, .Observe resident taking medications.2. The clinical record for Resident 77 was reviewed on 04/23/2026 at 9:57 A.M. A Significant Change Minimum Data Set (MDS) assessment, dated 03/15/2026, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited, Metabolic encephalopathy (a brain dysfunction caused by underlying systemic illnesses-such as liver failure, kidney failure, or diabetes-that disrupt normal metabolism, leading to altered brain chemistry) and adult failure to thrive. The February and March 2026 Electronic Medication Administration Record indicated the resident had not received the following medications due to them being unavailable:- Megestrol Suspension 400 mg, twice a day for adult failure to thrive. The resident did not receive the medications on 02/25/2026 from 7:00 P.M. to 11:00 P.M., 02/26/2026 from 7:00 A.M. to 11:00 A.M., and 02/26/2026 from 7:00 P.M. to 11:00 P.M., and - Sodium Chloride 1,000 mg, three times a day. The resident did not receive the medications on 03/02/2026 at 2:00 P.M., 03/02/2026 at 8:00 P.M., and 03/03/2026 at 8:00 A.M. The resident's clinical record lack physician notification related to the resident's medications not being available. During an interview, on 04/24/2026 at 10:34 A.M., RN 11 indicated if a resident's medication wasn't available in the medication cart, then she would check their emergency drug kit. If it was available from there then she would get it and administer it. If the medication was not available in the emergency drug kit, then she would get it STAT (immediately or without delay). If she ordered it STAT, then it would come within two to four hours. They would get medications delivered daily from 6:00 A.M. to 8:00 A.M. If resident's medications weren't available, then the physician should be notified. She would document in the EMAR or the progress notes that the medication was unavailable and that the physician was notified. The current facility policy titled, Medication Shortages/Unavailable Medications, with a revision date of 08/01/2024, was provided by the Regional Director Clinical Services on 04/24/2026. The policy indicated, .Upon discovery that Facility has an inadequate supply of a medication to administer to a resident, Facility staff should immediately initiate action to obtain the medication from Pharmacy.If the medication shortage is discovered at the time of medication administration, Facility staff should immediately notify the Pharmacy.410 IAC (Indiana Administrative Code) 16.2-3.1-25(a)410 IAC (Indiana Administrative Code) 16.2-3.1-25(b)(4)

Based on record review and interview, the facility failed to ensure misappropriation of resident's medications did not occur for 2 of 3 residents reviewed for misappropriation. (Resident B and Resident C) Findings include:1. During an interview, on 07/18/25 at 9:18 A.M., Registered Nurse (RN) 2 indicated that Resident B requested pain medication on 06/19/25 around 10:00 P.M While administering the medication she noticed the pills popped out of the card lightly. Upon observation, she identified tape on the back of the card holding in the two pills she had dispensed. Both pills were different shapes and upon observation one had a small, scratched mark in the center of it to make it appear scored. She immediately contacted the Director of Nursing (DON) and notified her of the findings. After she checked the entire medication cart for other discrepancies, she determined Resident C also had a medication taped back into his narcotic medication card. The clinical record for Resident B was reviewed on 07/18/2025 10:20 AM. A Quarterly Minimum Data Set (MDS) assessment, dated 07/02/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, hypertension, malnutrition, and Parkinson's disease. A current physician's order, with a start date of 04/07/25, indicated that staff were to administer Norco (a narcotic pain medication), 5-325 milligrams (mg), 2 tablets by mouth every six hours as needed for pain. A controlled drug record for Norco for Resident B, dated 05/30/25, indicated the medication was signed out by RN 4 on 06/19/25 at 05:00 P.M. changing the quantity from 15 pills to 13 pills. On 06/19/25 at 11:00 P.M. RN 2 changed the quantity remaining to 11 pills, after discovering the two pills packaging for #13, and #12 were altered and they were not the correct medication. Then reduced it into 9 pills remaining after administrating two unaltered pills to the resident. During an interview, on 07/18/2025 10:49 AM., Resident B indicated she usually asked for pain medicine at night before bed and just took a Tylenol during the day if she was feeling some pain. During an interview, on 07/17/2025 10:50 AM, Licensed Practical Nurse (LPN) 3 indicated she was orienting RN 4 on 06/19/25. It was RN 4's first day on orientation, so that morning she just watched LPN 3 pass morning medications. Around 10:00 A.M. RN 4 asked to have the keys to the medication cart so that she could familiarize herself with the cart. LPN 3 gave RN 4 the keys to the cart. Later, RN 4 asked if she could do some insulins before lunch and LPN 3 allowed her to. Then she returned the keys back to her before they left for lunch. After lunch RN 4 asked for the keys to the cart again to administer an oral medication that a resident took after lunch. An extended period of time went by after RN 4 went to give the oral medication, so LPN 3 went looking for her. LPN 3 could not find RN 4. During a second attempt with additional staff, they located her in a resident's bathroom. RN 4 stated she had washed her hands. Later that evening RN 4 questioned LPN 3 asking if she was pretty good at memorizing her pills. LPN 3 stated she never administered the medications without the Medication Administration Record in front of her to prevent any errors. During evening shift change the narcotic medications were counted with on coming staff. RN 4 counted with night shift, and all counts appeared correctly because there were pills in each bubble. They never looked at the backside of the cards. LPN 3 stated RN 4 should have never been in the narcotics box at all during their shift. Only one narcotic was administered that day and it was that morning and LPN 3 administered it herself. During an interview, on 07/17/2025 at 10:09 AM, the Director of Nursing (DON) indicated that when she called RN 4 in to investigate the missing narcotics, she admitted to taking the medications. RN 4 stated she replaced the pills with other medications, and stated she checked the resident's allergies to make sure it wouldn't cause a reaction when they received the wrong medication. After they finished their investigation, RN 4 was terminated. 2. The clinical record for Resident C was reviewed on 07/17/2025 3:19 P.M. A Significant Change in Status MDS assessment, dated 06/19/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, malnutrition, asthma, and diabetes. A current physician's order, with a start date of 05/16/25, indicated the staff were to administer Norco 5-325 mg, 1 tablet by mouth every six hours as needed for pain to Resident C. A controlled drug record for Norco for Resident C, dated 05/26/25, indicated the medication was signed out by RN 4 on 06/19/25 at 05:10 P.M. changing the quantity from 25 pills to 24 pills. On 06/19/25 at 11:30 P.M. RN 2 corrected the quantity remaining to 23 pills after discovering the #24 pill was not the correct medication and the packaging had been altered. The current facility policy titled, Abuse Prohibition, Reporting, and Investigation, with a revision date of June 2023, was provided by the DON on 07/17/25 at 11:20 A.M. The policy indicated, .the policy. to provide each resident with an environment free from abuse, neglect, misappropriation of resident property.misappropriation of resident funds or property - deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's property or money without the resident's consent . This deficient practice was corrected on 07/09/25 after the facility reviewed records, assessed residents, educated staff, discharged the staff member, and added new audits for monitoring narcotic counts. This citation relates to Complaint 1808214. 3.1-28(a)

Based on observation, interview, and record review, the facility failed to maintain resident snack refrigerators appropriately related to the storage of staff food items, incomplete labeling, and the storage of non-food items for 2 of 3 resident snack refrigerators observed. (100/200 Hall Resident Snack Refrigerator and the 400 Hall Resident Snack Refrigerator) Findings include: 1. The 100/200 Hall Resident Snack Refrigerator was observed on 04/28/25 at 12:38 P.M., with Licensed Practical Nurse (LPN) 7, and contained the following: - LPN 7's lunch bag, - One unopened carton of vanilla ice cream with no resident name, date, or room number, - One opened carton of vanilla ice cream dated 03/11/25 with no resident name or room number, - A tan plastic grocery bag with a paper note labeled with Qualified Medication Aide (QMA) 4's name and the numbers, 3-12 to 6-12, as identified by LPN 7, and - One long, over 12 inches, black ice pack with no resident name. The signage on the front of the refrigerator indicated the REFRIGERATOR RULES included, but were not limited to, For Residents & Visitors Only (Not For Staff Personal Items); Every open item must have a label with an open date and a use by date; NO STAFF FOOD! USE FRIDGE IN 400 HALL BREAK ROOM. The 100/200 Hall Resident Snack Refrigerator was observed on 04/28/25 at 12:51 P.M., with the Physical Therapist (PT). PT indicated the black ice pack belonged to the Therapy Department and had been used on a resident's neck. He did not know how the ice pack had gotten into the residents' snack refrigerator. 2. The 400 Hall Resident Snack Refrigerator was observed on 04/28/25 at 12:58 P.M., with Medical Records, and contained the following: - One open bottle of yellow soda, 3/4 full, dated 04/22/25, with the initials A.H., and - One unopened bottle of dark soda, dated 04/22/25, with the initials A.H. During an interview on 04/28/25 at 1:00 P.M., LPN 8 indicated there were no residents residing on the 400 Hall who had the initials A.H. The current Food Brought in by Family and Visitors policy, with a revised date of 05/2023, was provided during the Entrance Conference. The policy indicated, .Food brought in by family and visitors will be easily distinguishable from facility food and stored to ensure food safety .If food must be stored, it will be labeled with the resident's name, the date the item was brought in, and the date it should be consumed or discarded .Staff will monitor for food in need of disposal . 3.1-21(i)(3)

Based on interview, observation, and record review, the facility failed to prevent pressure ulcers and implement Care Plan interventions for a resident who was at risk for pressure ulcers for 1 of 5 residents reviewed. (Resident 23) Findings include: During an interview and observation, on 04/22/25 at 12:41 P.M., Resident 23 indicated he had sores on both of his heels, and it felt like pins and needles were sticking into them. His heels were lying flat against the bed mattress. No soft boots or extra pillows were noted in the visible area. The resident indicated staff did not put a pillow behind his calves to keep the pressure off his heels or put soft boots on his feet. During an observation, on 04/23/25 at 3:45 P.M., the resident was lying in bed with his eyes closed, flat on his back with his heels flat against the bed mattress. No extra pillows or soft boots were noted on the floor or in the immediate area. During an observation, on 04/24/25 at 9:42 A.M., the resident was lying in bed with his eyes closed, flat on his back with his heels flat against the bed mattress. Staff members were exiting the room following the provision of care, carrying bags of soiled linens. The resident's wound treatments were observed, on 04/25/25 at 12:58 P.M., with Licensed Practical Nurse (LPN) 2. The nurse donned a gown and gloves, explained the procedure to the resident, and removed the soft boots and socks from the resident's feet. The left heel had a thick dime sized dried scab. The right heel had a silver dollar size dark area with a nickel size dried scab in the center. During an interview, on 04/25/25 at 2:51 P.M., Certified Nurse Aide (CNA) 5 and CNA 6 indicated Resident 23 required two staff members for assistance with transferring from his wheelchair to the bed. During an interview, on 04/25/25 at 3:37 P.M., the Director of Nursing (DON) indicated the resident's heels started looking purple on 03/07/25. During an interview, on 04/28/25 at 1:45 P.M., the Assistant Director of Nursing (ADON) indicated the resident was admitted to the facility from the hospital on 02/25/25. He had no pressure ulcers at that time. He had calluses on both heels but no Deep Tissue Injuries (DTIs), just thick calluses. On 03/07/25, a CNA came and told her the resident had some discoloration on his heels. She went and measured them, and they were both 2.5 centimeters (cm) x (by) 1.5 cm, with no depth or drainage. She applied Skin Prep (a skin toughening agent), floated his heels using pillows, completed an Event in the computer, and opened a new Care Plan on 03/07/25. Preventative measures in place prior to the development of the pressure ulcers included a pressure reducing mattress, a pressure reducing cushion to his wheelchair, turning and repositioning every two hours and as needed, an incontinence care check every two hours and as needed, and house barrier cream as needed for incontinence care. That was the standard practice and in place prior to the development of the DTIs to his heels. They were not doing anything extra for the resident's feet prior to the development of the DTIs. He required staff help for positioning. Sometimes one person could roll him from side to side. For scooting up in bed, the resident needed the assistance of two staff members. The clinical record for Resident 23 was reviewed on 04/24/25 at 10:49 A.M. The resident's admitted was 02/25/25. A Significant Change Minimum Data Set (MDS) assessment, dated 04/21/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, heart failure, obstructive uropathy, diabetes, and depression. The resident was at risk for pressure ulcers and had two unstageable Deep Tissue Injuries that were not present on admission. The resident had a pressure reducing device for the bed and his chair. The Admission MDS assessment, dated 03/04/25, indicated the resident was at risk for pressure ulcers but had no unhealed pressure ulcers. The New Skin Event records, dated 03/07/25, were provided by the DON on 04/25/25 at 3:31 P.M., and indicated the resident had the following: - A DTI to the right heel, measuring 2.5 cm x 0.5 cm, purple in color, with a new treatment order for Skin Prep, and - A DTI to the left heel, measuring 2.5 cm x 0.5 cm, purple in color, with new treatment orders for Skin Prep and to float the heels. The CNA Approaches on Profile pocket sheets describing individual resident needs and interventions was provided by CNA 6 on 04/24/25 at 2:10 P.M. The record indicated Resident 23 had DTIs to his left and right heels, his heels were to be floated while in bed, and he was to wear Heel Boots (soft pillow-like boots) while in bed. The Admission Braden Scale for Predicting Pressure Sore Risk assessment, dated 02/25/25, was provided by the Regional Director of Clinical Services on 04/28/25 at 2:05 P.M. The record indicated the resident was at Moderate Risk for pressure sores. The current SKIN MANAGEMENT PROGRAM policy, dated 05/2022, was provided by the DON on 04/25/25 at 3:31 P.M. The policy indicated, .It is the policy of American Senior Communities to ensure that each resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers .and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing . 3.1-40(a)(1) 3.1-40(a)(2)

Based on record review and interview, the facility failed to ensure the physician prescribed medications were available for 2 of 6 residents reviewed for pharmacy services. (Residents 23 and 35) Findings include: 1. The clinical record for Resident 23 was reviewed on 04/24/25 at 10:49 A.M. The resident's admitted d was 02/25/25. A Significant Change Minimum Data Set (MDS) assessment, dated 04/21/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, heart failure, obstructive uropathy, diabetes, and depression. The Electronic Medication Administration Record (EMAR) indicated the resident had a physician's order, with a start date of 02/25/25 and a discontinued date of 04/07/25, for Modafinil 100 milligrams (mg) once a day for a diagnosis of major depressive disorder. The medication was not administered on the following dates due to the medication not being available: - 02/26/25, - 02/27/25, - 02/28/25, - 03/01/25, - 03/02/25, - 03/03/25, - 03/04/25, - 03/05/25, and - 03/10/25. During an interview, on 04/25/25 at 2:07 P.M., the Director of Nursing (DON) indicated when a resident was admitted , the nurse on the floor admitting the resident would transcribe the resident's medication orders into the computer system and the medication orders were automatically sent to the pharmacy. The medications should arrive within 24 hours. If a medication was not available right away the facility could use a local pharmacy, or the family could bring in medications they had at home. 2. The clinical record for Resident 35 was reviewed on 04/28/25 at 9:32 A.M. An Admission MDS assessment, dated 03/24/25, indicated the resident was cognitively intact. The resident's diagnosis included, but were not limited to, hepatic encephalopathy, ascites (build-up of fluid in the abdomen), and Nonalcoholic Steatohepatitis (NASH). The EMAR indicated the resident had a physician's order for Xifaxan 550 mg twice a day for a diagnosis of NASH, with a start date of 03/07/25 and a discontinued date of 03/13/25. The medication was not administered on the following dates and times due to the medication not being available: - 03/07/25 from 7:00 P.M. to 11:00 P.M., - 03/08/25 from 7:00 A.M. to 11:00 A.M., - 03/08/25 from 7:00 P.M. to 11:00 P.M., - 03/09/25 from 7:00 A.M. to 11:00 A.M., - 03/09/25 from 7:00 P.M. to 11:00 P.M., - 03/10/25 from 7:00 A.M. to 11:00 A.M., - 03/10/25 from 7:00 P.M. to 11:00 P.M., and - 03/11/25 from 7:00 A.M. to 11:00 A.M. During an interview, on 04/28/25 at 9:56 A.M., the Assistant Director of Nursing (ADON) indicated Resident 35 came to the facility following a hospital stay. He had formerly lived at a local Assisted Living (AL) facility. The resident received paracentesis treatments (needle drainage of fluid from a body cavity) due to his diagnosis of NASH. They had to get his supply of Xifaxan from the local AL he had resided at because it was high-cost medication and there was extra paperwork involved. The resident should not have gone five days without his medication. When the medication was ordered, the nurse on the floor would call the pharmacy about the medication and complete the required documents. The resident was discharged to the hospital on 03/11/25. When the resident came back from the hospital on 03/17/25, the facility had received the medication. The medication was for the resident's diagnosis of NASH. The medication is categorized as an antibiotic. The current Medication Shortages/Unavailable Medications policy, with an effective date of 12/01/07, was provided by the DON on 04/25/25 at 3:31 P.M. The policy indicated, .If a medication is unavailable during normal Pharmacy hours .If the medication has not been ordered, the licensed Facility nurse should place the order or reorder for the next scheduled delivery .If the next available delivery causes a delay or a missed dose in the resident's medication schedule, Facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose .If the medication is not available in the Emergency Mediation Supply, Facility staff should notify Pharmacy and arrange for a STAT (immediate) delivery, if medically necessary .If a medication is unavailable is [sic] discovered after normal Pharmacy hours .Facility nurse should call Pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. Action may include .Emergency delivery .or .Use of an emergency (back-up) third-party Pharmacy . 3.1-25(a)

Based on interview and record review, the facility failed to follow physician's orders related to a Gradual Dose Reduction (GDR) of a medication for 1 of 18 residents reviewed for quality of care. (Resident 47) Findings include: Resident 47's clinical record was reviewed on 04/23/35 at 2:00 P.M. A Quarterly Minimum Data Set assessment, dated 02/05/25, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, dementia, psychotic disorder, and depression. The resident experienced hallucinations. The resident's medication orders as of 01/15/25 included, but were not limited to, the following: - An open-ended order, with a start date of 07/12/24, for Risperdal (an antipsychotic medication). The resident received 1 milligram (mg) of the medication in the morning and 0.5 mg in the evening, and - An open-ended order, with a start date of 11/21/24, for sertraline (an antidepressant medication). The resident received 150 mg at bedtime. An Evaluation for Gradual Dose Reduction of Psychotropic Medication, dated 01/15/25, recommended a GDR of the Risperdal medication. The Psychiatric Nurse Practitioner (Psych NP) gave new physician's orders to increase the resident's sertraline to 200 mg every day and decrease the resident's Risperdal to 0.5 mg twice a day. A Progress Note documented by the Social Services Director, dated 01/15/25 at 1:17 P.M., indicated the Psych NP ordered a reduction of the resident's Risperdal to 1 mg in the morning and 0.5 mg in the evening, and an increased in the resident's sertraline to 200 mg in the evening. There was no indication in the resident's record that the medication orders were changed and the resident continued to receive the medications daily at the previously ordered doses. A Nursing Progress Note, dated 01/19/25 at 6:27 A.M., indicated the resident experienced no psychosocial distress related to the GDR of the Risperdal and the increase of the sertraline. A Nursing Progress Note, dated 01/21/25 at 9:39 A.M., indicated the resident experienced no psychosocial distress related to the GDR of the Risperdal and the increase of the sertraline. A Nursing Progress Note, dated 01/23/25 at 3:22 A.M., indicated the resident was hallucinating. He was seeing bugs on his feet. A Behavior Review Note, dated 01/24/25 at 12:40 P.M., indicated the resident urinated on the floor and exhibited increased confusion. A Nursing Progress Note, dated 01/24/25 at 3:43 P.M., indicated the resident's urine was checked and the results indicated the resident did not have a urinary tract infection. On 01/24/25, the resident's Risperdal medication order was changed to 0.5 mg twice a day. The resident's sertraline order remained the same, 150 mg at bedtime. The resident received the medications daily as ordered. A Pharmacy Consultation Report, dated 02/13/25, indicated the following: ***CLINICAL PRIORITY RECOMMENDATION: PROMP RESPONSE REQUESTED*** During the behavior management meeting in January, an order was given to increase the resident's sertraline to 200 mg a day. The order has not been processed. The resident continued on 150 mg daily. The resident's sertraline order was changed to 200 mg at bedtime on 02/14/25. During an interview, on 04/28/25 at 1:37 P.M., the Assistant Director of Nursing indicated the resident's orders weren't changed when the Psych NP decreased the Risperdal and increased the sertraline. The Psych NP came in a week later and realized the Risperdal hadn't been changed so she wrote a repeat order to decrease it again. Then, after the pharmacy recommendation they determined the sertraline hadn't been adjusted either. Nursing staff were noticing behaviors with the resident and thought the GDR was failing, but the medications hadn't actually been changed as ordered. During an interview, on 04/28/25 2:25 P.M., the Regional Director of Clinical Services indicated the facility did not have a policy related to following MD orders, it was just standard nursing practice. 3.1-25(i)

Based on interview and record review, the facility failed to completely and accurately document the assessment and monitoring of a resident after a fall for 1 of 3 residents reviewed for Resident Records. (Resident 58) Findings include: During an interview, on 04/23/25 at 1:03 P.M., Resident 58 and the resident's family member indicated the resident had fallen three times in three weeks. The family member was present for one of the falls and indicated the resident was standing with her walker when she started to feel shaky and fell to the floor. The family member notified staff at the time of the fall. The resident's clinical record was reviewed on 04/25/25 at 2:20 P.M. An Annual Minimum Data Set assessment, dated 02/11/25, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, hypertension, overactive bladder, and weakness. The resident used a walker and wheelchair. The resident required partial to moderate staff assistance to move from a sitting to a standing position and required staff supervision or touching assistance when walking. The resident experienced no falls since the last assessment. A Nursing Progress Note, dated 04/08/25 at 10:58 A.M., indicated the resident's family member requested help because the resident was on the floor next to her bed. The family member indicated the resident did not hit her head. The resident stood up to get into her wheelchair to go to lunch and said, I am going to fall. The resident lost her balance and fell to her right side. There were no injuries. A Nursing Progress Note, dated 04/08/25 at 11:06 A.M., indicated the Nurse Practitioner (NP), Director of Nursing (DON), and the resident's Power of Attorney (POA) were aware of the fall. The resident's record lacked further documentation related to the fall the resident experienced on 04/08/25. During an interview, on 04/25/25 at 2:20 P.M., Licensed Practical Nurse 9 indicated when a resident fell , nursing staff were to assess the resident and notify the NP, DON, Administrator, and POA. A progress note would be entered in the computer as well as a Fall Event. Specifics about the fall would be documented in the Fall Event so staff could determine what the issue might have been that caused the resident to fall, like if the resident wasn't wearing appropriate footwear or if they had to go to the bathroom so they got up without staff assistance. An immediate intervention would be put into place, and the Interdisciplinary Team (IDT) would review the fall to determine the root cause and if further interventions were warranted. The resident's care plan would be updated with any new interventions. During an interview, on 04/28/25 at 10:30 A.M., the Physical Therapist indicated he was familiar with the resident, and she was currently receiving physical therapy. She had experienced a few falls in the last month or so. He reviewed the facility's fall report every day. The report was generated from Fall Events documented in the residents' records. He was unaware the resident experienced a fall on 04/08/25 because there was not a Fall Event documented in the computer. During an interview, on 04/28/25 at 11:25 A.M., the Regional Director of Clinical Services (RDCS)indicated the resident did experience a fall on 04/08/25. There should have been a Fall Event created in the computer, an IDT review of the fall, and new fall intervention should have been implemented. The current facility policy, titled Fall Management Policy, dated 08/2022, was provided by the RDCS on 04/28/25 at 2:35 P.M. The policy indicated, .Any resident experiencing a fall will be assessed immediately .A fall event will be initiated as soon as the resident has been assessed and cared for .The report must be completed in full in order to identify possible root causes of the fall and provide immediate interventions .All falls will be discussed by the interdisciplinary team at the 1st IDT meeting after the fall to determine root cause and other possible interventions to prevent future falls .the fall event will be reviewed by the team .IDT note will be written .The care plan will be reviewed and updated as necessary .Hot Charting will be initiated post fall . 3.1-50(a)(2)

Based on record review and interview, the facility failed to follow physician's orders related to hold parameters for a resident's blood pressure medication for 1 of 18 residents reviewed for quality of care. (Resident 34) Findings include: A Quarterly MDS (Minimum Data Set) assessment, dated 02/24/24, indicated Resident 34 was severely cognitively impaired. The resident's diagnoses included, but were not limited to, Parkinson's disease, dementia, and hypertension. The resident's current physician's orders included an opened-ended order, with a start date of 11/16/22, for staff to administer Resident 34's losartan (a blood pressure medication). The resident was to receive 100 mg (milligrams) once a day. The medication was to be held if his SBP (Systolic Blood Pressure) was less than 110. The March and April 2024 EMAR (Electronic Medication Administration Records) indicated the resident received the medication when his SBP was less than 110 on the following dates: - On 03/14/24, the resident's SBP was 101, - On 03/30/24, the resident's SBP was 104, - On 04/08/24, the resident's SBP was 100, and - On 04/17/24, the resident's SBP was 108. During an interview on 05/17/24 at 2:51 P.M., LPN (Licensed Practical Nurse) 3 indicated if a resident had hold parameters for a blood pressure medication, the blood pressure should be assessed. If the resident's blood pressure was too low, staff were to hold the resident's medication and document it on the EMAR. During an interview on 05/17/24 at 3:32 P.M., the DON (Director of Nursing) indicated they did not have a facility policy on following MD orders, it was just standard nursing practice. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure medications were available and document medication administration for 1 of 14 residents reviewed for pharmacy services. (Resident 1) Findings include: 1.a. During an observation and interview on 05/17/24 at 12:57 P.M., Resident 1 was sitting in his wheelchair in his room. The resident had no current concerns with receiving his medications. The clinical record for Resident 1 was reviewed on 05/16/24 at 9:46 P.M. An Annual MDS (Minimum Data Set) assessment, dated 02/26/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, seizure disorder, depression, hypertension, and spinal stenosis. An open-ended physician's order, with a start date of 05/04/23, indicated the resident was to have phenytoin (an anticonvulsant medication) 150 mg (milligrams), adminiustered three times a day. The April and May 2024 EMAR/ETAR (Electronic Medication Administration/Electronic Treatment Administration Record) indicated the medication was not administered due to the drug/item being unavailable for the following dates and times: - On 04/10/24 at 8:00 P.M., - On 04/11/24 at 8:00 A.M., and 2:00 P.M., - On 04/12/24 at 8:00 P.M., and - On 05/13/24 at 8:00 A.M., 2:00 P.M., and 8:00 P.M. The resident's record lacked documentation of the physician's notification when the medication was not administered. During an interview on 05/17/24 at 2:36 P.M., RN 2 indicated phenytoin was only available in the emergency drug kit in a 100 mg capsule and Resident 1's dose was 150 mg tablet. They were not able to obtain the medication out of the emergency drug kit because it wasn't the same form. If the resident's medication wasn't available to administer, then she would call the pharmacy and ask if the medication had been ordered. The pharmacy would sometimes STAT medications and they would get them in a few hours, or they would come the next business day. The physician should have been notified each time the medication was not administered to see if something else needed to be given. 1.b. An open-ended physician's order with a start date of 05/04/23, indicated the resident was to take cyclobenzaprine 10 mg, every 8 hours for spinal stenosis. The April and May 2024 EMAR/ETAR lacked documentation the resident had received the medication on the following dates and times: - On 04/16/24 at 10:00 P.M., - On 05/06/24 at 10:00 P.M., and - On 05/08/24 at 10:00 P.M. During an interview on 05/17/24 at 1:08 P.M., LPN (Licensed Practical Nurse) 4 indicated there should always be something documented in the EMAR. There should never be a blank. The current facility policy titled, Receiving Pharmacy Products and Services from Pharmacy, with a revision date of 01/01/13, was provided by the DON (Director of Nursing) on 05/18/24 at 5:26 P.M. The policy indicated, .Facility staff should reorder medications using an electronic list of resident and medications due or by use of barcode technology . The current facility policy titled, Receiving Pharmacy Products and Services from Pharmacy was provided by the DON on 05/17/24 at 3:34 P.M. The policy indicated, .Document necessary medication administration/treatment information [e.g .when medication are given .] . 3.1-25(b)(3) 3.1-25(g)(3)

Based on observation, interview, and record review, the facility failed to label and store medications appropriately for 1 of 2 medication storage refrigerators observed. (100/200 Hall Medication Storage Refrigerator) Findings include: The Medication Room for the 100/200 Halls was observed with RN 3 on 05/17/24 at 1:07 P.M. The 100/200 Hall Medication Storage Refrigerator contained an open vial of TB (Tuberculin) serum with no label indicating when it was opened. The vial was one quarter full. During an interview on 05/17/24 at 1:17 P.M., RN 3 indicated the TB serum package indicated the vial was received from the pharmacy on 04/10/23. The serum was good for 28 or 30 days after it was opened. There was no opened on date on the vial of serum, the box the serum came in, or the plastic bag the box was in. The serum should have been labeled when it was first opened. She was unsure of when the TB serum was last administered. The serum was received over a year ago. The TB serum package insert was provided by the DON (Director of Nursing on 05/17/24 at 2:28 P.M. The directions for storage indicated, .vials in use more than 30 days should be discarded . The current facility policy, titled Medication Storage Guidance, and dated 2023, was provided by the DON on 05/17/24 at 2:28 P.M. The policy indicated, .Tuberculin Tests .Date when opened and discard unused portion after 30 days . 3.1-25(o)

Based on observation, interview, and record review, the facility failed to implement a person-centered dementia care plan related to a female resident seeking male companionship for 1 of 3 residents reviewed for Dementia Care. (Resident C) Findings include: A Progress Note, dated 5/29/23 at 10:06 a.m., indicated a male resident grabbed Resident C's breast. The residents were immediately separated. Resident C had no injuries or bruising noted. Neither resident had any recollection of the event. An Incident report, dated 5/29/23 at 10:15 a.m., indicated Resident D and Resident C were witnessed by staff and immediately separated. The residents had no history of sexual behavior. The record for Resident C was reviewed on 6/6/23 at 11:41 a.m. An Admission MDS (Minimum Data Set) Assessment, dated 5/29/23, indicated the resident was severely cognitive impaired. The diagnoses included, but were not limited to, dementia, anxiety, and depression. Resident C's Care Plans in place at the time of the incident included, but were not limited to, the following: - A care plan, dated 5/23/23, and titled Psychosocial Well-Being Life Story indicated the resident believed that everyone should love one another. The resident enjoyed going to church and spending time with her family. The interventions included, but were not limited to, encourage the resident to share important aspects of life story. - A care plan, dated 5/23/23, and titled Psychosocial Well-Being Resident Strengths indicated the resident was driven and family oriented. The interventions included, but were not limited to, encourage resident to continue making plans with her family. - A care plan, dated 5/23/23, and titled Mood State indicated the resident was at risk for signs and symptoms of anxiety Resident had a diagnosis of anxiety. The interventions included, but were not limited to, encourage activities of interest. Encourage resident to verbalize fears and anxiety; offer validation and reassurance. Maintain a calm environment; move to quiet area as needed. - A care plan, dated 5/23/23, and titled Cognitive Loss / Dementia indicated the resident was severely cognitively impaired. The interventions included, but were not limited to, encourage participation in daily activities, particularly regarding orientation, socialization, and stimulation. Give the resident choices throughout the day regarding decisions as able. Provide resident with prompts and cues. Resident C's clinical record lacked a care plan for behaviors related to seeking out male attention. The clinical record for Resident D was reviewed on 6/6/23 at 12:08 p.m. A Quarterly MDS Assessment, dated 3/21/23, indicated the resident was severely cognitive impaired. The diagnoses included, but were not limited to, cerebral infarction, vascular dementia with behavior, and anxiety. Resident D's Care Plans in place at the time of the incident included, but were not limited to, dated 5/31/23, and titled Behavioral Symptoms indicated the resident displays inappropriate sexual behavior at times and has been known to grope and grab body parts. The interventions included but were not limited to, stay calm and be patient, redirect to another activity. Gently but firmly tell the resident that the behavior was inappropriate. Match your body language to your words - frown and shake your head. Maintain consistent, firm boundaries. During an observation on 6/6/23 at 1:35 p.m., Resident D and Resident C were observed in the sunroom, just the two of them, and no staff were present. They were holding hands; she was standing, and he was in a wheelchair. During an observation on 6/6/23 at 1:38 p.m., CNA (Certified Nursing Aide) 2 was walking with two female residents from the dining area to the sunroom. The CNA identified Resident C and tried to get her to leave the area. Resident C stated, she wanted to stay with him (Resident D) and did not want to go with the staff. The CNA waiting until QMA 3 arrived. During an observation on 6/6/23 1:40 p.m., QMA (Qualified Medication Aide) 3 came to the area. The CNA was able to get Resident C to leave the area by telling her that she was going to go to take her to the bathroom and would then bring her back to the area where Resident D was sitting and would even get her a chair. During an observation on 6/6/23 at 1:48 p.m., the two staff and Resident C exited the room next door to her room and walked down the hall to the dining room area. Resident C immediately went to another male resident (Resident F) and started pointing out the window and talking. The two staff members left Resident C with Resident F and walked over to the nurses station across the room. During an interview on 6/6/23 at 2:04 p.m., The Memory Care Coordinator (MCC) indicated she was working on 5/29/23. She was at the desk charting when she saw Resident D in the sunroom on the monitor camera. She saw Resident C walk down to the sunroom, she was standing by the window and Resident D leaned forward and with his right hand wiped down her front, touching her breast. The monitor was about the size of a regular cell phone. Immediately Resident D was put on 15-minute checks, but that was discontinued. The current care plan interventions were to keep them separated and involved in activities. During an interview on 6/6/23 at 2:10 p.m., QMA 3 indicated she was at the medication cart, and the MCC was at the nurses' station charting. The MCC told her that Residents D and C were in the sunroom, and he had touched her breast. The QMA immediately reported it. The interventions put into place immediately were to keep a visual on where he was at and what he was doing. A reasonable time to not have a visual on him would be maybe 15 minutes. If they were found together then immediate separate them and make sure they were safe. During an observation on 6/6/23 at 3:53 p.m., Resident C was observed in the dining room talking to a male resident (Resident F) pointing out the window and talking with him. During an interview on 6/7/23 at 10:35 a.m., the MCC indicated when a resident was newly admitted to the locked unit, staff would find out their life story and have their things brought from home to try to give them a more at homelike feel. They would find out their preferences from the family members. The resident did not really say a lot of words, and it was mostly word salad (nonsensical words). The resident gravitated toward the men and liked someone to hold her hand. Resident D was admitted a year ago and she was not aware of having any inappropriate physical behaviors prior to this incident. He was easy to redirect, and until Resident C came, there was never any inappropriate touching. During an interview on 6/7/23 at 11:00 a.m., the DON (Director of Nursing) indicated Resident C was a new admit and had not initiated the incident. Resident D had been in the facility about a year and had never had any other incident of inappropriate touching. Resident D was immediately put on one on one observation with staff. During an interview on 6/7/23 at 11:35 a.m., the Psychiatric Nurse Practitioner (NP) indicated she saw both residents and neither one of them had any recall of the incident. Resident D had not had any incidents of sexual behavior prior that she was aware of. It was hard to tell what occurred, she was told the incident was seen on the monitor which was about the size of a cell phone. She was not really sure that it actually happened because there was not a history of any sexual behaviors prior. Resident C was new to the environment and had word salad and could not really give an answer. The NP talked with the DON, and the previous Social Services Director (SSD), and it was determined the new interventions were to keep them involved in activities and keep them in sight of staff. The reasoning was if they were busy then they would not have time for inappropriate behaviors. During an interview on 6/7/23 at 11:46 a.m., the Regional Clinical Support Nurse indicated that after the incident involving Residents D and C, Resident D was placed on one on one observation with staff and that was canceled after the NP saw them. Resident D was not exhibiting any behaviors. The NP believed this to have been a situational behavior due to Resident C's shirt having a print over the breast and the residents had no recollection of the incident. The current facility policy, titled Behavior Management, with a revision date of 8/22, was provided by the DON on 6/7/23 at 3:10 p.m. The policy indicated, .to provide behavior interventions for resident with problematic or distressing behaviors .Interventions provided are .individualized .and part of a supportive psychosocial environment that is directed toward preventing, relieving and/or accommodating a resident's behavior expressions. This Federal tag relates to IN00409588. 3.1-37(a)

Based on interview and record review, the facility failed to ensure a cognitively impaired resident was free from mental and physical abuse. Using the reasonable person concept, the resident would likely have chronic or recurrent fear and anxiety from the purposefully actions to agitate and physically contain the resident. These deficient actions resulted in psychological harm for 1 of 24 residents reviewed for abuse. (Resident 59). Findings include: During an interview on 03/13/23 at 1:45 P.M., Resident 59's family member indicated there was an incident about a month ago involving some staff members that were reportedly rough with the resident. The resident's clinical record was reviewed on 03/15/23 at 4:09 P.M. A Quarterly MDS (Minimum Data Set) Assessment, dated 01/12/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited, dementia with behavioral disturbances, anxiety, and depression. The resident exhibited verbal behaviors directed towards others and rejection of care during the assessment review period. During an interview on 03/15/23 at 2:23 P.M., CNA (Certified Nurse Aide) 11 indicated she regularly worked on the dementia unit. Her shift started at 2:00 P.M. on 02/08/23, QMA (Qualified Medication Aide) 9 had worked in the unit on dayshift and was still there. Just after supper, Resident 59 was sitting in her recliner in the common area. The resident liked to sleep in the recliner. If she fell asleep there, they would just recline the chair, so her feet were up. QMA 9 was trying to get the resident to go to bed. The QMA turned the volume on the TV up really loud. She was trying to agitate the resident; she said the resident would go to bed if the TV was turned up. The resident was screaming, she was red in the face, and she wanted the TV turned down. CNA 11 told QMA 9 to turn the TV down, and CNA 11 continued clearing dishes and dealing with other residents. CNA 10 came onto the unit. QMA 9 and CNA 10 were in the common area talking and CNA 11 went to assist another resident in the bathroom. CNA 11 finished helping that resident and was walking with her down the hallway when she heard a commotion in Resident 59's room. CNA 11 opened the room door to see what was going on. Resident 59 was on her bed. CNA 10 was at the head of the bed holding the resident's hands. QMA 9 was holding the resident's legs and she was pushing on them. The resident was screaming and kicking and scratching at them. She noticed the recliner from the common area had been brought into the resident's room. CNA 11 closed the door to Resident 59's room and assisted the resident she was with to their room. When she was done getting that resident settled, a different resident came out of their room at the end of the hall, asking about the commotion. CNA 11 assisted that resident back to their room and got them situated. When CNA 11 was finally done assisting the other residents, approximately 20 to 25 minutes had gone by and she observed Resident 59 back in the common area sitting in a dining room chair. CNA 10 was with the resident in the dining room. QMA 9 had left the facility. When Resident 59 saw CNA 11 she started yelling, saying she was going to call the cops. After that, CNA 10 was being sweet to the resident. There were no more issues that evening. During an interview on 03/15/23 at 3:28 P.M., the DON (Director of Nursing) indicated on 02/10/23, QMA 9 told her about some behaviors exhibited by Resident 59 on 02/08/23. QMA 9 said the resident was being aggressive and bothering other residents. CNA 11 came to her as well, and she was upset about what went on that evening. The DON reviewed video surveillance from the common area of the unit. From the video, it seemed like the resident did not want QMA 9 around. QMA 9 and CNA 10 tried different tactics to get the resident to her room. The DON determined the volume of the TV had been adjusted based on the video, but there was no sound to review. That was not acceptable treatment of the resident. There was no video footage of the resident's room. They reported the incident and conducted a thorough investigation. They determined QMA 9 and CNA 10 failed to provide the expected resident care. QMA 9 and CNA 10 were no longer employed by the facility. During an interview on 03/16/23 at 2:15 P.M., the DON indicated the video footage was only saved on their system for ten days and was no longer able to be reviewed. Corporate Support Staff indicated they created a timeline of events from the video and provided a copy of the documented timeline reviewed. The timeline included, but was not limited to, the following observations: - At 7:07 P.M., the resident was sleeping in her recliner., - At 7:29 P.M., QMA 9 took ice water to the resident., - At 7:30 P.M., the resident leaned away from QMA 9, covered her left shoulder with her blanket and turned her head away from QMA 9., - At 7:32 P.M., QMA 9 walked away from the resident, the TV was turned on., - At 7:34 P.M., the resident got up out of the recliner and started pointing at the TV and appeared to be telling QMA 9 something. QMA 9 walked over to the resident., - At 7:35 P.M., QMA 9 was pointing to the TV and the other residents in the area, then walked the resident back to her recliner., - At 7:36 P.M., QMA 9 walked to the resident's room., - At 7:37 P.M., the resident got up and walked to the nurses' station area., - At 7:38 P.M., CNA 10 took the resident's recliner from the dining area and put it in the resident's room. QMA 9 brought out the resident's purses from her room. QMA 9 was directing the resident towards her room., - At 7:39 QMA 9 walked to the resident's room with purses and a doll. CNA 10 was walking into a neighboring room., - At 7:40 P.M., the resident began to walk toward her room. The resident hesitated a couple of times and stood in the doorway. The resident entered the room fully and CNA 10 re-entered the resident's room and closed the door., - At 7:48:54 P.M., CNA 10 came out of the adjoining room and held the door closed to Resident 59's room. QMA 9 came out of the adjoining room., - At 7:49 P.M., CNA 10 let go of the resident's door., - At 7:50 P.M., the resident came out of the room, looked down the hall and walked towards the dining area., - At 7:51 P.M., the resident was standing in the middle of the dining area and QMA 9 turned off the lights., - At 7:52 P.M., the resident was sitting in a dining room chair in the dark., - At 8:15 P.M., QMA 9 left the unit., and - At 8:40 P.M., CNA 10 sat with the resident and began to talk to her. The current facility policy, titled Abuse Prohibition, Reporting, and Investigation, with a most recent revision date of January 2023, was provided by the Administrator on 03/12/23. The policy indicated, .It is the policy .to provide each resident with an environment that is free from abuse, neglect, physical abuse, mental abuse .and involuntary seclusion . 3.1-27(a)(1) 3.1-27(a)(4)

Based on interview and record review, the facility failed to adequately implement care planned interventions and strategies for a resident with anxiety, combative behaviors, and a diagnosis of dementia that resulted in the resident's increased agitated state and poor behavior management for 1 of 3 residents reviewed for Dementia Care. (Resident 59) Findings include: The resident's clinical record was reviewed on 03/15/23 at 4:09 P.M. A Quarterly MDS (Minimum Data Set) Assessment, dated 01/12/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited, dementia with behavioral disturbances, anxiety, and depression. The resident exhibited verbal behaviors directed towards others and rejection of care during the assessment review period. The resident Care Plans in place at the time of the incident included, but were not limited to, the following, A care plan, titled Mood State, indicated the resident displayed signs and symptoms of mood distress as evidenced by finding little interest or pleasure in doing things, difficulty concentrating, and being short tempered. Interventions included, but were no limited to: establishing a trusting relationship with the resident, and explore past effective and ineffective coping mechanisms. A care plan, titled Behavioral Symptoms, indicated the resident could become combative with care. Interventions included, but were not limited to: change staff, give resident time and space, use white noise machine for calming and relaxation, offer resident comfort, offer snack, and redirect to activity of choice such as listening to country music. A care plan, titled Communication, indicated the resident had difficulty making herself understood related to dementia. Interventions included, but were not limited to: Provide a quiet, non-hurried environment, free of background noises and distractions. A care plan, titled Cognitive Loss/Dementia, indicated the resident was severely cognitively impaired. Interventions included, but were not limited to: Give resident choices throughout the day regarding decisions as able. The clinical record lacked a care plan related to paranoid behaviors or the resident's dislike of being alone. During an interview on 03/14/23 at 10:30 A.M., CNA 2 indicated she worked on the dementia unit all the time. The interventions for behaviors could be different with each resident. Resident 59 was easily angered. She was very territorial. She thought the items on top of the activity cupboard and the gray recliner belonged to her. The table she usually sat at was her table. CNA 2 heard that some evening staff were rough with the resident. They tried to make her change her clothes. They redirected her wrong. When that resident was agitated, she needed to be left alone. Staff could see resident care plans, including appropriate interventions. They had access to the computer and the resident's charts. During an interview on 03/15/23 at 3:42 P.M., the DON indicated there was an incident involving Resident 59, QMA (Qualified Medication Aide) 9, and CNA (Certified Nurse Aide) 10 in the dementia unit. QMA 9 and CNA 10 said the resident was bothering other residents in the common area. They were trying to get the resident to her room to go to bed. The aides tried to persuade her to go into her room with her personal items. They moved her recliner from the common area into her room. The resident liked to be in the common area. The resident's family indicated the resident was exhibiting some signs of paranoia before admission to the nursing home. She liked to sit in the common area where she could see everything, she didn't like to be alone in her room. During the investigation, it was reported by CNA 11 that QMA 9 turned the volume of the TV up in the common area to try and get the resident leave the room and go to bed. CNA 11 indicated she later observed QMA 9 and CNA 10 holding the resident down in her bed. QMA 9 and CNA 10 denied holding the resident down in bed and indicated the resident was being combative. From what they saw on the video and their investigation, the facility determined it was poor behavior management on the dementia unit. QMA 9 should have walked away. Both staff members continued to approach the resident when she was in an agitated state. They both worked on the dementia unit, they should have known what to do. During an interview on 03/15/23 at 2:23 P.M., CNA 11 indicated on 02/08/23, QMA 9 turned the volume on the TV in the common area up really loud. She was trying to agitate the resident; she said the resident would go to bed if the TV was turned up. The resident was screaming, she was red in the face, she wanted the TV turned down. Later that evening, CNA 11 heard a commotion in the resident's room. CNA 11 opened the room door to see what was going on. The resident was on her bed. CNA 10 was at the head of the bed holding the resident's hands. QMA 9 was holding the resident's legs and she was pushing on them. The resident was screaming and kicking and scratching at them. An Employee Communication Form, dated 02/22/23, indicated on 02/08/23 the Code of Conduct policy was violated. CNA 10 failed to provide customer service. The form indicated, .Poor management of behaviors .Residents are to be treated with kindness, patience, understanding, consideration, respect and dignity .Employee failed to provide expected resident care . CNA 10's employment was terminated. An Employee Communication Form, dated 02/22/23, indicated on 02/08/23 Resident Care policies were violated by QMA 9. The form indicated, .Poor management of behaviors .Residents are to be treated with kindness, patience, understanding, consideration, respect and dignity. Employee failed to provide expected resident care . QMA 9's employment was terminated. The current facility policy, titled Behavior Management, with a revision date of 08/22, was provided by the DON on 03/16/23 at 3:53 P.M. The policy indicated, .provide behavior interventions for residents with problematic or distressing behaviors .Interventions provided are both individualized .and part of a supportive physical and psychosocial environment that is directed toward preventing, relieving, and/or accommodating a resident's behavioral expressions .Direct care staff will be educated as to the interventions for residents . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure adequate care and supervision was in place when a resident (Resident B) with dementia and a wanderguard exited the building without supervision, on 8/18/19 at 8:02 p.m. The resident exited through an unlocked and unsecured door on the dementia unit without staff knowledge. The resident ambulated 0.9 miles away from the facility and was found by a bystander located by a gas station on a busy intersection. The speed limit in the area was 30 miles per hour. The resident was transported to the facility in the bystanders' car after the bystander was able to contact the family and he was returned to the facility at 9:04 p.m., for 1 of 3 residents reviewed for supervision. This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 8/18/19 at 8:02 p.m., when a cognitively impaired male resident, with a wanderguard in place, exited the facility through an unlocked and unsecured door on the dementia unit. The resident ambulated 0.9 miles away from the facility. He was found by a bystander located by a gas station at a busy intersection and transported to the facility in the bystanders' car. The Health Facility Administrator and Director of Nursing were notified of the Immediate Jeopardy on 8/23/19 at 12:20 a.m. The Immediate Jeopardy that began on 8/18/19 was removed and the deficient practice was removed and corrected, on 8/19/19, prior to the start of the survey and was therefore Past Non-Compliance. Findings include: The incident report, dated 8/18/19 at 8:25 p.m., indicated Resident B was found walking outside and was returned to the facility. The resident had a wanderguard in place. The clinical record for Resident B was reviewed on 8/22/19 at 10:15 p.m. The resident's [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set), dated 7/26/19, indicated the resident was severely cognitively impaired. The care plan, dated 5/3/19, indicated the resident was at risk for elopement per the Elopement Risk Assessment. The resident was independently mobile, requested to go home, pushed on exit doors, had a history of [REDACTED]. The interventions were to call his family member, encourage activities, and a wanderguard to the right ankle. The Elopement Risk Assessment, dated 7/26/19 at 9:13 a.m., indicated the resident was cognitively impaired, had a communication deficit, and ambulated independently, he often requested to go home, was often seen pushing on doors, trying to open or pacing near exit doors. An Event Report dated 8/18/19 at 8:05 p.m., indicated the resident was pacing up and down the hallway, asking where his wife was, stated he had to get home, and would walk if he had to. The resident had turned the lock on the door and asked repeatedly to call his family member. The skin assessment, dated 8/19/19, indicated the resident had no injuries or skin impairment. The re-admission elopement assessment, dated 8/18/19 at 9:52 p.m., indicated the resident was cognitively impaired with a [DIAGNOSES REDACTED]. A timeline document, dated 8/18/19, provided by the Facility Administrator, indicated the facility was notified by family at 8:41 p.m., the resident was seen walking by a family friend and the couple was bringing the resident back to the facility. The resident arrived back at the facility at 9:04 p.m. The written statement from LPN (Licensed Practical Nurse) 2, provided by the Administrator on 8/22/18 at 9:45 p.m., not dated and untimed, indicated on 8/18/19 the resident was agitated in the afternoon and the LPN gave the resident [MEDICATION NAME] (anxiety medication) around 4:30 p.m. Around 6:00 p.m. the resident was pacing, repeatedly asked where his wife was, and stated I want to go home. Around 8:40 p.m., the LPN was notified by staff the resident's family member was on the phone and said a family friend found the resident walking on the road. The written statement from QMA 4, dated 8/18/19 and untimed, indicated the QMA unlocked the porch door for another resident and their family member between 4:00 p.m. and 4:30 p.m. Resident B was exit seeking and given an [MEDICATION NAME] around 4:30 p.m. She forgot to lock the door back and forgot to notify the oncoming staff about the unlocked door. The temperature outside on 8/18/19 from 6:00 p.m. to 12:00 a.m., was 70 degrees. The resident was dressed in a flannel shirt, long pants, shoes, and a ball cap. During an interview and observation on 8/22/19 at 9:20 p.m., the ED indicated, the resident exited through a side door that was not used and kept locked. The side door lead to a porch with a low railing measuring 42 inches, with two cross bars measuring 24 and 30 inches from the ground up. The resident climbed over the railing and exited the property. The resident could have stepped on a chair and stepped over the railing or could have used the cross bars to climb over the railing. The current policy titled Elopement Prevention and Response Program and dated 10/17, included, but was not limited to, Policy .It is the policy of this facility that staff who have resident under their care are responsible for knowing the location of those residents . The Past Non-Compliance Immediate Jeopardy began on 8/18/19. The Immediate Jeopardy was removed and deficient practice corrected by 8/19/19 after the facility implemented a systemic plan that include: residents' charts were reviewed to ensure all residents at risk for elopement had the appropriate interventions. All exit doors on the locked unit were secured. All staff were educated and in serviced on elopement risk and door security. This Federal tag relates to Complaint IN 492 3.1-45(a)(2)

Based on record review and interview, the facility failed to immediately report and thoroughly investigate an allegation of verbal and physical abuse. This affected 1 of 3 residents reviewed who met the criteria for abuse and had the potential to affect all 70 residents in the facility. (Resident #B) This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy was identified on 12/16/14, and began on 11/29/13. The Administrator and the Director of Nursing Services (DNS) were notified of the Immediate Jeopardy, related to verbal and physical abuse, at 5:10 p.m., on 12/16/14. The Immediate Jeopardy was removed on 12/18/14, but the facility remained out of compliance at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy based on deficient practice related to not investigating and reporting an allegation of verbal and physical abuse. Findings include: During an interview, on 12/15/14, at 1:02 p.m., a family member indicated she heard RN #1 tell Resident #B to "shut up", then heard Resident #B say "You b*****d nurse, you hit me." The family member indicated she didn't see anything, she just heard it and that later on that night after supper, she noticed Resident #B had a bruise near her mouth. The family member indicated she reported this to the DNS on 11/29/14 by text message, but the family member thought the event happened around Thanksgiving and had already been reported. The family member indicated she didn't report it right away because she didn't want to get involved. During a confidential interview, a facility nurse indicated a family member told her that she had heard RN #1 yelling at Resident #B on the weekend of 11/22/14. The family member reported this a week after the event because she did not want to get involved. She indicated Resident #B had never had any self inflicted injuries, but couldn't say she didn't hit herself that evening. During an interview, on 12/16/14 at 11:04 a.m., the DNS indicated she had heard from a family member via text message on 11/29/14 and follow up phone call on 11/30/14. The family member indicated she had concerns about RN #1, felt he was abusive and the DNS needed to listen to staff about him. The DNS asked the family member if she witnessed him be abusive, and she said "Yes, with Resident #B", and told her RN #1 took Resident #B to her room and she heard Resident #B say "that b*****d hit me". Following the incident, RN #1 came into the dining room and sat with Resident #B. The family member then told the DNS Resident #B ended up with a bruise on her lip. The DNS called the Executive Director and told her what the family reported. The Executive Director asked the DNS to call the family member and request she come in and give a statement. The family member declined this request. The DNS said she did not document the text she received from the family member on 11/29/14. The DNS indicated they did not do an investigation into this allegation of abuse received on 11/29/14. The DNS indicated it was not investigated because it had already been investigated with the determination the bruise on the resident's face was due to her self injurious behavior. On 12/16/14 at 4:50 p.m., the ED indicated they initially investigated the event on 11/23/14 with Resident #B hitting herself in the mouth. None of this was reported to ISDH. During an interview, on 12/16/14, at 12:45 p.m., RN #3 indicated a family member reported she had heard a conversation between RN #1 and Resident #B. The family member told RN #3 she heard RN #1 tell Resident #B to "shut up", then heard Resident #B say "You hit me you b*****d." The family member told RN #3 the day after she heard this verbal exchange she saw Resident #B had a bruise on her face. RN #3 indicated she called the DNS, because it was the weekend. She did not remember the day, but thought it was on a Sunday. The family member told her the incident had happened approximately one week prior to when she was reporting it to her. RN #3 indicated when she called the DNS, the DNS told her the family member had already talked to her and she would take care of it. RN #3 indicated RN #1 was not working the day she reported what the family member had told her, and she was never questioned any further. During an interview, on 12/16/14 at 11:55 a.m., the Social Service Director (SSD) indicated the family member told her in a phone conversation on Monday 12/1/14, that she didn't witness RN #1 and Resident #B's situation, but was reporting what she had heard. The SSD further indicated the event of Resident #B's face being bruised that occurred, on 11/23/14, had been investigated as a behavior with Resident #B hitting herself in the mouth. Resident #B's record was reviewed on 12/15/14 at 2:06 p.m. The record indicated Resident #B was admitted with [DIAGNOSES REDACTED]. An Annual Minimum Data Set assessment, dated 9/30/14, indicated Resident #B was severely impaired, rarely/never made decisions in cognitive skills for daily decision making, and had poor long term, and short term memory. A care plan, initiated 11/24/14, indicated: "Resident at risk for self harm d/t (due to) smacks self in mouth, smacks objects in hallway knocking items off wall, rolls w/c into wall while sitting in it. Goal: Will have no harm. Approach: Assure resident is safe." A care plan, initiated 11/24/14, indicated: "Resident is at risk for bruising related to use of anticonvulsant medication, will head butt staff, hit objects off the wall, or hit self. Goal: Resident will remain free from bruising. Approach: Staff to ask resident not to hit self or objects as it could cause bruising. Document abnormal findings and notify MD. Medications as ordered. Observe for increased bleeding, bruising, headaches, diarrhea, fatigue, dizziness, stomach pains, black tarry stools, ringing in the ears." A policy, titled "Abuse Prohibition, Reporting, and Investigation", was provided by the Executive Director on 12/15/14 at 10:13 a.m. The policy indicated, but was not limited to: "It is the policy of American Senior Communities to protect residents from abuse including physical abuse, sexual abuse, verbal abuse, mental abuse, neglect, involuntary seclusion, and misappropriation of resident property and/or funds. Definition of Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm or pain, or mental anguish. This includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well being. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, or pain, or mental anguish. Physical Abuse - includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. Verbal Abuse - defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples would include, but are not limited to: threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family member again; or scolding and/or speaking to them in harsh voice tones...Policy/Procedure: 1. American Senior Communities will not permit residents to be subjected to abuse by anyone, including employees, other residents, consultants, volunteers, staff or personnel of other agencies serving the resident, family members, legal guardians, sponsors, friends, or other individuals...4. Residents and their families are educated as to whom and how to report allegations, incidents, and/or complaints without fear of retribution. Residents and families are also educated on the process of receiving feedback/resolution regarding concerns that have been expressed. This education will occur at admission, and during resident and family council meetings...6. The Executive Director is the designated individual responsible for coordinating all efforts in the investigation of abuse allegations, and for assuring that all policies and procedures are followed. In the absence of the Executive Director, this responsibility will be delegated to the Director of Nursing Services. 7. The Executive Director/designee will report all unusual occurrences, which include allegations of abuse, immediately, to the Long Term Care Division of the Indiana State Department of Health. Upon completion of the investigation, which must occur within 5 working days of the reporting of an occurrence, a report of the investigation must be forwarded to the Long Term Care Division of the Indiana State Department of Health. Copies of the completed investigation must also be sent to Adult Protective Services, Ombudsman, and Director of Operations. 8. A comprehensive record of the abuse investigation is to be kept by the facility Executive Director and/or Director of Nursing Services...Resident Abuse - Staff member, volunteer, or visitor: Policy: It is the policy of American Senior Communities to assure appropriate interventions are in place and followed to assure safety of the resident (s) is maintained if abuse is identified or suspected. Procedure: If resident abuse is identified or suspected, the following guidelines will be followed: 1. The resident (s) involved in the incident will be protected and/or removed from the situation immediately...3. Any staff member implicated in the alleged abuse will be removed from the facility at once and will remain suspended until an investigation is completed...." An Immediate Jeopardy was identified on 12/16/14. The Immediate Jeopardy began on 11/29/14 when a nurse was not immediately reported for verbal and physical abuse and continued to work, residents were not protected while the nurse was working, and there was no thorough investigation of the occurrence of physical and verbal abuse. The Administrator and Director of Nursing Services were notified of the Immediate Jeopardy, related to verbal and physical abuse, at 5:10 p.m. on 12/16/14. Through observations, interviews, and record reviews, it was determined the facility's corrective actions had removed the immediate jeopary situation on 12/18/14. Even though the immediate was removed, the facility remained out of compliance at patterned scope and level of no actual harm, with potential for more than minimal harm that is not immediate jeopardy, based on deficient practice related to not investigating and reporting an allegation of verbal and physical abuse. This Federal tag relates to Complaint IN 385. 3.1-28(c)

Based on record review and interview, the facility failed to implement their policies and procedures regarding investigating and reporting abuse, in that no thorough investigation of an allegation of physical and verbal abuse was done, the residents did not have a safe environment while the RN continued to work, and the allegations of abuse were not reported immediately to the ISDH and other agencies. This affected all 70 residents residing in the facility. This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy was identified on 12/16/14, and began on 11/29/14. The Administrator and Director of Nursing Services (DNS) were notified of the Immediate Jeopardy, related to verbal and physical abuse, at 5:10 p.m. on 12/16/14. The Immediate Jeopardy was removed on 12/18/14, but the facility remained out of compliance at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy based on deficient practice related to not following their policy and procedure for investigating, keeping residents safe while the nurse continued to work, and reporting an allegation of verbal and physical abuse. Findings include: During an interview on 12/15/14, at 1:02 p.m., a family member indicated she heard RN #1 tell Resident #B to "shut up" then heard Resident #B say "You b*****d nurse, you hit me." The family member indicated she didn't see anything, she just heard it and then later on that night after supper, she noticed Resident #B had a bruise near her mouth. The family member indicated she reported this to the DNS on 11/29/14 by text message, but the family member thought the event happened around Thanksgiving and had already been reported. The family member indicated she didn't report it right away because she didn't want to get involved. During a confidential interview, a facility nurse indicated a family member told her that she had heard RN #1 yelling at Resident #B on the weekend of 11/22/14. The family member reported this a week after the event because she did not want to get involved. She indicated Resident #B had never had any self inflicted injuries, but couldn't say she didn't hit herself that evening. During an interview, on 12/16/14 at 11:04 a.m., the DNS indicated she had heard from a family member via text message on 11/29/14 and follow up phone call on 11/30/14. The family member indicated she had concerns about RN #1, felt he was abusive and the DNS needed to listen to what staff said about him. The DNS asked the family member if she witnessed him be abusive, and she said "Yes, with Resident #B", and told her RN #1 took Resident #B to her room and she heard Resident #B say "that b*****d hit me". Following the incident, RN #1 came in and sat in the dining room with Resident #B. The family member then told the DNS Resident #B ended up with a bruise on her lip. The DNS called the Executive Director and told her what the family reported. The Executive Director asked the DNS to call the family member and request she come in and give a statement. The family member declined this request. The DNS said she did not document the text message she received from the family member on 11/29/14. The DNS indicated they did not do an investigation into this allegation of abuse received on 11/29/14. The DNS indicated it was not investigated because it had already been investigated with the determination the bruise on the resident's face was due to her self injurious behavior. On 12/16/14 at 4:50 p.m., the ED indicated they initially investigated the event on 11/23/14 with Resident #B hitting herself in the mouth. None of this was reported to ISDH. During an interview, on 12/16/14, at 12:45 p.m., RN #3 indicated a family member reported she had heard a conversation between RN #1 and Resident #B. The family member told RN #3 she heard RN #1 tell Resident #B to "shut up", then heard Resident #B say "You hit me you b*****d." The family member told RN #3 the day after she heard this verbal exchange she saw Resident #B had a bruise on her face. RN #3 indicated she called the DNS, because it was the weekend. She did not remember the day, but thought it was on a Sunday. The family member told her the incident had happened approximately one week prior to when she was reporting it to her. RN #3 indicated when she called the DNS, the DNS told her the family member had already talked to her and she would take care of it. RN #3 indicated RN #1 was not working the day she reported what the family member had told her, and she was never questioned any further. During an interview, on 12/16/14 at 11:55 a.m., the Social Service Director (SSD) indicated the family member told her in a phone conversation on Monday, 12/1/14, that she didn't witness RN #1 and Resident #B's situation, but was reporting what she had heard. The SSD further indicated the event of Resident #B's face being bruised on 11/23/14 had been investigated and determined to be due to Resident #B's behavior of hitting herself in the mouth. RN #1's timecard was provided by the Executive Director, on 12/16/14 at 3:35 p.m. The timecard indicated RN #1 had worked the following hours since the allegation of verbal and physical abuse on 11/29/14: 12/1/14 from 5:45 a.m. to 6:20 p.m., 12/3/14 from 5:46 a.m. to 8:38 p.m., 12/5/14 from 5:43 a.m. to 6:34 p.m., 12/8/14 from 5:42 a.m. to 6:46 p.m., 12/11/14 from 5:47 a.m. to 8:41 p.m., and 12/12/14 from 5:45 a.m. to 7:58 p.m. A policy, titled "Abuse Prohibition, Reporting, and Investigation", was provided by the Executive Director on 12/15/14 at 10:13 a.m. The policy indicated, but was not limited to: "It is the policy of American Senior Communities to protect residents from abuse including physical abuse, sexual abuse, verbal abuse, mental abuse, neglect, involuntary seclusion, and misappropriation of resident property and/or funds. Definition of Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm or pain, or mental anguish. This includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well being. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, or pain, or mental anguish. Physical Abuse - includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. Verbal Abuse - defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples would include, but are not limited to: threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family member again; or scolding and/or speaking to them in harsh voice tones...Policy/Procedure: 1. American Senior Communities will not permit residents to be subjected to abuse by anyone, including employees, other residents, consultants, volunteers, staff or personnel of other agencies serving the resident, family members, legal guardians, sponsors, friends, or other individuals...4. Residents and their families are educated as to whom and how to report allegations, incidents, and/or complaints without fear of retribution. Residents and families are also educated on the process of receiving feedback/resolution regarding concerns that have been expressed. This education will occur at admission, and during resident and family council meetings...6. The Executive Director is the designated individual responsible for coordinating all efforts in the investigation of abuse allegations, and for assuring that all policies and procedures are followed. In the absence of the Executive Director, this responsibility will be delegated to the Director of Nursing Services. 7. The Executive Director/designee will report all unusual occurrences, which include allegations of abuse, immediately, to the Long Term Care Division of the Indiana State Department of Health. Upon completion of the investigation, which must occur within 5 working days of the reporting of an occurrence, a report of the investigation must be forwarded to the Long Term Care Division of the Indiana State Department of Health. Copies of the completed investigation must also be sent to Adult Protective Services, Ombudsman, and Director of Operations. 8. A comprehensive record of the abuse investigation is to be kept by the facility Executive Director and/or Director of Nursing Services...Resident Abuse - Staff member, volunteer, or visitor: Policy: It is the policy of American Senior Communities to assure appropriate interventions are in place and followed to assure safety of the resident (s) is maintained if abuse is identified or suspected. Procedure: If resident abuse is identified or suspected, the following guidelines will be followed: 1. The resident (s) involved in the incident will be protected and/or removed from the situation immediately...3. Any staff member implicated in the alleged abuse will be removed from the facility at once and will remain suspended until an investigation is completed...." An Immediate Jeopardy was identified on 12/16/14. The Immediate Jeopardy began on 11/29/14 when a nurse was not immediately reported for verbal and physical abuse and continued to work, residents were not protected while the nurse was working, and there was no thorough investigation of the occurrence of physical and verbal abuse. The Administrator and Director of Nursing Services were notified of the Immediate Jeopardy, related to verbal and physical abuse, at 5:10 p.m. on 12/16/14. The Immediate Jeopardy was removed on 12/18/14, but the facility remained out of compliance at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy based on deficient practice related to not following their policy and procedure for investigating, keeping residents safe while the nurse continued to work, and reporting an allegation of verbal and physical abuse. This Federal tag relates to Complaint IN 385. 3.1-28(c)