Every finding on record at Ashford Place Health Campus

Based on observation, interview, and record review, the facility failed to ensure infection control was maintained by not disinfecting a glucometer (a device used to obtain blood sugar readings) per the manufacturer's instructions for 1 of 2 residents observed during medication administrations of blood sugar readings. (Resident 43)Findings include: The clinical record for Resident 43 was reviewed on 8/8/25 at 2:30 p.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus.A physician's order, dated 7/22/25, indicated Resident 43 was to receive nine units of Novolog (fast acting) insulin before meals. If the resident's blood sugar reading was less than 100; hold the insulin. An observation was conducted of obtaining Resident 43's blood sugar reading with Licensed Practical Nurse (LPN) 3 on 8/8/25 at 11:17 a.m. LPN 3 was observed removing the glucometer from the medication cart. She then wiped the glucometer utilizing an alcohol wipe. She then went to the resident's room. LPN 3 was observed pricking the resident's finger, placing a drop of blood from the resident's finger onto the test strip inserted in the glucometer device to obtain the reading. After, she left the resident's room and returned the glucometer into the medication cart. There was no disinfecting the glucometer after the resident's blood sugar was obtained. An interview was conducted with LPN 3 on 8/8/25 at 11:56 a.m. She indicated she had used the wrong wipes to disinfect the glucometer before and after use. Alcohol wipes were not to be used to disinfect the glucometer. At that time, she provided the germicidal bleach wipes the staff were to use to disinfect the glucometers. The manufacturer's instructions of the glucometer were provided by the Director of Nursing Services on 8/12/25 at 2:06 p.m. It indicated, .Cleaning and Disinfecting.2. Open the cap of the Clorox Germicidal Wipes Container, pull out 1 towelette and close the cap. 3. Wipe the entire surface of the meter 3 times horizontally and 3 times vertically using one towelette to clean blood and other body fluids.5. Pull out 1 new towelette and wipe the entire surface of the meter 3 times horizontally and 3 times vertically to remove blood-borne pathogens. 3.1-18(b)(1)

Based on interview and record review, the facility failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for alarm use for 2 of 2 residents reviewed for falls. (Resident 17 and Resident 25)Findings include: 1. The clinical record for Resident 17 was reviewed on 8/11/25 at 11:30 a.m. The diagnoses included, but were not limited to, dementia. A fall care plan, dated 1/16/24, indicated Resident (17) is at risk for falling r/t [related to] decreased mobility, medication regimen, weakness, incontinent status and other comorbidities. The interventions included but were not limited to: the resident's usage of a clip alarm when in wc/chair [wheelchair] with a start date of 3/6/25, and usage of a floor mat alarm when in recliner with a start date of 11/14/24. A physician's order, dated 3/5/25, indicated Resident 17 was to wear a personal pull tab alarm while in the wheelchair every shift. A physician's order, dated 5/21/25, indicated Resident 17 was to have a floor mat alarm in place every shift. The 7/7/25 Quarterly MDS assessment for Resident 17 indicated the resident did not use alarms. An interview was conducted with the MDS Coordinator on 8/12/25 at 3:14 p.m. She indicated the Quarterly July 2025 MDS assessment for Resident 17 was coded incorrectly. The resident was using alarms. The assessment was going to be modified and corrected. 2. The clinical record for Resident 25 was reviewed on 8/8/25 at 10:40 a.m. The diagnoses included, but were not limited to, Parkinson's disease and traumatic brain injury. A physician's order, dated 6/10/25, indicated he was to have a pressure alarm at all times. The pressure alarm was to be moved from the wheelchair to the recliner or bed with the resident. A Quarterly MDS assessment, completed 7/9/25, indicated bed and/or chair alarms had not been used during the assessment period. During an interview on 8/12/25 at 3:14 p.m., the MDS Coordinator indicated the bed and chair alarm should have been coded on the Quarterly MDS completed on 7/9/25. The facility used the Resident Assessment Instrument Manual as the policy for completing the MDS assessments.

Based on observation, interview, and record review, the facility failed to ensure an insulin flex pen was primed prior to dialing up the dosage to be given when administering insulin per the manufacture directions for 1 of 2 residents observed during insulin administration. (Resident 8)Findings include: The clinical record for Resident 8 was reviewed on 8/8/25 at 2:00 p.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus.A diabetic care plan, dated 7/1/25, indicated the staff was to administer the medication as ordered. A physician's order, dated 6/16/25, indicated Resident 8 was to receive 10 units of lispro insulin (fast acting insulin) with a flex pen before meals. An observation was conducted of an insulin administration for Resident 8 with Licensed Practical Nurse (LPN) 3 on 8/8/25 at 11:03 a.m. LPN 3 was observed obtaining the resident's blood sugar reading of 273. After, she prepared to administer 10 units of lispro insulin using an insulin flex pen. During that time, LPN 3 wiped the flex pen with an alcohol wipe and placed the needle on the pen. She then dialed up 10 units of insulin and administered the insulin to the resident. LPN 3 was not observed priming the insulin flex pen prior to the administration of the 10 units of lispro insulin. An interview was conducted with the Director of Nursing Services (DNS) on 8/12/25 at 2:01 p.m. She indicated the insulin flex pens were to be primed prior to the administration of the insulin dosage.Instructions for use insulin Lispro manufacture instructions at website www.//pi.lilly.com ,dated 12/2023, was retrieved on 8/13/25. It indicated .Prescribing information .Priming your pen Prime before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 6: To prime your pen, turn the dose knob to select 2 units. Step 7: Hold your pen with the needle pointing up, tap the cartridge holder gently to collect air bubbles at the top. Step 8: Continue holding the pen with needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure a gait belt was used during the manual transfer of a resident and to ensure an evaluation was conducted timely for the usage of personal alarms for 2 of 2 residents reviewed for accidents. (Resident 17 and Resident 25) Findings include: 1a. The clinical record for Resident 25 was reviewed on 8/8/25 at 10:40 a.m. The diagnoses included, but were not limited to, Parkinson's disease and traumatic brain injury. A physician's order, dated 3/23/25, indicated he was to have a pressure alarm in his wheelchair at all times. This order was discontinued on 5/23/25. A physician's order, dated 5/23/25, indicated he was to have a pressure alarm to his wheelchair and recliner when he was present. This order was discontinued on 6/10/25. A physician's order, dated 6/10/25, indicated that he was to have a pressure alarm at all times, ensure pressure alarm was moved from wheelchair to recliner and bed with him. A Quarterly Minimum Data Set (MDS) assessment, completed 7/9/25, indicated he was dependent on staff for chair to bed transfers and to go from a sitting to a standing position. He had fallen one time, with no injury, since his last MDS assessment. A care plan, last reviewed and revised on 8/7/25, indicated Resident 25 was at risk for falling related to decreased mobility, weakness, Parkinson's disease, subdural hematoma (pool of blood between the brain and its outermost covering), and orthostatic hypotension (blood pressure drops when standing up). The goal was for him to remain free of falls with major injury. The interventions included, but were not limited to, pressure alarm at all times, scoop mattress on his bed, and mattress next to the bed at bedtime. An Alarm and Restrictive Device Evaluation, dated 8/7/25, indicated Resident 25 had a chair and bed alarm. The alarms were being used to identify patterns or routines. There were no other Alarm and Restrictive Device Evaluations present in the clinical record. During an interview on 8/12/25 at 3:37 p.m., the Nurse Consultant (NC) and the Director of Nursing Services (DNS) indicated the alarm evaluations for the usage of the sounding alarms should have been completed when the pressure alarm was initiated. 1b. During an observation on 8/8/25 at 10:24 a.m., Resident 25 was sitting in a recliner in the common area, two Certified Resident Care Associates (CRCAs) approached Resident 25 with his wheelchair. The two CRCA's manually transferred Resident 25 from the recliner chair to his wheelchair by lifting Resident 25 under the arms and holding the back of his pants. A gait belt was not used. The pressure alarm sounded and was silenced by another staff member. The pressure alarm was placed in the wheelchair prior to the CRCAs sitting Resident 25 down in the wheelchair. During an interview on 8/12/25 at 1:32 p.m., the Therapy Director (TD) indicated Resident 25 required two staff members and a gait belt to transfer. A gait belt should be utilized. On 8/11/25 at 2:30 p.m., the NC provided the Guidelines for Gait Belt Use, last reviewed 12/17/24, that indicated .The purpose of this policy is to: To ensure safety for the resident and staff during transfers and mobility activities. 2. The clinical record for Resident 17 was reviewed on 8/11/25 at 11:30 a.m. The diagnoses included, but were not limited to, dementia. A fall care plan, dated 1/16/24, indicated Resident (17) is at risk for falling r/t [related to] decreased mobility, medication regimen, weakness, incontinent status and other comorbidities. The interventions included but were not limited to, the resident's usage of a clip alarm when in wc/chair [wheelchair] with a start date of 3/6/25, and usage of a floor mat alarm when in recliner with a start date of 11/14/24. A progress note, dated 11/1/24, indicated .Was up in wheelchair for couple of hours today and went to therapy. Alarm in place and working well will continue to monitor an assist as needed. A physician's order, dated 3/5/25, indicated Resident 17 was to wear personal pull tab alarm while in wheelchair every shift. A physician's order, dated 5/21/25, indicated Resident 17 was to have floor mat alarm in place every shift. An alarm and restrictive evaluation, dated 8/7/25, indicated the resident was in use of alarms for bed, chair, floor, and clipped alarm. An interview was conducted with the Nurse Consultant and the DNS on 8/12/25 at 3:37 p.m. The DNS indicated Resident 17 started using the sound alarms in November 2024. The resident currently was in use of a chair and a floor mat alarm. The alarm evaluations for the usage of the sounding alarms should have been completed in November. The Guidelines for Position Change Alarms policy was provided by the DNS on 8/11/25 at 11:29 a.m. It indicated, .The purpose of this policy is to: To ensure completion of observation and evaluation for appropriate use of positioning alarms for each resident.Procedure. 1. Types of position change alarms include chair and bed silent alarm sensor, and motion alarm detectors. Alarm should also be evaluated to determine if device is a restraint or enabler.3. A restraint/enabler event and associated observations should be completed, in the resident's EHR [electronic health record], upon initiating a positioning alarm. 3.1-45(a)(1) 3.1-45(a)(2)

Based on interview and record review, the facility failed to timely refer a resident for a level II evaluation for 1 of 1 resident reviewed for Preadmission Screening and Resident Review (PASRR). (Resident 19)Findings include: The clinical record for Resident 19 was reviewed on 8/8/25 at 3:17 p.m. The diagnoses included, but were not limited to, diabetes and psychotic disorder with delusions. A PASRR Level I evaluation, dated 8/10/23, indicated Resident 19 was approved with no Level II required. On 6/1/24, Resident 19 received a new diagnosis of psychotic disorder with delusions. During an interview on 8/8/25 at 2:59 p.m., the Executive Director (ED) indicated Resident 19 did not have a Level II. During an interview on 8/11/25 at 2:35 p.m., the Social Services Director (SSD) indicated Resident 19 should have been referred for a Level II with the new diagnosis of psychosis. On 8/11/25 at 11:29 a.m., the Nurse Consultant (NC) provided the current Indiana PASRR Standard Operating Procedure, which indicated .Overview Preadmission Screening and Resident Review [PASRR] is a federal requirement to help ensure that individuals are appropriately placed in nursing facilities for long-term care .Change in status and Level II follow up Social Services ensures paperwork is submitted. They will print out the outcome letter and upload to Matrix file .

Based on interview and record review, the facility failed to provide bathing, as scheduled, to 1 of 3 residents reviewed for bathing. (Resident D) Findings include: The clinical record for Resident D was reviewed on 4/4/25 at 10:49 a.m. Her diagnoses included, but were not limited to, depression and diabetes. She was admitted to the facility on [DATE] and discharged on [DATE]. The 3/21/25 Admission MDS (Minimum Data Set) assessment indicated she required substantial, maximal assistance for bathing and was cognitively intact. The 3/18/25 ADL (activities of daily living) care plan indicated she required staff assistance to complete self-care and mobility functional tasks completely and safely. The goal was for her to have her functional needs met safely by staff. An approach was for showers on Wednesdays and Saturdays on the evening shift. A telephone interview was conducted with Resident D on 4/4/25 at 12:38 p.m. She indicated she did not receive baths or showers in the facility twice a week. The first time she asked for a shower, it took about a week and half before she finally received one. The second shower she received was because she had an accident. She only received two showers while there. The Point of Care ADL report indicated she received a bed bath, on 3/18/25, and a shower on 3/25/25. It indicated she received other type of bathing, on 3/23/25 and 3/24/25, both signed off by CNA (Certified Nurse Aide) 4. All the other days indicated a partial bed bath only. An interview was conducted with the DON (Director of Nursing) on 4/4/25 at 11:59 a.m. She indicated residents were scheduled to be bathed twice weekly. She reviewed the CNA assignment sheet and indicated Resident D's shower days were scheduled for Monday and Thursday mornings. She was unsure what other bath meant on the Point of Care ADL report. She was unaware Resident D missed any bathing while at the facility. She didn't see anything in the progress notes about her refusing or therapy providing her with showers. The only verification of bathing was the Point of Care ADL report. An interview was conducted with CNA 4 on 4/4/25 at 12:07 p.m. She indicated Resident D got washed up on the toilet on 3/23/25 and 3/24/25. Resident D did most of it herself, and she didn't know how to chart it, so she documented other. Resident D never refused bathing for her. If a resident refused, they could document refused in Point of Care and inform the nurse. The Guidelines for Bathing Preference policy was provided by the Nurse Consultant on 4/4/25 at 12:54 p.m. It indicated, Bathing shall occur at least twice a week unless the resident preference states otherwise. This citation is related to Complaint IN00456300. 3.1-38(b)(2)

Based on interview and record review, the facility failed to ensure interventions to prevent falls were effectively implemented when Resident C exhibited signs and symptoms of lethargy, drowsiness, and sedation and failed to ensure staff used a gait belt during the transfer of a Resident D who required more than limited assistance with transfers for 2 of 3 residents reviewed for falls. This deficient practice resulted in Resident C falling in the shower and sustaining fractures to the left shoulder blade, the left second rib, and the endplate of the third lumbar spinal disc. (Resident C and Resident D) Findings include: 1. The clinical record for Resident C was reviewed on 8/14/24 at 8:30 a.m. The diagnoses included, but were not limited to, dementia, osteoporosis, and insomnia. A quarterly Minimum Data Set (MDS) assessment, dated 5/2/24, indicated Resident C was cognitively impaired. The resident's functional status was dependent of the staff person to provide all the effort for the resident to bathe. The staff was to provide more than half of the effort to assist with transferring in and out of shower. The resident did receive antidepressants and had a history of falling. A care plan, dated 1/16/24, indicated, Resident has impairment in functional status r/t [related to] decreased mobility, weakness, and other comorbidities . A physician order, dated 3/22/24, indicated staff was to monitor Resident C for signs of adverse effects with the usage of hypnotic/sedative/tranquilizer medication. A care plan for fall risk, dated 6/3/24, indicated staff should review the use of a sleep aid medication, change the administration time of a sleep aid medication, encourage activities in common area prior to breakfast, check the resident every two hours during the night shift, encourage resident to sleep in bed at night, use a silent bed alarm on the bed and the recliner, keep wheelchair out of site (sic), offer to get up at 4:00 a.m., utilize a fall mat, utilize a low bed, and staff should assist with transfers as needed. A psychiatric visit note, dated 6/28/24, indicated, The patient's trazodone was reduced per pharmacy recommendation and she has had significant difficulty with sleeping. We are going to increase trazodone from 75 milligrams to 150 milligrams at HS [night] . A physician order, dated 6/28/24, indicated Resident C was to receive 150 milligrams (mg) of trazodone (antidepressant medication) at night for insomnia. The antidepressant was used as a hypnotic medication. The medication was discontinued on 7/27/24. A psychiatric visit note, dated 7/26/24, indicated resident continued to have problems with sleeping. The plan was to increase current trazodone medication dosage from 150 milligrams to 200 milligrams. A physician order, dated 7/27/24, indicated Resident C was to receive 200 mg of trazodone at night. The medication was discontinued on 7/31/24. The July 2024 Medication Administration Record (MAR) indicated the resident was showing signs and symptoms of side effects with the usage of hypnotic/sedative/tranquilizer medication on the following day and shift: 7/31/24 - evening shift - drowsiness. A nursing note written by Director of Nursing (DON), dated 7/31/24 at 1:43 p.m., indicated the resident was more lethargic, had difficulty staying awake during meals, and the psychiatric care provider was notified. A nursing note, dated 8/1/24 at 6:19 a.m., indicated Psych [psychiatric] services gave ok to reduce Trazodone down to previous dose . A physician order, dated 8/1/24, indicated Resident C was to receive 150 mg of trazodone at bedtime. The August 2024 MAR indicated the following days and shifts the resident was showing signs and symptoms of side effects with the usage of hypnotic/sedative/tranquilizer medication: 8/2/24 - evening shift - extreme drowsiness, 8/3/24 - evening shift - drowsiness, 8/4/24 - day shift - drowsiness and evening shift - sedation. Resident C's clinical record reviewed on 8/14/24, did not include additional safety interventions initiated to address the resident's change of condition. A nursing note, dated 8/4/24 at 1:54 p.m., indicated [Resident C's Representative] in to visit resident, states she has noticed resident is sleeping a lot more lately and would like trazodone held this eve [evening]. A nursing note, dated 8/4/24 at 3:13 p.m., indicated, Resident fell in shower while being assisted with shower by nursing assistant . A care plan for fall risk, revision date 8/5/24, indicated the resident was to utilize a shower chair during showers. A nursing note by DON, dated 8/6/24, indicated, IDT [Interdisciplinary team] note: Resident has been more lethargic, [Psych Provider 13] increased Trazodone on 7/26. Since reached out to [Psych Provider 13] to let her know that resident was sleeping all day and not tolerating increased dose. Dose was reduced back down to previous dose. Resident continues to be very lethargic and requiring increased assistance with transfers and mobility. Resident had a fall on 8/4, slipped off bench in shower .IDT recommend staff to use shower chair when giving resident a shower. [Resident C Representative] has requested Trazodone be held on 8/4 and 8/5 due to lethargy and not waking to eat meals. Improvement noted in alertness, continues to have difficulty staying awake for long periods of time. Resident did get up and go down for breakfast this morning. Sent email to [Psych Provider 13] to address concerns with Trazodone . A nursing note, dated 8/6/24, indicated, Res [resident] had x-ray done to left arm with results showing a fx [fracture] to left scapula NP [Nurse Practitioner] here and made nursing aware of results. Res cries out in pain when moving res from recliner to w/c [wheelchair] or when touching area of back shoulder. Res sleeps most of the day but is easy to arouse .Writer talked with [representative] and thought sending her out to the ER [emergency room ] would be best. Facility transported res via w/c, report called to [name of hospital] ER . An Episodic Event Report for Resident C, completed on 8/8/24, was provided by the Executive Director on 8/13/24 at 9:59 a.m. It indicated, the date of event 8/4/24, Resident slid off shower bench. Fractures to left scapula [shoulder blade], left 2nd rib fracture, L3 [third lumbar spinal disc] endplate fracture [tearing of the cartilage and bone on the top and bottom of each disc in back] . A nursing progress note, dated 8/11/24, indicated, Resident returned to facility from hospital on 8/9/24 . A statement by Certified Resident Care Assistant (CRCA) 6, dated 8/5/24, indicated the following, .I was taking her to the shower and placed her on the shower bench. I went to warm up the water and had it spraying in the corner. While she was sitting there with the water running, she started to lean or slide off the bench and I attempted to keep her from falling. But she continued to fall to her side . An interview was conducted with the Occupational Program Director on 8/14/24 at 10:39 a.m. She indicated Resident C was a single staff person transfer. The staff utilizing a shower bench or shower chair was fine. The resident could tolerate either one. Prior to the resident fall, it was safe to place her on the shower bench. An interview was conducted with CRCA 6 on 8/14/24 at 1:37 p.m. She indicated, on 8/4/24, Resident C was not drowsy or lethargic that day. CRCA 6 often placed the resident on the shower bench during showers. The resident was able to tolerate sitting on the bench on previous shower days, so she continued to sit the resident on the bench during bathing. She does get report from previous shifts of the condition of the residents for example: when the resident was last toileted and if they are out of the building. Trazodone medication at MedlinePlus drug information at website www.medlineplus.gov, dated 1/15/22, was retrieved on 8/19/24. The website indicated the following, .Trazodone is used to treat depression. Trazodone is in a class of medications called serotonin modulators. It works by increasing the amount of serotonin, a natural substance in the brain that helps maintain mental balance .Trazodone is also sometimes used to treat insomnia .Trazodone may cause side effects .weakness or tiredness .dizziness or lightheadedness 2. The clinical record for Resident D was reviewed on 8/14/24 at 9:20 a.m. The diagnoses included, but were not limited to, stroke and muscle weakness. An annual MDS assessment, dated 7/24/24, indicated Resident D was cognitively intact. The resident's functional status was dependent of the staff person to provide all the effort for the resident to go from a sitting position to a stand position. The staff person was to assist over half of the effort when a resident needed to be transferred from a chair to wheelchair. The risk of falling care plan, dated 9/28/21, indicated, Resident is at risk for falling r/t [related to]: dx [diagnosis] of acute encephalopathy [brain disease], CVA [stroke], weakness, decreased mobility, medication regimen, requires assistance with transfers, incontinent status, pain, and other comorbidities .Encourage resident to assume standing position slowly, Ensure the floor is free of liquids and foreign objects, Keep call light in reach, Encourage to assume standing position slowly, Keep personal items and frequently used items within reach, Provide non-skid footwear . A nursing note written by Registered Nurse (RN) 5, dated 7/26/24, indicated, Res [resident] was being transferred to recliner and was dropped. No sign of injury . A nursing note written by the DON, dated 8/2/24, indicated, .fall on 7/26, staff was assisting resident from recliner to w/c [wheelchair] to go to the bathroom when the CRCA [Certified Resident Care Assistant 6] had difficulty with transfer causing resident to fall. No injuries noted. Resident just startled from fall. IDT [Interdisciplinary team] recommends gait belt with transfers. Resident remains an assist of 1 [one] with [Activities of Daily Living] ADL's and transfers. Able to make needs and wants known. Resident able to ambulate short distance with walker and uses w/c for long distance . An event report, dated 7/26/24, indicated Resident D had a witnessed fall in her room while ambulating with assistance. The resident requires assistance to transfer. The risk of falling care plan, with a revision date 8/6/24, indicated a new intervention, start date of 7/31/24, for the staff to utilize a gait belt when transferring the resident. A typed statement for CRCA 6, dated 7/26/24, indicated the following, Resident [D] needed to use the restroom, so I went to help her transfer. Resident was in her recliner, and I went to assist her into her wheelchair. During the transfer the resident was unsteady, so I lowered her to the floor . An interview was conducted with Physical Therapist 3 and Occupational Program Director on 8/14/24 at 10:32 a.m. They indicated they recommend staff to utilize gait belts for all resident transfers. An interview was conducted with CRCA 4 on 8/14/24 at 11:59 a.m. She indicated gait belts were to be utilized to assist with resident transfers. An interview was conducted with Resident D on 8/14/24 at 1:25 p.m. She indicated she had fallen. She stood up from her recliner to be transferred to her wheelchair. The staff person was too little to transfer me, and lowered her to the floor. She was not hurt. An interview was conducted with RN 6 on 8/14/24 at 1:50 p.m. She indicated she would assume that staff should use gait belts to transfer residents. An interview was conducted with CRCA 6 on 8/14/24 at 1:37 p.m. She indicated she was the staff person that was assisting Resident D with a transfer, on 7/26/24, when she had fallen. She did not utilize a gait belt to assist while transferring the resident at the time of the fall. Staff are required to use gait belts for some residents, but not all. An interview was conducted with the DON on 8/14/24 at 1:55 p.m. She indicated it was optional for staff to utilize gait belts to assist with transferring a resident unless the resident was care planned for gait belt use. A fall management program guidelines policy, revised 5/31/17, was provided by the Executive Director (ED) on 8/13/24 at 9:30 a.m. The policy indicated, .PURPOSE .strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures .intensive efforts will be directed toward minimizing or preventing injury .PROCEDURES .b. Care plan interventions should be implemented that address the resident's risk factors .2 .This includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possibly contributing factors, interventions to reduce the risk of repeat episode and a review by the IDT to evaluate thoroughness of the investigation and appropriateness of the interventions .5. The resident care plan should be updated to reflect any new or change in interventions A gait belt policy was provided by the Executive Director on 8/14/24 at 1:20 p.m. The policy indicated, .Purpose .To ensure safety for the resident and staff during transfers and mobility activities. Procedures . 1. Gait belts should be used according to the plan of care for the individual resident. 2. If resident requires use of gait belt, add to resident plan of care that will be communicated to the caregiver. 3. If a resident requires more than limited assists and does not require a lift a gait belt may be used with transfers. 4. An individual campus may designate a gait belt be used during all mobility activities. 5. Gait belts will be provided by the campus and should remain in the campus at all times for use by all staff during transfers. 6. Campus should have various sizes of gait belts available. 7. Failure to use a gait belt as defined in the resident plan of care or as designated by campus protocol may lead to disciplinary action up to and including termination. The Indiana State Department of Health Nurse Aide Curriculum, revised November 19, 2015, indicated the following, .PROCEDURE #24: USING A GAIT BELT TO ASSIST WITH AMBULATION .3. Place belt around resident's waist with the buckle in front and adjust to a snug fit ensuring that you can get your hands under the belt .4. Assist the resident to stand on count of three .6. Stand to side and slightly behind resident while continuing to hold onto belt .PROCEDURE #26: TRANSFER TO WHEELCHAIR .2. Place wheelchair on resident's unaffected side .4. Stand in front of resident and apply gait belt around the resident's abdomen . This citation is related to Complaints IN00440513 and IN00440297. 3.1-45(a)(1) 3.1-45(a)(2)

Based on interview and record review, the facility failed to timely address a grievance for 1 of 1 resident reviewed for dignity (Resident B). Findings include: The clinical record for Resident B was reviewed on 4/25/24 at 12:03 p.m. The Resident's diagnosis included, but were not limited to, hypertension. A Quarterly MDS (Minimum Data Set) Assessment, completed 2/5/24, indicated she was cognitively intact, frequently incontinent of bowel and bladder, and needed maximal assistance of staff for toileting. During an interview on 4/25/24 at 12:03 p.m., FM (Family Member) 20 indicated that approximately a week and a half ago, they had filed a grievance because Resident B had been brought to an appointment on the facility bus after being incontinent of bowel. The facility bus driver had gone back to the facility to get new clothing so that FM 20 could clean Resident B before the appointment. FM 20 was concerned that Resident B had not been toileted prior to leaving the facility. During an interview on 4/30/24 at 2:39 p.m., AS (Activity Assistant) 12 indicated that she had been the bus driver that transported Resident B to her appointment on 4/17/24. Resident B had attended an out of facility activity for approximately 30 minutes prior to her the appointment. AS 12 had taken Resident B from the out of facility activity to the appointment. When AS 12 took Resident B into the building for the appointment AS 12 had heard Resident B tell FM 20 that she had not been cleaned up before she left. FM 20 had taken Resident B into the bathroom and then come back and informed AS 12 that Resident B was a complete mess and asked AS12 to go the facility and get Resident B clean clothes. AS 12 had gone to the facility and informed ED (Executive Director) 1 about the incident and taken clean clothing back to the appointment for Resident B. AS 12 had not noted any odors or visible soiling of Resident B's clothing when she transported her to the appointment. During an interview on 4/30/24 at 3:00 p.m., the SSD (Social Services Director) indicated she had found grievance involving Resident B on the grievance log. The grievance was dated 4/17/24 and did not have a resolved date. SSD was unsure why it was not resolved. On 4/30/24 at 3:23 p.m., the SSD provided a grievance, dated 4/17/24, that indicated Resident B had arrived at a doctor's appointment on 4/17/24 covered in BM. AS 12 had been sent back to the facility for a change of clothes. FM 20 was concerned that Resident B was not toileted after lunch or before appointments. The resolution was dated 4/30/24 and indicated the SSD had contacted FM 20 and informed them that education had been provided to the staff on the importance of cleanliness and hygiene prior to going to appointments. On 4/30/24 at 3:26 p.m., ED 3 provided the Resident Concern Process Policy, last reviewed 12/31/23, which read .To provide a process for handling, tracking and resolving customer concerns to provide excellence in customer service .5. Enter the concern using the desktop icon labeled 'Resident Concern Form'. All concerns should be entered electronically .6. Concerns are reviewed in morning meeting, noting new entries and assigning them for follow up and resolution. 7. Follow up from the department leader will occur within 24-48 [sic] with resolution entered in KeyStats . This Federal Tag relates to complaint IN00430913. 3.1-7(a)(2)

Based on interview and record review, the facility failed to ensure the required medical and contact information was sent to the hospital for 1 of 1 resident reviewed for discharge. (Resident 54) Findings include: The clinical record for Resident 54 was reviewed on 4/29/24 at 10:28 a.m. Her diagnoses included, but were not limited to, stage 4 chronic kidney disease and stage 4 pressure ulcer of the sacral region. She was discharged from the facility to the hospital on 1/27/24. The 1/27/24, 10:06 p.m. nurse's note read, Res [Resident] has no output in catheter and was flushed x [times] 2. IV [Intravenous] 1L [liter] finished this morning and has drank fluids this shift. Per [name of physician] and spouse send to ed [emergency department] for eval [evaluation.] The 1/28/24 Clinical Discharge Observation, recorded and completed on 2/2/24, indicated a paper-based reconciled medication list was sent to the hospital with Resident 54. There was no information in the clinical record to indicate the contact information of the practitioner responsible for the care of Resident 54, Resident 54's representative information including contact information, advance directive information, all special instructions or precautions for ongoing care, comprehensive care plan goals, and all other necessary information was sent to the hospital to ensure a safe and effective transition of care. An interview was conducted with the DON (Director of Nursing) on 4/29/24 at 11:20 a.m. She indicated when a resident was sent to the hospital, they sent a bed hold policy, continuity of care documentation, and code status with the resident in a packet given to the EMTs (emergency medical technicians.) Most of the time, nursing documented that in a progress note, but not all of the time. The DON reviewed Resident 54's clinical record and indicated she did not see any documentation to verify that information was sent to the hospital for Resident 54. 3.1-12(a)(3)

Based on observation, interview and record review, the facility failed to timely revise a resident's care plans for refusal of showers and depression with individualized interventions for 1 of 5 residents reviewed for unnecessary medications (Resident 20). Findings include: The clinical record for Resident 20 was reviewed on 4/26/24 at 9:18 a.m. The Resident's diagnosis included, but were not limited to, depression and anxiety. A care plan, with a start date of 5/5/22 and last reviewed 4/17/24, indicated Resident 20 demonstrates symptoms of depression as evidenced by a score of on the PHQ-9 (depression assessment) sadness and tearfulness. The goal was that the resident will not demonstrate an increase in depressive symptoms. The approaches were GDR (Gradual Dose Reduction) of anti-depressant 4/3/24. Inform psych of an adverse effects noted or any changes in mood/ behavior, initiated 4/8/24, anti-depressant increased 2/5/24 due to failed GDR. Inform psych of any changes in mood/ behavior, initiated 2/5/24, anti-depressant decreased per GDR on 10/20/23 per psych, initiated 10/23/23, assess symptoms of depression with PHQ-9 as needed, initiated 5/5/22, encourage family to visit and participate in the resident's plan of care, initiated 5/5/22, encourage resident to participate in structured group activity and individual leisure activities per choice, initiated 5/5/22, encourage resident to remain actively involved in the plan of care and treatment plan, initiated 5/5/22, meds per order, initiated 5/5/22, observe for overt signs and symptoms of increased depression, initiated 5/5/22, observe mood, affect and behaviors, initiated 5/5/22, provide support and reassurance to resident daily and validate resident's feelings, initiated 5/5/22, provide supportive counseling contacts as needed and refer to psych services as needed, initiated 5/5/22. A care plan, with a start date on 1/17/23 and last reviewed 4/17/24, indicated Resident 20 demonstrated non-compliance with physician orders and/ or plan of care as evidenced by refusing showers at times. The goal was that her preferences will be honored to the extent that non-compliance with physician orders will not result in injury to self or others. The approaches, initiated 1/17/23, were to educate resident regarding physician orders and risk and benefits of compliance, encourage resident to actively participate in care plan and decision making, encourage resident to participate in decision making by offering choices and discussion of advanced directives, observe resident's ability to give informed consent and fluctuations in decision making, and offer alternatives to showers. An Annual MDS (Minimum Data Set) Assessment, completed 1/11/24, indicated she was cognitively intact, needed maximal assistance of staff for showers, and received an anti-depressant daily. A Nursing Home Psychiatric Subsequent Visit Form, dated 3/22/24, indicated that Resident 20's medication history included a reduction on her Lexapro (anti-depressant) to 10 mg (milligram) on 10/20/23 as a GDR. Lexapro was increased to 20 mg on 1/26/24 because the GDR failed. Current psychotropic medications included Lexapro 20 mg each morning. The presenting problem and patient interview on 3/22/24 indicated Resident 20 denied difficulty with sleep at that time. She reported that her depression was no longer a problem. The treatment plan indicated Resident 20 reported her depression had not been a difficulty for her since her Lexapro was increased. She had no side effects with Lexapro. A gradual dose reduction was contraindicated due to her symptoms improving. The March and April 2024 Medication Administration Record indicated she had taken her Lexapro 20 mg daily, as prescribed by the physician, until 4/3/24. A progress note, dated 4/3/24, read .resident refused Lexapro this am, stating it makes her feel weird and is having weird dreams. Resident does not want to take this med anymore. Notified [psychiatric nurse practitioner] and order to d/c Lexapro. During an interview on 04/26/24 at 9:18 a.m., Resident 20 indicated that she did not get her showers as she should. The staff would say that she refused the shower, but she just wanted them right before bed because the shower helped her relax. She went to bed at different times depending on how she felt and what was on television. She felt bad that she couldn't clean up and was having trouble moving around. She had a counselor when she was at home to talk to but did not have one here. She was observed to be tearful during the interview. She was going to go to bingo later in the day, which she really enjoyed. During an interview on 4/30/24 at 10:02 a.m., the DNS (Director of Nursing Services) indicated Resident 20's Lexapro had been discontinued because she had been refusing the medication and said it made her feel funny in the head. Resident 20 was tearful often, even when taking the Lexapro. Resident 20 had multiple health issues, including a large cyst on her left ovary. She saw multiple specialists. She has good days and bad days and was seen by the psychiatric nurse practitioner. Staff tried to get her out of the room as much as they could to the dining room or to bingo. The care plan for symptoms of depression had not been updated to reflect that Resident 20 had requested the Lexapro to be discontinued, multiple health concerns which may affect her depression, or to encourage Resident 20 to go to bingo and the dining room for meals. During an interview on 4/30/24 at 2:49 p.m., CNA (Certified Nursing Assistant) 13 and COTA (Certified Occupational Therapy Assistant) 14 indicated that Resident 20 preferred her showers in the evening. There were 3 or 4 CNA's who Resident 20 really liked to shower her and she would refuse showers at times if she didn't like the CNA who was assigned to her. If one of the CNA's she preferred was working, then staff would have that CNA shower her. COTA 14 indicated that she would also assist Resident 20 with showers sometimes. The care plan for refusal of showers at times had not been updated to offer alternate care givers which Resident 20 preferred. On 4/30/24 at 3:45 p.m., the Regional Nurse Consultant provided the Comprehensive Care Plan Guidelines Policy, dated 5/22/18, which read .To ensure appropriateness of services and communication that will meet the resident's needs, severity/ stability of conditions, impairment, disability, or disease in accordance with state and federal guidelines .Care plan interventions should be reflective of risk area[s] or disease processes that impact the individual resident .Should new identified area of concern arise during the resident's stay, they should be addressed on the care plan . 3.1-35(b)(2)

Based on observation, interview, and record review, the facility failed to administer a resident's medication, as ordered, and to timely address an issue with a physician's order for a new eye medication for a resident whose insurance did not cover the costs of the medication for 2 of 3 residents reviewed for pharmacy services and medication administration. (Resident E and Resident 16) Findings include: 1. The clinical record for Resident E was reviewed on 4/25/24 at 11:55 a.m. Her diagnoses included but were not limited to, type 2 diabetes mellitus and metastatic bone cancer. She was admitted to the facility from the hospital on 4/19/24. An interview was conducted with Resident E on 4/25/24 at 12:00 p.m. She indicated she was discharged from the hospital on a whole list of medications. Because she was admitted to the facility on a Friday, she did not start getting some of the medications until the following Monday. The 4/19/24 hospital discharge medication list indicated to administer one 75 mg capsule of Glucofunction twice daily and one 950 mg Nutrient capsule twice daily. The April, 2024 MAR (medication administration record) indicated the Nutrient capsule was not administered on the following dates due to the drug/item being unavailable: once on 4/20/24, twice on 4/23/24, and once on 4/26/24. The Glucofunction capsule was not administered on the following dates due to the drug/item being unavailable: once on 4/20/24, once on 4/22/24, twice on 4/23/24, and once on 4/26/24. An interview was conducted with the DON (Director of Nursing) on 4/29/24 at 10:59 a.m. She called the pharmacy during this interview to inquire as to why the Nutrient and Glucofunction were unavailable for administration on the above dates. After speaking with the pharmacy, the DON indicated neither the Glucofunction nor the Nutrient was delivered from pharmacy. The only thing she could think of was that since both items were over the counter, they were in the medication cart on the assisted living side of their facility, where Resident E resided prior to her being hospitalized , and staff literally walked over and got them, but not until after the above administrations were missed. The Admissions Checklist was provided by the RNC (Regional Nurse Consultant) on 4/29/24 at 12:07 p.m. There was a column to check yes or no as to whether medications were delivered and a column to check yes or no as to whether a second check of the orders was completed. 41129 2. The clinical record for Resident 16 was reviewed on 4/30/24 at 9:31 a.m. Resident 16's diagnoses included, but not limited to, diabetes type II, gout, chronic kidney disease, anxiety disorder, and retention of urine. A physician's order dated 4/10/24 for Resident 16 indicated to administer 1 drop of 0.1% Nevanac ophthalmic solution (a nonsteroidal anti-inflammatory medication used to treat eye pain, irritation, and inflammation) into eye twice a day. This order was discontinued on 4/19/24. A copy of Resident 16's April 2024 MAR (medication administration record) provided by DON (Director of Nursing) on 4/30/24 @ 4:15 p.m. indicated, on the following dates and times, Resident 16 did not receive the Nevanac eye medication: 4/11/24 - morning and evening doses 4/12/24 - morning dose 4/14/24 - morning and evening doses 4/15/24 - morning dose 4/16/24- morning and evening doses 4/17/24 - morning dose 4/18/24 - morning dose 4/19/24- morning dose A nursing note dated 4/10/2024 at 10:22 p.m. indicated, Resident 16 was seen by the eye doctor that day and a new order for Nevanac eye drops was received and noted. A nursing note dated 4/17/2024 at 2:36 p.m. indicated, the facility had attempted to reach Resident 16's eye doctor due to the new order for Nevanac eye drops was not covered by Resident 16's insurance. The nursing note also indicated a voicemail was left asking for the eye doctor to return the phone call to facility. A nursing note dated 4/18/2024 at 6:14 p.m. indicated, Resident 16's eye doctor had called the facility back regarding the Nevanac not being covered by the resident's insurance and inquired if another eye medication, Xibrom 0.9% would be covered by Resident 16's insurance as a substitution for the Nevanac. The nursing note indicated, facility's pharmacy was called and was to call the facility back regarding coverage and possible other substitutions that would be covered by the resident's insurance. An interview with the facility's pharmacy conducted on 4/30/24 at 9:44 a.m. with Pharm T (Pharmacy Technician) 6 indicated, they had received the physician's order for Resident 16 for the Nevanac on 4/10/24. They further indicated, that on 4/10/24 at 9:42 p.m., they had sent an unable to send medication communication form regarding Resident 16's Nevanac eye drops not being covered by insurance and that it would be an out of pocket cost of over $300. An interview with DON conducted on 4/30/24 at 10:15 a.m. indicated, when the pharmacy faxes an unable to send medication communication form, it goes to the fax machine at the nursing station and the expectation was for the resident's nurse on duty to contact the physician and get issue with the order addressed. DON indicated, she would have expected the resident's nurse that evening or at least the next day to resolve the pharmacy's unable to fill medication communication. An interview with the facility's pharmacy conducted on 5/1/24 at 10:06 a.m. with Pharm T 7 indicated, Resident 16's eye medication, Nevanac, was never delivered to the facility because of the cost issue. Pharm T 7 indicated, on 4/11/24, they called the facility to inquire about what to do about Resident 16's eye medication, Nevanac, and at that time, the facility indicated, for them (the pharmacy) to place the medication on hold until they speak to the provider. When the pharmacy did not hear back from the facility by 4/16/24, they sent another faxed unable to fill medication communication form to the facility. Pharm T 7 indicated, they still had not heard back from the facility regarding Resident 16's medication issue by 4/19/24 so they faxed another unable to fill medication communication form to the facility. When they hadn't heard back from the facility by 4/24/24, they called the facility and were then notified that the order for Resident 16's eye medication was switched to a medication covered by her insurance. Pharm T 7 verified the Nevanac for Resident 16 was never delivered to the facility. A Guidelines for Medication Orders policy received on 4/30/24 at 4:17 p.m. from ED (Executive Director) 3 indicated, Purpose to establish uniform guidelines in the receiving and recording of medication orders .Telephone/verbal orders .Telephone or verbal orders may be accepted by a licensed nurse only .Telephone or verbal orders shall be recorded in Matrix when received by the nurse receiving the order. 3.1-25(b)(1) 3.1-25(g) 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure: an ophthalmic (eye) medication was labeled with the date it was opened (Resident 24); the timely destruction of medications for an expired resident (Resident 272); and the controlled medication lock box was permanently affixed within the medication refrigerator (Facility) when reviewed for medication storage and labeling. Findings include: A medication storage observation was conducted on 4/30/24 starting at 4:02 p.m. and ending at 4:37 p.m. During the observation, the following was witnessed: 1. In the medication cart on [NAME] hallway with RN (Registered Nurse) 8, inside a drawer was an opened bottle of Timolol eye drops for Resident 24 with an opened date of 3/21. 2. An observation of the medication room on the healthcare side made with RN 9 found inside a cabinet, an opened bottle of Tylenol contained 10 tablets. The Tylenol bottle was labeled for Resident 272 and according to RN 9, Resident 272 was no longer a resident at the facility. Also, inside the medication room, was a medication refrigerator with a metal, locked box which contained controlled medications. The metal locked box was not permanently affixed within the fridge. An observation of the metal lock box for controlled medications inside the refrigerator was made with DON (Director of Nursing) on 4/30/24 at 4:37 p.m. It was observed a metal wire that, according to DON, had been attached to the metal locked medication box was broken and was no longer attached to the metal box. She indicated, she had not been made aware of the controlled medication lock box was no longer tethered to the fridge and was not sure how long it had been like that. A clinical record review for Resident 272 conducted on 5/1/24 at 9:28 a.m. indicated, Resident 272 had expired on 12/24/23. Resident 272's tylenol tablets should have been destroyed/returned in a timely manner. The National Library of Medicine at https://pubmed.ncbi.nlm.nih.gov/Hanssens JM, [NAME]-[NAME] C, [NAME] S, El-Zoghbi N, [NAME] V, [NAME] C, [NAME] JF. Shelf Life and Efficacy of Diagnostic Eye Drops. Optom Vis Sci. 2018 Oct;95(10):947-952. doi: 10.1097/OPX.0000000000001288. PMID: 30234830 last accessed 5/2/24 indicated, pharmaceutical companies recommend discarding ophthalmic drugs 28 days after opening. A Labeling of Medications and Biologicals policy received on 5/1/24 at 11:32 a.m. from RNC (Regional Nurse Consultant) indicated, Facility staff should date the label of any multi-use vial when the vial is first accessed .The staff will check the expiration date of each medication before administering it .No expired medications will be administered to a resident . 3.1-25(k) 3.1-25(n) 3.1-25(o) 3.1-25(r)

Based on interview and record review, the facility failed to timely obtain a urinalysis, as ordered by the physician, for 1 of 5 residents reviewed for unnecessary medications (Resident 23). Findings include: The clinical record for Resident 23 was reviewed on 4/29/24 at 10:30 a.m. The Residents diagnosis included, but did were not limited to, diabetes and kidney failure. A Quarterly MDS (Minimum Data Set) Assessment, completed 3/6/24, indicated that she was cognitively intact. A Nurse Practitioner Nursing Home Visit note, dated 4/25/24, indicated that Resident 23 reported urinary frequency, dysuria, and urgency. The plan was to complete a STAT (right away) urinalysis with culture and sensitivity. A physician's order, dated 4/25/24, indicated to obtain a STAT UA with C and S. During an interview on 4/29/24 at 12:44 p.m., the DNS (Director of Nursing Services) indicated that the UA had not been sent to the lab on 4/25/24. It should have been obtained on 4/25/24. On 4/29/24 at 4:01 p.m., the Regional Nurse Consultant provided the current Ordering Lab Test Policy which read . Once the specimen has been collected .Lab Services Customer Care Team to arrange for transport of your STAT specimen[s] to the STAT partner with which we have contracted for you . 3.1-49(a)

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control policy by not performing hand hygiene prior to glove use and after dropping a pill onto a medication cart, picking up the pill with bare hands and administering it to the resident for 1 of 3 residents reviewed during the medication administration observation. (Residents 9 and 16) Findings include: 1. A medication administration observation with RN (Registered Nurse) 4 was conducted on 4/30/24 at 8:43 a.m. RN 4 was observed while she prepped and administered Resident 16's oral medications. After administering the oral medications, she turned around back to her medication cart; touched the medication cart and her keys to unlock the cart; opened a drawer and retrieved a pill bottle which contained Resident 16's eye drops bottle. RN 4 had, without performing hand hygiene, donned (put on) gloves and administered the eye drops to Resident 16. An interview with RNC (regional Nurse Consultant) conducted on 4/30/24 at 11:53 a.m. indicated, yes, RN 4 should have performed hand hygiene prior to donning clean gloves and administering Resident 16's eye medication since she had administered medication, touched her keys, unlocked the medication cart, and retrieved the medication out of the cart prior to donning the gloves. 2. A medication administration observation with LPN (Licensed Practical Nurse) 5 was conducted on 4/30/24 at 9:10 a.m. LPN 5 was observed preparing the medications for Resident 9. LPN 5 was opening the pill packets with scissors and then dumping them into a medication cup when one tablet from a pill packet had fell on to the medication carts top. LPN 5, with bare hands, quickly picked up tablet from the top of the medication cart and placed the tablet into the medication cup with Resident 9's other tablets and administered the medications to the resident. She had not performed hand hygiene prior to touching the tablet with her bare hands. An interview with LPN 5 was conducted after the medication administrations and when asked why she picked up the medication off the medication cart with her bare hands, she explained that with the pill packets, she didn't have another tablet (of the same medication) which to replace it. LPN 5 identified the medication she dropped as Resident 9's pantoprazole (acid reducing medication)tablet. LPN 5 indicated, she was unsure if the facility's emergency drug supply carried that medication. An Infection Prevention and Control General Guidelines policy received on 5/1/24 at 2:37 p.m. from ED (Executive Director) 3 indicated, the purpose of the policy was To provide guidelines to prevent the spread of infection from one person to another .Hand washing is the most important method of infection prevention and control .Hands should be washed between direct contact with any resident, after doing cleaning tasks, after using the restroom or any other tasks that provides an opportunity for infection .Gloves should be worn when coming in contact with blood or body secretions . The Centers for Diseases and Control website at https://www.cdc.gov/handhygiene/providers/index.html; Last Reviewed: January 8, 2021, Source: Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of Healthcare Quality Promotion (DHQP) last accessed 5/1/24, Glove Use When and Where to use Gloves indicated, Wear gloves, according to Standard Precautions, when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment could occur. Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment. Perform hand hygiene immediately after removing gloves. 3.1-18(b) 3.1-18(l)

Based on interview and record review, the facility failed to protect the residents' right to be free from sexual abuse by not appropriately determining their capacity to consent to sexual interactions and implementing an effective plan to address the sexual activity between 2 residents for 2 of 2 resident's reviewed for abuse. (Resident 14 and Resident 28). The Immediate Jeopardy started on 5/5/22 when two cognitively impaired residents engaged in a sexual activity. Resident 14 and 28 continued to have sexual encounters after the 5/5/22 incident; resulting in increased falls, initiation of a prophylactic antibiotic, increase in antidepressant medication, initiation of a medication used to suppress sexual desire and emotional distress. The facility was unable to provide evidence an effective plan was in place to address the residents' sexual interactions and determining if Residents 28 and 14 had the mental capacity to consent to sexual activities. The Executive Director (ED), Director of Nursing Services (DNS), Nursing Clinical Support (NC) 3, Nursing Clinical Support 4, Registered Nurse 6, and Registered Nurse 7 were notified of the immediate jeopardy on 1/6/23 at 3:20 p.m. The Immediate Jeopardy was removed, and the deficient practice was corrected by 1/9/23 after the facility implemented a systemic plan that included the following actions: develop and implement a plan to address the residents' sexual interactions, their capacity to consent to such interactions, and ensure all staff are educated on sexual abuse. Findings include: 1a. The clinical record for Resident 14 was reviewed on 1/5/23 at 9:32 a.m. The Resident's diagnosis included, but were not limited to, Parkinson's disease, dementia, cognitive impairment, and depression. A Psychiatric Evaluation/ Follow-up note, dated 1/6/22, indicated Resident 14 was being seen for depression, dementia, and Parkinson's disease. He is alert and oriented to person only. His cognition is fairly declined, with long term memory fair to poor, short term memory and concentration poor. His executive functioning and abstract thinking are very impaired. His MOCA (Montreal Cognitive Assessment Test for Dementia) was 13/30 (10 to 17 points indicate moderate cognitive impairment). A care plan, initiated 1/7/22, indicated Resident 14 had impaired cognition with associated short term memory impairment and risk for confusion, disorientation, altered mood, and impaired or reduced safety awareness related to his dementia. The goal was for him to remain safe and not injure himself secondary to his impaired decision making. The interventions included, but were not limited to, assess his degree of hearing ability, impulsive behavior, and decrease in visual perception, initiated 1/7/22, observe for exit seeking behaviors, wandering into unsafe areas, and entering other resident rooms un-invited, initiated 1/7/22, redirect him when agitated behavior occurs or potential for injury is evident, initiated 1/7/22, determine if his decisions endanger himself or others. Intervene as necessary, initiated 1/7/22, give him feedback when inappropriate decisions are made, initiated 1/7/22, and pay attention to basic needs and provide ADL (Acts of Daily Living) care as required. Provide cues and supervision for decision making, initiated 1/7/22. A Quarterly MDS (Minimum Data Set) Assessment, completed 4/11/22, indicated Resident 14 had moderately impaired cognition. 1b. The clinical record for Resident 28 was reviewed on 1/5/23 at 2:30 p.m. The diagnoses for Resident 28 included, but were not limited to, stroke, major depressive disorder, mild cognitive impairment, and dementia with behavioral disturbance. The resident had previously been living in an assisted living and was transferred to long term care on 11/22/21 in the same facility. A care plan dated 4/3/20 indicated Resident [28] has impaired cognition with associated short term memory impairment and risk for confusion, disorientation, altered mood, impaired or reduce safety awareness .long term goal .Resident will remain safe and not injure self-secondary to impaired decision making Approach .Calm resident if signs or distress develop during the decision making process .Determine if decisions made by the resident endanger the resident or others. Intervene if necessary .Re-direct resident when agitated behaviors are present or potential for injury is evident . A physician order dated 11/22/21 indicated Resident 28 was to receive 30 milligrams of Paxil daily for depression. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident 28 was moderately cognitively impaired. A Quarterly MDS assessment dated [DATE] indicated Resident 28 was cognitively intact. An Annual MDS assessment dated [DATE] indicated Resident 28 was moderately cognitively impaired. A care plan dated 12/1/21 indicated Resident demonstrates physically abusive and resistive behaviors toward staff during hands on care/combative with care .Approach .Approach resident in a calm and unhurried manor to deliver care and provide services .Explain care process prior to delivery of care as needed .Observe for signs and sensory overstimulation and encourage resident to move into less stimulating environment as needed. Offer choices in all hands-on care and contacts. Psych to continue to follow . A physician order dated 5/3/22 indicated Resident 28 was to receive 125 milligrams and 250 milligrams of Depakote to total of 375 milligrams at bedtime for aggression and mood stabilization. A physician order dated 5/3/22 indicated Resident 28 was to receive 250 milligrams of Depakote twice a day for aggression and mood stabilization. A nursing progress note dated 5/4/22 indicated Res [Resident] [28] was in hall with another resident [Resident 14]and put her hand in his lap. Resident were separated at that time. No further action required. A nursing progress note, dated 5/05/22 at 9:00 p.m., indicated Resident 14 was in another resident's (Resident 28) room and the other resident was touching him inappropriately. The families of both residents were notified. A Behavior Event dated 5/5/22 for Resident 28 indicated .Describe behavior exhibited .sexual behavior towards other residents . Does resident's mental function vary over the course of the day? For example: Sometimes better, sometimes worse; behaviors sometimes present, sometimes not. [marked as] Yes .Indicate Non-Pharmacological measures taken - check all that apply . [marked as] redirection and relocated to quite (sic) location . A reportable incident to the Indiana Department of Health was provided by the ED on 1/5/23 at 2:23 p.m. It indicated a sexual interaction had occurred between Resident 28 and 14 on 5/5/22. The .brief description of incident .Both residents were in female resident's room. when staff entered room the observed resident with her hand under his shorts .Preventative Measures Taken .Psych to continue to follow for behaviors and make recommendations as needed .Follow us: No further resident to resident contact made. Psych to continue to follow for behaviors and make recommendations as needed . A Psych visit note for Resident 28 dated 5/5/22 completed by Psych Nurse Practitioner (NP) 1 indicated .Treatment Plan .5/5/22 .Staff reports she had an episode of putting her hand in the pants of a male peer. Writer notes the patient has a male peer in her room with the door shut. Nursing did remove the male from the room. The patient's Depakote was reduced last visit for a GDR. this has failed. The patient has been having behavior issues with being sexually aggressive and preoccupied. Her dose was increased back up to 250 [milligrams] mg bid [twice a day] and 375 mg hs [nightly] 2 days ago. If the patient's symptoms do not improve in 1 week we are going to look at increasing her Paxil from 30 mg to 40 mg daily. The patient was noted today to have a male in her room with the door shut. She is saying that she feels sex is normal and she is going to do what she wants .Her cognition continues to be very declined .The Psychiatric Examination:Appearance and Behavior: .Cooperative: no, .Memory: poor, Attention: fair, Thought Content: .Insight: poor, judgment: poor, .thought process: more confused, Orientation: Person: yes, Place: no, Time: no . An Interdisciplinary Team (IDT) note dated 5/6/22 indicated Last evening [5/5/22] resident [28] was in her room and another male resident [14] came to visit her. When staff entered room the observed resident with her hand under his shorts. Resident separated and skin assessments completed, no findings. Psych informed and had been in to visit resident earlier in day and medication adjustments made. Psych to continue to follow and make recommendations made as needed. A nursing progress note dated 5/6/22 at 8:35 p.m. indicated resident [28] has had sexual comments and behavior towards male resident [14] and staff members this shift . A Quarterly MDS Assessment, completed 5/10/22, indicated Resident 14 had moderately impaired cognition Resident 28's and Resident 14's clinical records did not include a plan of care and/or interventions in place for sexual behaviors at that time. A nursing progress note, dated 5/13/22 at 1:16 a.m., indicated Resident 14 was found in another resident's (Resident 28) room sitting on his knees beside her bed. The wheelchair was positioned in front of the door. He was returned to his own room and instructed to not enter other resident's rooms. A Behavior Event for Resident 28 dated 5/24/22 indicated .Description: inappropriately touching a male resident [Resident 14] . Event details:resident had her hand on male resident leg near privates .where did the behavior occur? resident [28]'s room .who was involved in the behavior? .2. possible triggers (contributing factors) .[marked as] other - expressed feelings toward male resident .3. intervention: [marked as] quieted environment .other resident removed from situation and taken back to room Evaluation notes: resident's monitored for inappropriate behavior and staff intervene as needed . A reportable incident to the Indiana Department of Health was provided by the ED on 1/5/23 at 2:23 p.m. It indicated a sexual interaction had occurred between Resident 28 and 14 on 5/24/22. The .brief description of incident .Resident [14] was found in resident [28]'s room and she was inappropriately touching him .Immediate Action Taken: .Residents were immediately separated. Head to toe assessments completed without injuries noted . Preventative Measures Taken .No further resident to resident contact made. Psych to continue to follow for behaviors and make recommendations as needed .Follow up: Resident's monitored for inappropriate behavior and staff continue to intervene as needed. Family aware and informed of resident's desire to be spend time together and socialize. Care plan updated. Residents continue to be followed by psych services and medications adjusted as needed. A physician order dated 5/25/22 indicated Resident 28 was to receive 2.5 milligrams of Zyprexa at night for sexual aggression. A progress note, dated 5/26/22 at 4:14 p.m., indicated Resident 14 was being monitored for inappropriate behavior and staff continued to intervene as needed. His family was aware and informed of residents' desire to be spend time together and socialize. The family was agreeable to allowing residents to spend time together and aware of their desire to be intimate. Residents continue to be followed by psych services. A progress note for Resident 28, dated 5/26/22, by Executive Director indicated, Resident's monitored for inappropriate behavior and staff continue to intervene as needed. Family aware and informed of resident's desire to spend time together and socialize. Family agreeable to allow resident to spend time together and aware of resident's desire to be intimate. Residents continue to be followed by psych services. A progress note dated 5/29/22 at 9:04 p.m. indicated Resident 14 was agitated when the CRCA (Certified Resident Care Assistant) and QMA (Qualified Medication Assistant) separated him from a female resident (Resident 28). He was sitting in the doorway of the female resident's room. Resident 14 stated that the workers were crows and always watching over him and the female resident. He was educated on why they needed to be separated and did not agree. He expressed that it was like a prison. Resident 14 was easily calmed down and did not attempt to go back into the female's room. A care plan for Resident 28, initiated 5/31/22, indicated Resident demonstrates inappropriate behaviors including: touching another male resident in a sexual manner .long term goal .Residents behaviors will not result in disruption of others environment and resident will remain safe .Approach .Assess for unmet needs such as need for toileting, rest, food, companionship, etc .Assist resident to away from other residents as needed .Determine cause for inappropriate behavior and refer to physician as needed for intervention .Encourage participation in structured activities as appropriate .Observe for triggers of inappropriate behaviors and alter environment as needed . A care plan for Resident 28, initiated 5/31/22, indicated Resident enjoys to[sic] company of another male resident/enjoys visiting with male resident in her room. Family aware of relationship although not 100% supportive .Long term goal .Resident will be safe .Approach .Family aware and consents of resident spending time with and socializing with male resident in her room .Intervene as needed .Psych to continue to follow . A care plan, initiated 5/31/22, indicated Resident 14 enjoyed the company of a female resident and visits with her in her room. The family was aware of the relationship although not 100% supportive. The goal was to keep Resident 14 safe. The approaches, initiated 5/31/22, were to intervene as needed, the family was aware and consented to resident's desire to spend time and socialize with the other resident, and for psychiatric services to continue to follow Resident 14. A care plan, initiated 5/31/22, indicated Resident 14 demonstrated inappropriate behaviors including touching another resident in a sexual manner. The goal was for the behavior not to result in disruption of others environment. The approaches were to determine the cause for the inappropriate behavior and refer to physician as needed for intervention, initiated 5/31/22, psychiatric services would continue to follow, initiated 5/31/22, encourage Resident 14 to participate in structured activities as appropriate, initiated 5/31/22, observe for triggers of inappropriate behaviors and alter the environment as needed, initiated 5/31/22, assess for unmet needs such as need for toileting, rest, food, companionship, etc., initiated 5/31/22, assist resident away from other residents as needed, initiated 5/31/22, and to administer anti-depressant medication as ordered, initiated 6/12/22. The clinical records for Resident 14 and Resident 28 did not contain information of informed consent to sexual activity such as, understanding of risks or benefits of sexual activity and knowledge of when sexual advances are appropriate such as time and place. A Psychiatric Evaluation/ Follow-up note, dated 6/2/22, indicated Resident 14 continued to receive Zoloft (anti-depressant) for depression and had no difficulty with side effects. His cognition remains somewhat confused but stable. He had been visiting a particular female (Resident 28) on his hall and was found allowing her to touch him privately He was provided with information about this being inappropriate and needing to avoid that female which he agreed to. A Psych Visit Note for Resident 28 dated 6/2/22 by Psych NP 1 indicated Interval History .6/2/22 Staff report the patient is continuing to have ongoing difficulty with sexual aggression. She was found fondling a male peer while lying in her bed. She makes frequent sexual comments about him. She was started on Zyprexa 2.5 mg hs to address her difficulty with delusions and sexual aggression .Presenting Problem & Patient Interview .She is fairly loud during our visit. She states nursing staff have been treating her poorly due to her affair. She describes this as something she enjoys, and she feels it is appropriate. She also states there should be no rule against people having sex in the facility. she also tells writer a story where she says that staff had blood on their shirts when they came in her room and they told her that a male peer had been in a motorcycle accident. She found out later this was not true and that he was fine. she says she is angry with staff for making up the story. The patient is illogical with this information. The patient was provided reality feedback. He (sic) also was provided with direction regarding inappropriateness of sexual relations in the facility with male peers. The patient disagrees with this somewhat loudly but is not derogatory during the discussion. Writer is unable to assist the patient to recent due to her level of cognitive decline .Treatment Plan .6/2/22 The patient is continuing significant difficulty with behavior issues and psychosis. Paxil is ordered for sexual aggression. we are going to increase from 30 mg to 40 mg daily due to her ongoing sexual aggression. The patient has fondled a male peer in her room. She continues to seek him out and talk about her relationship with him sexually. We are going to increase Zyprexa for psychosis. she was started on 2.5 [mg] last week and has not had improvement. She is delusional today talking about staff telling her male peer had a motorcycle accident. her cognition continues to be declining slowly . A physician order dated 6/3/22 indicated Resident 28 was to receive 40 mg of Paxil daily for sexual aggression. A physician order dated 6/3/22 indicated Resident 28 was to receive 5 mg of Zyprexa for psychosis with delusions, which was discontinued on 7/5/22. A Behavior Event for Resident 28 date 6/3/22 indicated .Description. med changes: Zyprexa and paxil - monitor behaviors of sexual nature. What behavioral expression was exhibited? behaviors of sexual nature Where did the behavior occur? room [ROOM NUMBER]. Evaluation Possible Triggers (contributing factors): Recent change in Medications - Zyprexa and paxil .3. Interventions: Engaged in a different activity .conversation .called family to talk .psych notified .Evaluation notes: Resident [28] has dx [diagnosis] of dementia with behaviors. Psych services aware and managing medications . A nursing progress note dated 6/4/22 for Resident 28 indicated resident lifting front of dress to male resident [14] x 2 [twice]. staff monitored closely and resident redirected when seen. resident spoke to male resident that she is not supposed to do that. resident monitored closely by staff this shift. A nursing progress note dated 6/7/22 for Resident 28 indicated .One episode of inappropriate talk with a male resident [Resident 14]. staff intervened and separated them. resident did not have any more behaviors after that. A nursing progress note dated 6/8/22 for Resident 28 indicated Resident up in wheelchair, able to move self around hallways. Resident was saying that she wanted a male resident friend [Resident 14] to eat dinner with or to eat in the [NAME] dining hall with her. Resident was easily redirected. Later resident was taking clothes off in hallway. She was wheeled back into her room and dressed 3 different times, each time wheeling back into the hallways and stripping again. A care plan dated 6/9/22 indicated Resident demonstrates inappropriate behaviors AEB [as evidenced by] taking clothes off in hallway/stripping .Approach .Assess for unmet needs such as toileting, rest, food, companionship, etc .Assist resident to away from other residents as needed .Determine cause for inappropriate behavior and refer to physician as needed for intervention .Encourage participation in structured activities as appropriate .Observe for triggers of inappropriate behaviors and alter environment as needed . A nursing progress note dated 6/9/22 for Resident 28 indicated .She was at the HUB [common area] after dinner and was tearful and sad. She was looking for her male companion she stated. She was tearful until she was ready for bed. A nursing progress note dated 6/10/22 for Resident 28 indicated .She was yelling in the hallway outside of her room at staff. She was trying to go into another male resident [14]'s room. When she was redirected away from male resident's room, she started yelling and crying and said she was going to throw a fit like a 2 year old. She wheeled herself out of her room and was talking inappropriately with another resident. Resident then wheeled into her room when asked to not talk like that . An Event Report, dated 6/11/22 at 10:25 p.m., indicated Resident 14 had a fall in another resident's (Resident 28) room. He was sexually active with another patient (Resident 28) at the time of the fall. There were no injuries noted. He was alert and oriented to person and place. He refused to stay out of the other resident's room. The notes include that he was found on his knees next to a recliner. He had his right hand on the other patient's body and his left hand on his penis. He had been incontinent of bladder. We was assisted to the wheelchair and assessed to have no injuries. He was agitated with staff for interrupting with multiple attempts to make care as difficult as possible. He threatened to have his family come to the facility to physically assault the staff. His family and the physician were called and notified. The Director of Health Services was notified. A nursing progress note, dated 6/12/22 at 10:05 a.m., indicated a message was left for the psychiatric nurse practitioner notifying her of Resident 14's behaviors on 6/11/22 with another resident (Resident 28). A nursing progress note, dated 6/12/22 at 11:33 a.m. indicated NP (Nurse Practitioner) 1 had returned call and given a new order for Resident 14 to receive Paxil (anti-depressant) 10 mg(milligram) daily. A care plan for Resident 28, initiated 6/13/22, indicated Resident demonstrates inappropriate behaviors AEB [as evidence by] inappropriate sexual comments in conversing with others .Approach .Assess for unmet needs such as need for toileting, rest, food, companionship, etc .Determine cause for inappropriate behavior and refer to physician as needed for intervention .Encourage participation in structured activities as appropriate .Observe for triggers of inappropriate behaviors and alter environment as needed .Psych to continue to follow . A care plan for Resident 28, initiated 6/13/22, indicated Resident demonstrates verbally abusive behaviors/yelling at staff .Approach .Encourage resident to express wants and needs during hands on care and contacts. Encourage resident to voice feelings constructively to staff as appropriate. Observe for patterns of behaviors that may trigger verbally abusive language. Alter as appropriate. Observe mood, affect, and behaviors with all hands on care and contacts. Psych to continue to follow. Re-direct resident during periods of frustration and anger . An IDT note for Resident 28 dated 6/15/22 indicated Patient continues to be monitored for behaviors. Was noted to yell out at times, have statements and behaviors of a sexual nature toward a male resident [Resident 14] and making inappropriate comments. Patient has a diagnosis of cerebral infarction, Major depressive disorder, Mild cognitive impairment and Unspecified dementia with behavioral disturbance. Is followed by psych with recommendations made as indicated. Patient started on Depakote 5/3 and takes it BID and was started on Paxil and zyprexa 6/3. Will continue to monitor for changes and further behaviors and consult psych as indicated. A nursing progress note for dated 6/16/22 for Resident 28 indicated this resident and a male resident in hallway sitting together. this resident unbutton top and let male resident rub all over her breast. Staff separated residents and took to room. resident sat in room quietly until put to bed. A nursing progress note for Resident 14, dated 6/16/22 at 8:41 p.m., indicated that he was with another resident in the hallway and found rubbing all over her breasts. He was redirected to his room and informed to stay away from the other resident. An Event Report, dated 6/18/22 at 7:30 p.m., indicated Resident 14 had a fall while he was transferring himself. There were no injuries noted from the fall. He was alert and oriented to person, place, time, and situation. He required assistants to transfer and ambulate and refused to comply with safety measures such as call light use, alarms, and appliances. He was taken to his room and assisted to bed after the fall. The notes for the event included, but were not limited to, the following: 6/18/22 at 8:20 p.m., Resident 14 was in Resident 28's room sitting in high fowlers (upright with legs extended in front of him). His wheelchair was on his right side and his back was against the door. It took a lot of encouragement by numerous staff to get him to move far enough away from the door to allow staff to enter the room. Staff entered the room after approximately 15 minutes and assisted him back to his wheelchair. He was fully dressed, and no inappropriate behaviors were noted. 6/23/22 at 1:35 p.m., Resident 14 had a fall while visiting Resident 28 in her room. The door was shut, and he was sitting with his back against the door. An intervention of leaving the door open when visiting was initiated. 6/25/22 at 1:46 p.m., Resident 14 was found in Resident 28's room. He often seeks companionship from this female resident. He was removed from room and returned to his own room. 6/27/22 at 3:06 a.m., Resident 14 was found to be returning to his room at 1:05 a.m. He was noted to have BM (Bowel Movement) on bilateral upper extremities from his fingertips to his elbows. He became agitated when being cleaned up and struck out at staff. A nursing progress note dated 7/1/22 for Resident 28 indicated she was admitted to hospital with urinary tract infection and pneumonia. Resident 28 returned from the acute care hospital on 7/5/22, with a physician's order to receive 300 mg cefdinir twice a day with a discontinuation date of 7/7/22. A Pharmacy Recommendations Event Report for Resident 14, dated 7/5/22 at 9:03 a.m., indicated he had Paxil added on 6/12/22 due to some inappropriate sexual behaviors. He was also receiving sertraline (anti-depressant) 50 mg, which is another SSRI (Selective Serotonin Reuptake Inhibitor). It is not recommended to use both, please review. A physician's order for Resident 14, dated 7/7/22, indicated to discontinue the Zoloft (Sertraline). A Psych Visit note dated 7/7/22 by Psych NP 1 indicated .Interval history .7/7/22 The patient had an episode of inappropriate talk with a male peer and also lifted the front of her dress for him. She also was noted to be undressing in the hall several times. She told staff she has performed sexual acts with the male peer. She has observed allowing him to touch her breast. She was sent to ER [emergency room ] 7/1/22. she has been back for 2 days with no sexual behaviors since her return. Her cognition is significantly declined. it is unchanged from last visit. An Event Report, dated 7/17/22 at 3:11 p.m., indicated Resident 14 was displaying sexual gestures to another female resident by attempting to stick his foot into Resident 28's private area while sitting in the open hub area. The possible changes included recent discontinuation of Zoloft and sexual desires. The interventions were that he was assisted to his room and his family was called. The notes for the event included, but were not limited to, the following: 7/17/22 at 3:08 p.m., Resident 14 was sitting in the hub area when noted to have his foot between another female resident's legs. He was educated that this was not appropriate, and he laughed and said heck, let's just screw right here. 7/18/22 at 8:38 p.m., Resident 14 and Resident 28 were in the hallway outside of Resident 28's room. She was manipulating his penis. A family member came to the nursing station to report the incident. The residents were immediately separated, and the Executive Director was informed. 7/21/22 at 8:27 p.m., Resident 14 was visiting Resident 28 with the door shut for a consensual visit. 7/26/22 at 1:30 a.m., Resident 14 was found on his knees in another resident's room without pants or a brief on. He had placed his wheelchair in front of the door to prevent staff from entering. He was assessed and found to have abrasions on both knees and complained of knee pain. The female resident in the room reported that they had engaged in sexual relations. He refused to leave room or let staff assist him off of the floor. The female resident asked him to kiss her and that she was going to bite his lip. Family notified of the incident an appears increasingly frustrated with the situation. A Behavior Event Note for Resident 28 dated 7/17/22 indicated .Description: sexual gestures to another male resident. What behavioral expression was exhibited? exposing herself to male resident who was trying to stick his foot in her private areas .Where did the behavior occur? in hub area. 2. Evaluation possible triggers (contributing factors) . under-stimulation (boredom) - sexual desires. 3.) Intervention: address unmet needs - she just wants [Resident 14]'s penis, assist to different area - away from [Resident 14], call family to talk - no answer Evaluation: IDT note: resident sexual gestures are consensual. staff encouraged to redirect and educate on safe/healthy habits. Encouraged to room for sexual desires for privacy . Resident 14's and 28's medical records did not include an assessment at that time for capacity to consent to sexual activity, nor plan of care plan with interventions in place to ensure safety regarding sexual encounters. A nursing progress note for Resident 28 dated 7/18/22 at 1:38 p.m. indicated resident told male staff member to stick his finger in her belly button after pulling her gown up. She then expressed the desire to stick her finger into a specific male resident [Resident 14]'s belly button. Then stated she was only joking to get a reaction out of writer. A nursing progress note for Resident 28 dated 7/18/22 at 1:42 p.m. indicated resident has been in hallway yelling twice for a specific male resident [Resident 14]. resident was asked to please not yell in the hallway as it disrupts other residents resting. resident got louder and yelled at writer and other staff around to push her up the hallway to this male resident's room. staff encouraged resident to propel her own chair which she did and that the other resident she was seeking was resting in his room. this resident then asked to go sit in the common area, which staff assisted with mobility. A nursing progress note for Resident 28 dated 7/20/22 indicated up in w/c sitting in doorway yelling down hall for male resident [Resident 14] .to get down to her room. No close contact with this resident as of yet today. An IDT note for Resident 28 dated 7/22/22 indicated Resident continues to have intimate relationship with another resident. Both residents enjoy the company of each other. They hand [sic] out in common area and in resident room. Residents are encouraged to go to room when having sexual desires for privacy. Resident educated and agreeable. Resident 28's POA made aware and understands situation, no concerns voiced. Discussed safety concerns with both resident and resident [28's POA]. A nursing progress note dated 7/26/22 for Resident 28 indicated Male resident [Resident 14] found on knees next to female resident's bed after reportedly falling off. Female resident stated, 'we were screwing' and had brief down around her knees. Male resident w [TRUNCATED]

Based on interview and record review, the facility failed to have the interdisciplinary team (IDT) determine and document that self administration of medications and treatments were clinically appropriate for 1 of 5 residents observed during medication administration. (Resident 40) Findings include: The clinical record for Resident 40 was reviewed on 1/10/23 at 2:23 p.m. The diagnoses for Resident 40 included, but was not limited to, chronic obstructive pulmonary disease. A Quarterly MDS assessment dated [DATE], indicated Resident 40 was cognitive intact. A physician order dated 1/27/22 indicated Resident 40 was to receive 50 micrograms (mcg) of flonase nasal spray. A physician order dated 8/25/22 indicated Resident 40 was to receive 100-25 mcg breo inhaler. An observation was made of a medication administration with License Practical Nurse LPN 15 on 1/10/23 at 9:40 a.m. During the preparing of a medication administration to Resident 40; LPN 15 indicated she had previously provided Resident 40 with his breo inhaler and flonase nasal spray. She had dropped them off to him earlier in the morning to administer himself. The resident was alert and oriented and able to administer the breo inhaler and flonase himself. Resident 40's clinical record did not include documentation the resident was able to self administer his medications. An interview was conducted with the Director of Nursing Services (DNS) on 1/10/23 at 3:17 p.m. She indicated Resident 40 had not had a documented self medication assessment. A Self-Administration of Medications policy was provided by the DNS on 1/10/23 at 3:17 p.m. It indicated .Purpose. To ensure the safe administration of medication for residents who request to self-medicate or when self-medication is a part of their plan of care. Procedures. 1. Residents requesting to self-medicate or has self-medication as part of their plan of care shall be assessed using the observation Trilogy-Self Administration of Medication within the electronic health record. Results of the assessment will be presented to the physician for evaluation and an order for self medication. a. The order should include the type of medication(s) the resident is able to self-medicate. i.e: [that is] all oral meds, oral meds with the exception of ., nebulizer treatment only, all medications including injection, oral, inhalers, drops, etc. 2. The resident and/or family/responsible party will be informed of the results of the assessment and whether the resident has been determined to safely self-administer medications .6. A Self-Medication plan of care will be initiated and updated as indicated . 3.1-11

Based on interview and record review, the facility failed to report to the Indiana Department of Health (IDOH) resident to resident sexual activity without the competency to consent for 2 of 2 residents reviewed for abuse. (Resident 14 and Resident 28) Findings include: 1a. The clinical record for Resident 14 was reviewed on 1/5/23 at 9:32 a.m. The Resident's diagnosis included, but were not limited to, Parkinson's disease, dementia, cognitive impairment, and depression. A Psychiatric Evaluation/ Follow-up note, dated 1/6/22, indicated Resident 14 was being seen for depression, dementia, and Parkinson's disease. He is alert and oriented to person only. His cognition is fairly declined, with long term memory fair to poor, short term memory and concentration poor. His executive functioning and abstract thinking are very impaired. His MOCA (Montreal Cognitive Assessment Test for Dementia) was 13/30 (10 to 17 points indicate moderate cognitive impairment). A care plan, initiated 1/7/22, indicated Resident 14 had impaired cognition with associated short term memory impairment and risk for confusion, disorientation, altered mood, and impaired or reduced safety awareness related to his dementia. The goal was for him to remain safe and not injure himself secondary to his impaired decision making. The interventions included, but were not limited to, assess his degree of hearing ability, impulsive behavior, and decrease in visual perception, initiated 1/7/22, observe for exit seeking behaviors, wandering into unsafe areas, and entering other resident rooms un-invited, initiated 1/7/22, redirect him when agitated behavior occurs or potential for injury is evident, initiated 1/7/22, determine if his decisions endanger himself or others. Intervene as necessary, initiated 1/7/22, give him feedback when inappropriate decisions are made, initiated 1/7/22, and pay attention to basic needs and provide ADL (Acts of Daily Living) care as required. Provide cues and supervision for decision making, initiated 1/7/22. A Quarterly MDS (Minimum Data Set) Assessment, completed 4/11/22, indicated Resident 14 had moderately impaired cognition. A care plan, initiated 5/31/22, indicated Resident 14 demonstrated inappropriate behaviors including touching another resident in a sexual manner. The goal was for the behavior not to result in disruption of others environment. The approaches were to determine the cause for the inappropriate behavior and refer to physician as needed for intervention, initiated 5/31/22, psychiatric services would continue to follow, initiated 5/31/22, encourage Resident 14 to participate in structured activities as appropriate, initiated 5/31/22, observe for triggers of inappropriate behaviors and alter the environment as needed, initiated 5/31/22, assess for unmet needs such as need for toileting, rest, food, companionship, etc., initiated 5/31/22, assist resident away from other residents as needed, initiated 5/31/22, and to administer anti-depressant medication as ordered, initiated 6/12/22. 1b. The clinical record for Resident 28 was reviewed on 1/5/23 at 2:30 p.m. The diagnoses for Resident 28 included, but were not limited to, stroke, major depressive disorder, mild cognitive impairment, and dementia with behavioral disturbance. The resident had previously been living in an assisted living and was transferred to long term care on 11/22/21 in the same facility. A care dated 4/3/20 indicated Resident [28] has impaired cognition with associated short term memory impairment and risk for confusion, disorientation, altered mood, impaired or reduce safety awareness .long term goal .Resident will remain safe and not injure self-secondary to impaired decision making Approach .Calm resident if signs or distress develop during the decision making process .Determine if decisions made by the resident endanger the resident or others. Intervene if necessary .Re-direct resident when agitated behaviors are present or potential for injury is evident . A care plan for Resident 28, initiated 5/31/22, indicated Resident demonstrates inappropriate behaviors including: touching another male resident in a sexual manner .long term goal .Residents behaviors will not result in disruption of others environment and resident will remain safe .Approach .Assess for unmet needs such as need for toileting, rest, food, companionship, etc .Assist resident to away from other residents as needed .Determine cause for inappropriate behavior and refer to physician as needed for intervention .Encourage participation in structured activities as appropriate .Observe for triggers of inappropriate behaviors and alter environment as needed . Resident 14 and Resident 28 had sexual interactions on the following dates: 6/2/22 - Resident 28 fondling a Resident 14 while lying in bed, 6/4/22 - Resident 28 lifting front of dress to Resident 14 twice, 6/11/22 - Resident 14 in Resident 28's room, touching Resident 28 and his penis while she is in bed, 6/16/22 - Resident 28 and Resident 14 sitting in hallway. Resident 28 unbutton top and let Resident 14 rub on her breast, 7/17/22- Resident 28 and Resident 14 sitting in common area. Resident 14's foot was positioned in between her legs while Resident 28's gown was pulled up revealing herself, 7/26/22 - Resident 14 and Resident 28 was in Resident 28's room. Resident 14 had fallen. He was on his knees with brief pulled down next to Resident 28's bed. Resident 28 was naked from waist down. Both residents verbalized sexual interaction took place at that time. 9/4/22 - Resident 28 and Resident 14 in hallway. Resident 28 placed Resident 14's foot in between her legs and unzipped her top exposing her breasts. The facility was unable to provide evidence those incidents were reported to the Indiana Department of Health. Cross Reference F600 During an interview that was conducted on 1/6/23 at 11:50 a.m., with the Executive Director (ED), Director of Health Services (DHS), Nurse Consultant (NC) 3 and NC 4, and the Social Services Director (SSD) were interviewed. The ED indicated that the first known sexual contact between Resident 14 and Resident 28 had occurred on 5/5/22 and a reportable incident was filed with the IDOH at that time. After investigating and looking into the interactions further it had been determined Resident 14 and 28's sexual interactions were consensual. He did not report sexual interactions between Resident 14 and Resident 28 to IDOH after 5/24/22. An abuse policy was provided by the ED on 1/5/23 at 10:56 a.m. It indicated, .Purpose. Trilogy Health Services (THS), LLC, has developed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse and neglect. Procedure. 1. This has implemented processes in an effort to provide a comfortable and safe environment 3. Definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology d. sexual abuse - is non-consensual sexual contact of any type with a resident .g. Reporting/response i. Any staff member, resident, visitor or resident representative may report known or suspected abuse, exploitation, neglect, or misappropriation to local or state agencies. II. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where the state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures .Iv. A written report of the investigation outcome, including resident response and/or condition, final conclusion, and actions taken to prevent reoccurrence will be submitted to the applicable State Agencies within five days . 3.1-28(e)

Based on observation, interview, and record review, the facility failed to accurately complete an Admission Minimum Data Set Assessment for 1 of 2 residents reviewed for dental services (Resident 21). Findings include: The clinical record for Resident 21 was reviewed on 1/4/22 at 2:24 p.m. The Resident's diagnosis included, but were not limited to, diabetes. An Admission MDS (Minimum Data Set) Assessment, completed 4/28/22, indicated Resident 21 was cognitively intact and had no dental concerns. On 1/04/23 at 2:21 p.m., Resident 21 was observed sitting in her wheelchair in her room. She had no natural teeth. She indicated she had recently seen a dentist who had referred her for new dentures. On 1/10/23 at 10:13 a.m., LPN (Licensed Practical Nurse) 20 provided the dental provider Patient Note History, dated 12/12/22, which indicated Resident 21 was seen by the dentist due to being edentulous. The dentures she currently had were [AGE] years old. During an interview on 1/11/23 at 12:15 p.m., the MDSC (Minimum Data Set Coordinator) indicated that Resident 21 being edentulous should have been captured on the Admission MDS Assessment.

Based on observation, interview, and record review, the facility failed to revise a resident's hearing loss care plan to include the use of an amplifier device for 1 of 16 residents whose care plans were reviewed. (Resident 16) Findings include: The clinical record for Resident 16 was reviewed on 1/4/23 at 2:00 p.m. Her diagnoses included, but were not limited to, dementia without behavioral disturbance. The 10/1/22 Quarterly MDS (Minimum Data Set Assessment) indicated she had a BIMS (brief interview for mental status) score of 14, indicating she was cognitively intact. It indicated she had minimal hearing difficulty with the use of a hearing aide or appliance. The 2/3/21 social services note, written by the SSD (Social Services Director) read, Resident is having increased difficulty with hearing and SS provided resident with a Superear-Personal Sound Amplifier today. SS tested this with resident and resident was able to understand everything that SS said to her and SS was talking in a normal tone. SS showed resident how to use the device and also showed CNA (Certified Nursing Assistant) and told nurse about it. Resident is very happy with this device. The hearing loss care plan, last revised 10/11/22, indicated she demonstrated hearing loss and heard best in a quiet setting. The goal was for to be able to effectively communicate wants and needs and participate in her plan of care daily. There were no interventions regarding the use of a superear-personal sound amplifier referenced in the above social services note. An interview was conducted with Resident 16 on 1/4/23 at 2:05 p.m. She was not wearing any hearing aides or using any hearing appliance during the interview. She had difficulty hearing throughout the interview and requested one repeat themselves multiple times. She would put her hand up to her left ear requesting you speak directly into it. An interview and observation was conducted with Resident 16 on 1/5/23 at 11:15 a.m. She was not wearing any hearing aides or using any hearing appliance. During this interview, one had to speak loudly, directly into her left ear and repeat themselves multiple times. She indicated when she left her room, she couldn't hear what others were saying, so she often remained in her room. If she could hear better, she would go to exercise activities more often. She indicated had different sets of hearing aids, but couldn't get them to work and was uncertain exactly where they were. She couldn't recall the last time she'd worn them, because they didn't help anyway. If they helped her to hear, that would be great. She began rummaging through drawers in a side table, but was unable to locate them. An interview was conducted with CRCA (Certified Resident Care Assistant) 8 on 1/5/23 at 11:23 a.m. She indicated she'd worked at the facility for 5 years and noticed Resident 16's hearing difficulty. She had never known Resident 16 to wear hearing aides or seen any hearing aides in her room. CRCA 8 would speak loudly and clearly when she spoke to her. An interview was conducted with PTA (Physical Therapy Assistant) on 1/11/23 at 10:50 a.m. She indicated Resident 16 began therapy last week. She noticed she was hard of hearing and was unaware she had an amplifier device. She stated, It would be great if she could hear me, so we could communicate better. An interview was conducted with the SSD on 1/5/23 at 12:04 p.m. She reviewed Resident 16's clinical record and indicated she had an amplifier device to assist with her hearing difficulty. It had headphones and was kind of like a Walkman. Resident 16 would hold it, and there was a volume button to adjust the volume. The SSD hadn't used it with her in a few months. It was kept in a little container in her room. She used it to do interviews with her. Resident 16 was receptive to using it, if the SSD initiated it, as Resident 16 wouldn't initiate using it herself. She definitely needed prompts to use it. An interview and observation was conducted with Resident 16 in her room with the SSD on 1/5/23 at 2:25 p.m. Resident 16 indicated she found her hearing aids and pointed to some small boxes on her bed. The SSD opened the boxes. There was a hearing aid in one of the boxes. Another box had an amplifier inside. The SSD took the amplifier and placed the earphones onto Resident 16. The SSD explained how to use the amplifier to Resident 16. Resident 16 thanked the SSD and indicated she could hear well now. Resident 16 informed the SSD she'd been staying in her room, because when she left, and people spoke to her, she couldn't hear them. Resident 16 agreed to leave the amplifier out for staff to use with her. An interview was conducted with the SSD on 1/5/23 at 2:30 p.m. She indicated if the amplifier was left out for use on a routine basis, it could be used more regularly. An interview was conducted with the SSD on 1/10/23 at 10:17 a.m. She reviewed Resident 16's hearing loss care plan and indicated it did not reference her use of the amplifier device, but it should. 3.1-35(d)(2)(B)

Based on interview and record review, the facility failed to provide the necessary services to maintain good grooming and personal hygiene for a resident who was unable to carry out activities of daily living by not ensuring twice weekly showers/complete bed baths for 1 of 1 residents reviewed for activities of daily living (ADLs). Resident 20 Findings include: The clinical record for Resident 20 was reviewed on 1/10/23 at 9:32 a.m. Resident 20's diagnoses included, but not limited to, COVID-19 infection, atrial fibrillation, major depressive disorder, and acute embolism and thrombosis of unspecified deep veins. Resident 20 tested positive for COVID-19 on 12/26/22 and was subsequently placed into droplet isolation precautions. Resident 20's annual MDS (minimum data set) dated 12/30/22 indicated, Resident 20 was cognitively intact and required extensive assistance of one person for bed mobility, toileting and personal hygiene; physical help in part of one person for bathing; and considered choosing between a tub bath, shower, bed bath or sponge bath very important. An interview with Resident 20 was conducted on 1/04/23 at 3:37 p.m. Resident 20 indicated, she had not received a complete bed bath or shower since she was placed into droplet isolation precautions for COVID-19 infection. An interview with CRCA (certified resident care assistant) 21 was conducted on 1/10/23 at 10:00 a.m. CRCA 21 indicated showers/complete bed baths were to be recorded in Matrix care and residents' shower schedules were also in Matrix care. A review of Resident 20's point of care (POC) task tab was reviewed on 1/10/23 at 9:42 a.m. It indicated, Resident 20 received showers on the following dates: 1/10/23, 1/3/23, and 12/23/22. The POC record did not indicate Resident 20 had received any complete bed baths or refusals during the time she was in isolation. Resident 20's progress notes did not contain documentation regarding any refusals for complete bed baths/showers during that COVID-19 isolation timeframe. A Guidelines for Bathing Preference policy was received on 1/10/23 at 10:42 a.m. from NC (nurse consultant) 4. The policy indicated, 4. Bathing shall occur at least twice a week unless resident preference states otherwise. 3.1-38(a)(3) 3.1-38(b)(2) 3.1- 38(b)(4)

Based on observation, interview and record review, the facility failed to transfer a resident with a mechanical lift as care planned, resulting in the resident having a fall with a fractured femur and one rib for 1 of 3 residents reviewed for falls. (Resident C) Findings include: The clinical record of Resident C was reviewed on 3-21-22 at 1:32 p.m. Her diagnoses included, but were not limited to, a displaced supracondylar fracture without intracondylar extension of lower end of right femur (fracture of the thigh bone, near the knee), fracture of the 9th rib on the left side, [CONDITION(S)], [CONDITION(S)], heart disease, [CONDITION(S)], age-related [CONDITION(S)], unspecified pain, body mass index (BMI) less than 19.9 or less, history of recent Covid-19, general muscle weakness and an above the knee leg amputation of the left leg. Her most recent Minimum Data Set (MDS) assessment, dated 2-15-22, indicated she was severely cognitively impaired, required extensive assistance of 2 or more persons for bed mobility, was dependent of 2 or more persons for transfers, was unable to walk and utilized a wheelchair for mobility. Review of Resident C's clinical record indicated on 3-5-22 at 7:00 p.m., during a transfer from her wheelchair to her bed, she was lowered to the floor. The nursing assessment immediately post-fall indicated the resident complained of pain to the right leg and had vomited. Upon notification to the Nurse Practitioner, a stat (immediate) xray of the right leg was ordered. The xrays identified a a displaced supracondylar fracture of the right leg. Orders were received to send Resident C to the local emergency room for further evaluation and treatment. She returned to the facility on the same date with new orders for a long-leg cast and to schedule an appointment with orthopedics. In an observation and interview with Resident C on 3-21-22 at 3:25 p.m., she was observed to be seated in a wheelchair in her room, with a left above the knee amputation. Her right leg was observed to be elevated on the wheelchair's leg extension and had multiple wrappings in place. She indicated she could not recall specifics, but she did recall she recently experienced a fall in which a female picked her up from her wheelchair and dropped her on the floor. Resident C indicated she continues to experience varying degrees of pain of her right leg with any movement, such as transfer from bed to chair or vice versa and repositioning in bed. A review of Resident C's care plan for ADL's (activities of daily living), with a start date of 6-5-17, indicated Resident C had a functional impairments, specific to transfers, bed mobility, toileting and eating due to joint deformities related to [CONDITION(S)] and her left above the knee amputation. On 11-20-19, it indicated she required Transfer with mechanical lift or as indicated by resident status. A review of Resident C's care plan for fall risk, with a start date of 8-19-16, indicated Resident C was at risk for falls related to [CONDITION(S)] with joint deformities, impaired balance and multiple other co-morbidities. An update to this care plan, dated 3-8-22, indicated, staff education on proper lifting/using lifts and transfers properly. In an interview with a family member of Resident C's on 3-23-22 at 9:51 a.m., she indicated she was informed by the Executive Director (ED) and Director of Nursing (DON) the aide transferring her mother did not use the mechanical lift as care planned. The family member indicated she was unaware if the aide had any assistance of other staff while manually transferring the resident from wheelchair to bed. The family member indicated Resident C had begun using the mechanical lift around the time of her above the knee amputation, approximately 3 years ago. She indicated prior to the leg amputation, the Resident used a stand-up type of mechanical lift because she had difficulty standing independently. In an interview on 3-23-22 at 11:00 a.m., with CNA 2 and CNA 3, each indicated it is the facility's policy is to use 2 staff members for any type of mechanical lift transfers. Both indicated they were familiar with Resident C and were aware she had used a mechanical lift for several years, because she has 1 leg amputated and has severe arthritis. In an interview on 3-23-22 at 11:25 a.m., with LPN 6, she indicated a mechanical lift was not used at the time of [Resident C's] fall earlier this month. LPN 6 indicated the facility provides aide assignment sheets to identify what each resident's care needs are, including what their mobility needs are and what devices they utilize for mobility. She added, the facility provides visual cues of the resident's mobility needs by placement of various magnets to signify what their needs are, located above each resident's bed. In an interview on 3-23-22 at 12:05 p.m., with the ED, he indicated the employee involved with the fall with Resident C, TNA 4, was hired on 1-17-22. He explained she had trained as a Temporary Nurse Aide (TNA), through both the corporation's program and the Indiana Department of Health's TNA training program. He indicated she is waiting to take her state certification test, but has not received notification yet to take the test. He indicated she was the only staff person involved in the fall with the resident. He indicated he could not locate any documentation that TNA 4 was or was not using a gaitbelt to assist her with the transfer. He specified TNA 4 had not been trained on the use of the mechanical lift until after the fall. The TNAs' should know that they are not allowed to transfer any resident with any mechanical lift without a second person and proper training. In an interview with the ED on 3-23-22 at 3:45 p.m., he indicated the facility does not have a specific policy or procedure related to the specific procedures a TNA can conduct, but follows the guidelines from their trainings, as well as their specific job check-offs that are conducted during their orientation period. He provided a copy of a document, dated 1-23-22, indicating TNA 4 had demonstrated sufficient knowledge to properly carry out the specific job duties for this position. The Indiana Department of Health issued a LTC (long term care) Newsletter on 3-24-22 which discussed Temporary Nurse Aide training, as well as the training reflecting the use of the Indiana State Department of Health Nurse Aide Curriculum, created July 1998 and revised on March 21, 2014. This curriculum indicated, under Standard 14, The nurse aide will perform only the tasks in the course standards and Resident Care Procedures manual, unless trained appropriately by licensed staff of the facility with policies and procedures and a system for ongoing monitoring to assure compliance with the tasks . This deficient practice relates to Complaints IN 779 and IN 266. 3.1-45(a)(2)

Based on interview and record review, the facility failed to timely initiate the bowel protocol to address a resident that was not having bowel movements within 72 hours, resulting in a hospitalization for 1 of 3 residents reviewed for change of condition. (Resident B) Findings include: The clinical record for Resident B was reviewed on 10/22/20 at 2:23 p.m. The [DIAGNOSES REDACTED]. A Quarterly MDS assessment dated [DATE], indicated Resident B was needing extensive assistance with 1 staff member for toileting and 2 staff members for transfers. A care plan dated 6/12/20 indicated Resident B .has impairment in functional status in regards to bed mobility, transfers, toileting, and eating r/t (related to): Ankylosing spondylitis of multiple sites in spine, hypertensive [MEDICAL CONDITION] stage 1 through stage 4 [MEDICAL CONDITION], and other multiple comorbidities .Approach Resident requires assist with eating, assist with transfers, assist with bed mobility, and assist with toileting as needed . A care plan dated 6/5/20 indicated Resident B was .at risk for pain r/t (related to): Ankylosing spondylitis of multiple sites in spine and other multiple comorbidities .Approach Administer medications as ordered and notify MD (medical doctor) for any side effects observed . A care plan dated 6/12/20 indicated Resident B .has potential constipation Approach Administer medications/enemas/suppository as ordered. Document frequency and character of BMs (bowel movements). Educate resident regarding the importance of responding to, rather than delaying, the urge to defecate .Position resident upright as able on bed pan for BMS. Position resident upright on toilet for BMs . A physician order [REDACTED]. The September and October 2020 MAR (Medication Administration Record) indicated he had received the [MEDICATION NAME] as ordered. A possible side effect for taking [MEDICATION NAME] can be constipation. A physician order [REDACTED]. On 9/9/20, the order was changed to administer once a day on Tuesdays and Thursdays. Then on 9/17/20, the order was changed to administer once a day as needed. A Nurse Practitioner note dated 9/9/20 indicated Resident B had complaints of constipation. The resident had not had a bowel movement in 6 days. A physician order [REDACTED]. On 10/2/20, the order was changed to administer every 8 hours. A physician order [REDACTED]. A physician order [REDACTED]. A physician order [REDACTED]. A physician order [REDACTED]. The September 2020 and October 2020 Bowel Report indicated the following days and bowel movements for Resident B: 9/1/20 - no bowel movement, 9/2/20 - yes - small, 9/3/20 - no bowel movement, 9/4/20 - no bowel movement, 9/5/20 - no bowel movement, 9/6/20 - no bowel movement, 9/7/20 - no bowel movement, 9/8/20 - no bowel movement, 9/9/20 - no bowel movement, 9/10/20 - yes - extra large, 9/11/20 - no bowel movement, 9/12/20 - no bowel movement, 9/13/20 - yes large, 9/14/20 - no bowel movement, 9/15/20 - no bowel movement, 9/16/20 - no bowel movement, 9/17/20 - no bowel movement, 9/18/20 - no bowel movement, 9/19/20 - yes - large, 9/20/20 - no bowel movement, 9/21/20 - no bowel movement, 9/22/20 - no bowel movement, 9/23/20 - no bowel movement, 9/24/20 - no bowel movement, 9/25/20 - no bowel movement, 9/26/20 - no bowel movement, 9/27/20 - no bowel movement, 9/28/20 - no bowel movement, 9/29/20 - no bowel movement, 9/30/20 - no bowel movement, 10/1/20 - no bowel movement, 10/2/20 - no bowel movement, 10/3/20 - yes medium, The September and October 2020 MAR indicated [REDACTED] 9/9/20 - Staff offered 1 suppository of 10 milligrams of [MEDICATION NAME] - Resident B refused, 9/9/20 - Staff offered 30 ml of Milk of Magnesium - Resident B refused, 9/10/20, 9/15/20, 9/17/20 - Scheduled 17 grams of Mirlax was administered, 9/19/20 - 17 grams of Mirlax as needed was administered. Staff documented as effective. 9/21/20 - Resident B requested to have 17 grams of Mirlax. Staff documented as effective. There was no bowel movement recorded in Resident B's clinical chart on 9/21/20. 10/2/20 - Staff administered 10 milligrams of [MEDICATION NAME], 17 grams of Mirlax, and 30 milliliters of [MEDICATION NAME] as ordered, 10/3/20 - Staff administered 10 milligrams of [MEDICATION NAME], 1000 milliliters of warm tap water enema, 8.6 milligrams of senna, and 30 milliliters of [MEDICATION NAME] as ordered. An interview was conducted with Family Member 10 on 10/22/20 at 3:53 p.m. Family Member 10 indicated Resident B had gone several days without having a bowel movement. He was transferred to the hospital and had to have emergency surgery. A progress note dated, 10/2/20 at 2:08 p.m., indicated Resident B had canceled his wound care appointment, because of feeling constipated. PRN (as needed) Mirlax given . A progress note dated 10/2/20 at 5:15 p.m., indicated .resident had 2 episodes of emesis. VSS. (vital signs stable) .NP notified of resident emesis and stomach pain. N.O. (new order) stat (as soon as possible) KUB, clear liquid diet x 24 hours . A KUB (x-ray of stomach) dated 10/2/20 indicated .Reason: constipation, vomiting, abdominal pain, abdominal distention .Impression: Moderate volume of fecal material is present in the colon . A progress note dated 10/2/20 at 11:20 p.m., indicated .c/o (complaints) of abdominal discomfort. Bowel sounds x 4 quads (quadrants) .It was reported to this nurse that resident had medium BM earlier this evening after receiving suppository which will be repeated x 8 hrs (hours) x 3 doses. No further result so far. Resident does state he is passing gas . The progress notes dated 10/3/20 on the night shift indicated Resident B was administered a suppository and had 3 bowel movements. The resident indicated stomach pain had subsided. A progress note dated 10/3/20 at 2:09 p.m., indicated Resident B had .two episodes of dark green emesis (vomit). The progress notes dated 10/3/20 on the evening shift, indicated Resident B had nausea and green color emeisis. The progress note dated 10/4/20 at 2:54 a.m., indicated Resident B was sent to hospital. The hospital records dated 10/4/20, indicated Resident B was .brought in from extended care facility for abdominal pain, nausea, and vomiting for the last 2 days. CT(computed tomography) imaging done emergency department shows a high grade small bowel obstruction. General surgery was consulted for further management .general surgery discussed the care with the patient (Resident B) and recommend operative intervention The CT scan for Resident B indicated .A small bowel obstruction is noted on the CT topogram. Air and fluid-filled loops of small bowel measuring up to 5.1 cm (centimeters) in diameter are noted over left hemiabdomen .A left-sided internal hernia may be present. Fluid is noted within portions of the colon and rectum. This may reflect a diarrheal process. Colonic [DIAGNOSES REDACTED] is noted. No evidence of diverticulitis. A mild amount of stool is noted within the majority of the colon . There Peri-opertive report for Resident B indicated .Post-Operative Diagnosis: [REDACTED]. Post-Operative Diagnosis: [REDACTED].Procedure Performed: diagnostic laparoscopy(operation performed in the stomach with the aide of camera), laparoscopic assisted small bowel resection with side to side anastomosis (connection) and lysis of the band (cut bands of tissue) On 10/22/20, the Nurse Consultant provided at 2:25 p.m, an Episodic Event for Resident B dated 10/9/20, indicating an incident had occurred on 10/4/20. Resident B was hospitalized with a [DIAGNOSES REDACTED].The root cause of the incident was a delay in treatment for constipation .Plan of Action .1. Staff educated on bowel protocol and bowel documentation. 2. Bowel assessments completed on all residents. 3. Nurses/QMA (Qualified Nursing Aide) to obtain desktop caretracker login to have access to BM report on weekends and during shift at anytime .Auditing changes made. MDS and ED (Executive Director) to review bowel list daily An interview was conducted with Assistant Director of Nursing Services (ADNS) and the Nurse Consultant on 10/23/20 at 9:15 a.m. The Nurse Consultant indicated Resident B required assistance of 1 staff person prior to his hospitalization with toileting. The system in place with bowel monitoring was a daily bowel report generated by the staff logging of the toileting patterns of the residents each shift. It was printed by the ADNS or DNS (Director of Nursing Services) to recognize if any residents were not having bowel movements within 72 hours. At that time, they would initiate the bowel protocol for any resident on the report that had not had a bowel movement in 72 hours. Resident B would have been on the report due to not having a bowel movement in that timeframe. The bowel protocol would have been initiated if it was recognized. The ADNS indicated she normally ran the bowel report, but it had not been printed or reviewed lately. It was missed that Resident B had not had a bowel movement for multiple days. The Nurse Consultant indicated after the investigation of the incident, all the staff have been educated on the bowel protocol. Adjustments have been made, and the MDS Coordinator was now responsible for the bowel report retrieval. On 10/22/20, the Nurse Consultant provided at 2:25 p.m., The Bowel Protocol Guidelines dated 11/9/17. It indicated, .Purpose: To provide guidance for the use of bowel stimulants for residents with constipation. Procedures 2. If the resident needs to utilize the bowel protocol, the Bowel Protocol order set may be opened and orders entered from order set. 3. The ineffective Bowel Pattern Event should be initiated for any resident not having a BM within 72 hours a. A progress note associated to the Ineffective Bowel Event, should be completed until the resident has a BM or the bowel pattern returns to normal for the resident. The progress note should include abdominal distention, pain and bowel sounds. 4. Nursing staff shall assess for effectiveness, orders may be written as follows; a. If no bowel movement within 72 hours, 2 tablespoons, (30cc) of 'Natural Laxative' b. If no results within 24 hours, after 'natural laxative' give 30 cc of Milk of Magnesia c. If no results within approximately 12 hours after MOM (Milk of Magnesia) administer [MEDICATION NAME] suppository d. If results of suppository are not satisfactory within 2 hours give Fleets enema. 5. If at any time there are indications of a bowel blockage the physician should be notified to receive instructions to proceed with the protocol or to intervene with further testing .7. Nursing staff will enter bowel movements, in the CareTracker system shifty . The Past Noncompliance was corrected on 10-12-2020, when the facility completed a root cause of the incident and determined there was a delay in treatment for constipation. The Plan of Action included; 1. Staff educated on bowel protocol and bowel documentation, 2. Bowel assessments completed on all residents. 3. Nurses/QMA (Qualified Nursing Aide) to obtain desktop caretracker login to have access to BM report on weekends and during shift at anytime, and auditing changes made. MDS and ED (Executive Director) will review bowel list daily. Adjustments have been made, and the MDS Coordinator are now responsible for the bowel report retrieval. This Federal tag relates to complaint IN 905. 3.1-37

Based on interview and record review, the facility failed to use an appropriate and safe transfer method for a resident, resulting in a fractured shoulder for 1 of 2 residents reviewed for accidents. (Resident 17). Findings include: The clinical record for Resident 17 was reviewed on 1/2/18 at 2:30 p.m. The [DIAGNOSES REDACTED]. The Annual MDS (minimum date set) assessment dated [DATE], indicated Resident 17 had a BIMS (brief interview mental status) score of 14 of 15 indicating cognitive intact. An interview was conducted with Resident 17 on 1/2/18 at 1:57 p.m. Resident 17 indicated by the use of a communication board and the nodding of his head yes or no, he had been dropped by the staff and hurt his left arm. A progress note dated 10/1/17, for Resident 17 indicated, Resident noted with assisted fall to bedroom floor beside his bed with staff of two at his side; with staff transferring resident from chair to scale to bed. Resident nonverbal but able to note any needs to staff with communication board and hand signs. ROM (range of motion) WNL (within normal limits), neurochecks initiated. No visible injury noted. Resident assisted per three nursing staff from floor and to bed . An Event Report dated 10/1/17, indicated Resident 17 was bare footed at time of fall. A progress note dated 10/2/17, indicated Family Member 22 had requested to have Resident 17's left shoulder x-ray done due to discomfort. A Radiology Report dated 10/2/17, indicated fracture to left shoulder with displacement. A general physician order [REDACTED]. A IDT (interdisciplinary team) note dated, 10/3/17, for Resident 17 indicated, .IDT met to follow up on patient's fall. Exray (sic) results positive for fracture. Patient sent to ER (emergency room ) for further evaluation and returned with shoulder immobilizer/sling .IDT investigated fall further and noted patient was not wearing any footwear at time of fall. CRCA (certified resident care assistant) states patient's feet slid as he was being transferred from weight chair to bed. A second CRCA was in room at time of fall. CRCA was transferring patient counterclockwise via (by) 'bear hug' when patient's feet slid. Patient was then lowered to ground and was leaning forward on feet CRCA with left shoulder and arm leaning against her. Second CRCA got nurse and alerted her to fall. When nurse arrived, patient was sitting upright with CRCA underneath him. Second CRCA and nurse assisted patient to bed along with third CRCA. Patient has orders for 1 person assist. IDT recommended lift assessment be completed. Results indicate lift transfers. Patient complains of pain to left arm at times and has noted to refuse Tylenol. NP (nurse practitioner) was here and agrees with lift transfers, orders received and changed A quarterly summary dated 5/25/17, indicated the following for Resident 17: .Safety Requires assistance to transfer, .Has disease or condition that predisposes to falls, .,Lift Evaluation: Is the resident ambulatory? No, .Can the resident be transferred with limited assist? No Can the resident reliably stand and pivot with only supervision and cueing? No, .Recommendation. Lift recommended for transfers .Total Mechanical Lift . An Occupational Therapy Progress and Discharge Summary dated 6/1/17, indicated Resident 17 had started therapy on 4/26/17 and ended care on 6/1/17. It indicated Resident 17's transfer status was dependent with a 100 percent assistance needed by staff for transfers. An interview was conducted with Certified Occupational Therapist Assistant (COTA) 25 on 1/8/17 at 10:58 a.m. She reported the last time Resident 17 was on caseload prior to his fall was from 4/26/17 until discharge on [DATE]. COTA 5 indicated Resident 17 had not been evaluated since until after his fall. She stated his last therapy evaluation regarding transfers indicated Resident 17 was 100 percent dependent which meant Resident 17 was recommended as a hoyer lift. COTA 25 indicated Resident 17 had not been assessed for the bear hug transfer. She stated bear hug transfers are used at times without a gait belt. She reported if Resident 17 had been assessed and could do the bear hug transfer safely then it could be used. COTA 25 indicated the transfer method that was recommended by therapy for the residents were care planned not ordered. The Quarterly MDS assessment dated [DATE], indicated Resident 17's functional status for transfers was extensive assistance with 2 person assist. The fall investigation folder for Resident 17 was provided by the Assistant Director of Health Services (ADHS) on 1/8/18 at 10:39 a.m. It included an Episodic Event documentation dated 10/9/17. The Episodic indicated, Event: Patient was assisted to the floor by staff when transferring from weight chair to bed. Patient noted to be barefoot and no gaitbelt was used at time of transfer. Patient slid and was guided to the floor with CNA .Root cause: improper use of footwear and gaitbelt. CNA 'bear hug' patient for transfer .Staff education with inservice .Monitor staff for proper gait belt use and accurate lift assessments . The binder included staff in-serviced on gait belt use. A documented interview was included dated 10/3/17, with CRCA 5. It indicated .CRCA 5 and CRCA 6 transferred to weight chair, attempted to go from chair to bed. No gait belt used . staff states they were told they weren't to use gait belt by Qualified Medication Assistant (QMA) 15 as he has a bad left arm. QMA 5 states when transferring patient's foot slipped and he was lowered to the floor. CRCA 5 'bear hug' patient and slid to the floor (symbol for with) patient, CRCA 6 was holding weight chair in place. Patient tipped forward on top of CRCA 5 as she was rotating left (counterclockwise). Left arm was against CRCA 5. Magnet states 1 person assist above bed. Orders 12/21/16 state transfer (symbol for with) assist x1 or as indicated by resident status. Nurse was behind CRCA 5 on L (left), CRCA 6 on R (right) (symbol for and) patient was assisted back to bed. No lift or gait belt used. CRCA 5 states she never felt any abnormalities or 'popping' from L side. A documented interview dated 10/3/17, with CRCA 6. It indicated .Around 9:00 pm came around CRCA 5 asked for my help weighing him. (Family Member 22) doesn't like him to be put on a lift of any sort so she taught us a way to get him in and out of bed. CRCA 5 got him out of the bed just fine. After we had gathered his weight she stood him back up to get him in bed, that is where things went bad. His knees began to buckle and both him and CRCA 5 fell to the floor. If Im not badly mistaken he hit the side table on the way down and landed on CRCA 5. After he had gotten back in bed we changed him and he did let (name of nurse) LPN (Licensed Practical Nurse) 16 know his shoulder was bothering him. I think, she just thought it was nothing more than his normal amount of pain. A documented interview dated 10/3/17, with LPN 16. It indicated .Nurse was alerted at about 8:20 pm by CRCA 6 that (Resident 17) had fallen. When entering room, patient was sitting upright with CRCA 5 under him. He was fulling dressed but barefoot. Patient was assisted to stand (symbol for with) 3 staff members and helped back to bed. Patient assessed, vital signs, neuro checks and ROM WNL. No visible injury noted and patient denied pain. md (medical provider) and (family) notified of fall. No orders received . A documented overview of investigation dated 10/2/17, by ADHS indicated an overview of her findings with interviews she had conducted with staff. She stated in report after speaking with CRCA 5 regarding the fall with Resident 17 on 10/1/17, .CRCA 5 stated she was told by Resident 17's family member 22 that staff are to never use gaitbelt as he has a bad left arm and it's hurtful and not effective to him. Family member 22 demonstrated to staff how she prefers Resident 17 to be transferred via 'bear hug' as she does at home. Family Member 22 takes Resident 17 home at times on the weekends and states she is able to handle him by herself. Family Member 22 also states patient is not be turned on his left side an has posted signage in his room written by Family Member 22. During investigation and questioning, CRCA 5 stated there were two staff members in room to transfer Resident 17 as he was being weighed. CRCA 5 stated she was transferring Resident 17 while CRCA 6 was holding the weight chair. She stated he 'usually can stand' and his feet slid during transfer from weight chair back to bed. CRCA 5 did explain he didn't have any footwear during transfer either. Writer counseled CRCA 5 on always ensuring proper footwear during transfers and use of gaitbelt. CRCA 5 explained she was under the understanding staff is to never to use gaitbelt with Resident 17 specifically and was acting in the direction that was established by (Family Member 22). CRCA 5 stated she lowered Resident 17 to the floor and had gone down with him and he landed on top of her.CRCA 5 stated she didn't hear or feel anything abnormal when Resident 17 was lowered to the floor and stated she never let go of him. CRCA 6 was also interviewed and stated she was there to help with transfer 'just in case'. CRCA 6 explained she was holding the weight chair when Resident 17 was transferred back to bed. CRCA 6 stated it was her understanding they were transfer Resident 17 with one person no gait belt. She explained it is rare that Resident 17 gets out of bed. only to go on appointments, to get weighed, or go home with wife. CRCA 6 stated CRCA 5 never let go of Resident 17 and that he followed CRCA 5 down to the floor, ending up on top of her. CRCA 5 explained she thought he may have hit the bedside table, but there was no bruising, swelling and no indication of injury when the nurse assessed him. Writer spoke with (Family Member 22) regarding fall and discussion of increased pain in left arm. MD was notified and 10/2 @ 5:46 xray was ordered, then completed 10/3 at 2340 (11:40 p.m.), indicating a fracture. Fall was discussed further with (Family Member 22), she stated Resident 17 told her he felt like he had a [MEDICAL CONDITION] at the time of fall and he can usually tell when he has them and knows when they are about to happen. When writer asked Resident 17 if he had a [MEDICAL CONDITION] he shook his head yes. MD was notified and new orders received 10/6 to draw [MEDICATION NAME] level which was completed 10/7 and was normal . An overview of investigation by the Director of Health Services (DHS) was included in the investigation. It indicated, .Resident status was reviewed, pain management was implemented, and a lift assessment was completed. For the resident's continuing safety, a hoyer lift was implemented . A care plan dated 4/22/16 and revised on 11/20/17, for Resident 17 indicated, Resident at risk for falling r/t (related to) diagnosis's of hemplegia, [MEDICAL CONDITION], debility and medication received. 10-2 (10/2/17) lowered to floor with shoulder fracture .Approach: start date: 10/3/17 - weight by hoyer scale, start date: 10/2/17 - total mechanical left, start date: 8/25/16: provide proper, well-maintained footwear A care plan dated 4/22/16, and revised on 12/15/17, for Resident 17 indicated, I have problems providing my own care r/t debility/hemplegia r/[MEDICAL CONDITION] .Approach: start date 8/25/16, At present I require assist of 1 or 2 with transfers dependent on status at the time. I am currently non-ambulatory and rely on a wheelchair and staff assist for my locomotive needs . A care plan dated 6/14/16, for Resident 17 indicated, .If I feel rushed during care I have a hx (history) of where I hit at them/hit them and if staff approach me and I am not aware of it due to my impaired vision. I have a history of yelling at staff and pushing at staff during care. I get easily frustrated due to my difficulty verbalizing my needs and staff has difficulty understanding me . A care plan dated 4/22/16, for Resident 17 indicated, I have a [MEDICAL CONDITION] disorder that places me at risk for injury An interview was conducted with the ADHS on 1/5/17 at 3:11 p.m. She indicated she had conducted the investigation regarding Resident 17's fall. She stated CRCA 5 had transferred Resident 17 from a bed to a weight chair at bedside to be weighed. She reported as CRCA 5 was transferring Resident 17 back from the weight chair to the bed Resident 17 fell and so did CRCA 5. She stated Resident 17 had not been lowered to the floor both Resident 17 and CRCA 5 fell on the floor. The ADHS indicated Resident 17 was not suppose to be transferred by bear hug or bare footed. She reported CRCA 5 was in the room, but was holding the weight chair which did not move. The ADHS indicate the root cause of Resident 17's fall was the staff did not use a gait belt during transfer and was bare footed. The ADHS stated Resident 17 should have had gripper socks on. She reported Family Member 22 transfers Resident 17 all the time using the bear hug transfer. She even takes him home on occasions. The ADHS indicated residents have magnet light bars in there room, and that bar has the residents transfer status. Resident 17 had a 1 person transfer indicated on his light bar. He also had an order dated 12/21/16, to transfer with one assistance or as indicated by resident status. She also stated he was care planned as 1 or 2 person transfer. The ADHS reported quarterly assessments are done by nursing. She indicated after the staff nurse completes the assessment if there are any changes with current orders the staff nurse would need to place a new order in the system to have the MD aware of change. The ADHS stated there was no order placed in the system for the 5/25/17, quarterly assessment that indicated Resident 17 was recommended to be transferred by mechanical lift. She indicated there should have been. It must have been missed. She reported CRCA 5 transferred Resident 17 by the bear hug transfer, because she had been told in orientation to transfer him that way. Family Member 22 preferred that transfer. She indicated Resident 17 has chronic pain in his left shoulder, and he had ROM that was normal after fall. An interview was conducted with the DHS on 1/5/18 at 3:40 p.m. She reported Family Member 22 did not like the mechanical lift or gait belt used on Resident 17. Family Member 22 wanted CRCAs to use the bear hug method only during transfers. The DHS stated the preference of the bear hug transfer, and staff not to use the gait belt on Resident 17 was not care planned nor could she locate any entry of progress notes documenting as such. The DHS indicated she also thought the mechanical lift had been discussed at some point with Resident 17 and Family Member 22, but could not locate documentation. She stated Family Member 22 preferred the mechanical lift not to be used. She indicated it should have been care planned. The DHS stated Resident 17 was now a hoyer lift during transfers. She reported Family Member 22 was aware, and she preferred Resident 17 to remain in bed most of the time, but he does transfer in that method as of now. Family Member 22 prior to the fall did not want the left arm moved due to pain in that arm, so she preferred the bear hug method during transfers. The DHS stated Family Member 22 was very involved with care, and had her preferences on how she wanted Resident 17 to be cared for. She visited frequently. The DHS indicated Family Member 22 had transferred Resident 22 using the bear hug transfers all the time. She would transfer Resident 17 to chair by herself and even take him home for visits. The DHS reported the last time Family Member 22 had taken Resident 17 home was in September. An interview was conducted with the ADHS on 1/8/17 at 9:44 a.m. She indicated the staff was to use gait belts for transfers. She stated the only staff aware of Resident 17 was to be transferred without a gait belt and by bear hug method was the CRCAs prior to his fall. If she was aware, Resident 17 would have been assessed by therapy to see what would be the safest transfer for him. She indicated Family Member 22 and Resident 17 would have been spoken to, and they all would have worked out a transfer method that would have been acceptable and safe. An interview was conducted on 1/10/18 at 9:07 a.m. with CRCA 3. She indicated she has worked at the facility for 6 months, and she has always transferred Resident 17 by hoyer. She stated she had never transferred Resident 17 any other way. A gait belt policy was provided by the ADHS on 1/8/18 at 10:39 a.m. It indicated, .Policy. Guidelines for Gait Belt Use. Purpose. To ensure safety for the resident and staff during transfers and mobility activities. Procedures. 1. Gait belts should be used according to the plan of care for the individual resident. 2. If resident requires use of gait belt, add to resident plan of care that will be communicated to the caregiver. 3. If a resident requires more than limited assists and does not require a lift a gait belt must be used with transfers .5. Gait belts will be provided by the campus and should remain in the campus at all times for use by all staff during transfers .7. Failure to use a gait belt as defined in the resident plan of care or as designated by campus protocol may lead to disciplinary action up to and including termination . 3.1-45(a)