Every finding on record at Beech Grove Meadows

Based on observation, interview, and record review, the facility failed to ensure a dependent resident received assistance eating for 1 of 3 residents reviewed for assistance with activities of daily living (ADL). (Resident B) Findings include:On 3/26/26 from 9:11 a.m. until 9:35 a.m., Resident B was sitting up in bed looking forward with a blank star. Resident B spoke nonsensical and repeated the same words. Sitting in front of Resident B was a meal tray on the bedside table which had been pulled up to her. The food had been uncovered and was uneaten. During the observation, Resident B never acknowledged the meal tray that had been sitting in front of her.On 3/26/26 at 9:31 a.m., CNA 1 walked into Resident B's room and asked Resident B why she hadn't eaten any of her food. CNA 1 picked up the spoon and offered to feed Resident B some scrambled eggs. Resident B spoke nonsensical to CNA 1. At that time, CNA 1 indicated staff should have been in Resident B's room to assist her to eat. The clinical record for Resident B was reviewed on 3/26/26 at 10:35 a.m. The diagnoses included, but were not limited to, dementia, malnutrition, and heart failure.An Annual Minimum Data Set (MDS) assessment, dated 12/22/26, indicated Resident B was severely cognitively impaired, had complaints of difficulty and pain swallowing, and had been placed on a mechanically altered diet.A care plan, dated 9/24/20 and current through 6/9/26, indicated Resident B required assistance with ADL's including, but not limited to, eating related to her recent hospitalization. Interventions included, but were not limited to, assist with eating and drinking as needed.During an interview on 3/26/26 at 1:51 p.m., RN 1 indicated the meal tray should not have been left sitting in front of Resident B. The CNA should have taken the tray into her room, prepared the meal for her, and asssited Resident B to eat right then. On 3/26/26 at 1:13 p.m., the Administrator provided a copy of a skills competency, titled Assist to Eat, dated 3/2023, and indicated this was the current skills competency used by the facility. A review of the competency indicated assist resident to sit in upright position. Make sure resident is comfortable and serve meal with main course toward the resident.This citation relates to Intake 2801211410 IAC (Indiana Administrative Code) 16.2-3.1-38(a)(3)

Based on observation, interview, and record review, the facility failed to ensure a dependent resident prescribed with a mechanically altered diet received ground meat for the breakfast meal for 1 of 3 residents reviewed for meal service. (Resident B) Findings include:On 3/26/26 from 9:11 a.m. until 9:35 a.m., Resident B was sitting up in bed staring forward. Sitting in front of Resident B was a meal tray on the bedside table which had been pulled up to her. The meal ticket that sat on the meal tray indicated Resident B had been placed on a regular diet with ground meat. Resident B was to be served scrambled eggs, ground meat sausage patty with pork gravy, toast, butter and jelly. On the tray, a whole (unground) sausage patty with no pork gravy was observed.On 3/26/26 at 9:31 a.m. CNA 1 indicated Resident B's sausage patty should have been ground and there should have been pork gravy on the tray. The clinical record for Resident B was reviewed on 3/26/26 at 10:35 a.m. The diagnoses included, but were not limited to, dementia, malnutrition, and heart failure.An Annual Minimum Data Set (MDS) assessment, dated 12/22/26, indicated Resident B was severely cognitively impaired, had complaints of difficulty and pain swallowing, and had been placed on a mechanically altered diet.A care plan, dated 9/29/20 and current through 6/9/26, indicated Resident B was at risk for unintentional weight loss due to increased nutritional needs. Interventions included, but were not limited to, regular diet with ground meats and monitor food and fluid intake at meals.A current physician's order, started on 4/17/25, indicated Resident B had been placed on a regular diet with ground meats.During an interview on 3/26/26 at 2:00 p.m., the Dietary Manager indicated the sausage patty that had been served to Resident B should have been ground before it left the kitchen.On 3/26/26 at 1:34 p.m., the Administrator provided a copy of a facility policy, titled Diet Orders, dated 8/2025, and indicated this was the current policy used by the facility. A review of the policy indicated in order to help maintain/improve nutrition and quality of life the Registered Dietitian, or designee, will evaluate the need for more restricted diet therapy according to each resident's individual medical condition, needs, desires, and rights.This citation relates to Intake 2801211.410 IAC (Indiana Administrative Code) 16.2-3.1-21(a)(3)

Based on observation, interview, and record review, the facility failed to ensure a resident's meal consumption had been documented accurately for 1 of 3 residents reviewed for documentation. (Resident B) Findings include:On 3/26/26 at 9:11 a.m. until 9:35 a.m., Resident B was sitting up in bed staring forward. Resident B spoke nonsensical and repeated the same words. Sitting in front of Resident B was a meal tray on the bedside table which had been pulled up to her. On the plate was scrambled eggs, toast, a sausage patty, oatmeal, and orange juice. The food had been uncovered and uneaten. The silverware was still in the napkin. On 3/26/26 at 9:31 a.m., CNA 1 walked into Resident B's room and asked Resident B why she hadn't eaten any of her food. CNA 1 picked up the spoon and offered to feed Resident B some scrambled eggs. Resident B spoke nonsensical to CNA 1.The clinical record for Resident B was reviewed on 3/26/26 at 10:35 a.m. The diagnoses included, but were not limited to, dementia, malnutrition, and heart failure.An Annual Minimum Data Set (MDS) assessment, dated 12/22/26, indicated Resident B was severely cognitively impaired, had complaints of difficulty and pain swallowing, and had been placed on a mechanically altered diet.A care plan, dated 9/29/20 and current through 6/9/26, indicated Resident B was at risk for unintentional weight loss due to increased nutritional needs. Interventions included, but were not limited to, regular diet with ground meats and monitor food and fluid intake at meals. The meal consumption documentation, dated 3/26/26 at 9:20 a.m., indicated CNA 1 documented that Resident B had consumed 26-50% of her breakfast meal. This documentation was entered into the electronic medical record approximately ten minutes before CNA 1 entered Resident B's room and asked why she hadn't eaten any of her food.During an interview on 3/26/26 at 1:51 p.m., RN 1 indicated CNA 1 should not have documented Resident B's meal consumption before she checked to see if she had eaten anything.On 3/26/26 at 1:13 p.m., the Administrator provided a copy of a skills competency, titled Assist to Eat, dated 3/2023, and indicated this was the current skills competency used by the facility. A review of the competency indicated after the meal is finished document the meal consumption.This citation relates to Intake 2801211.410 IAC (Indiana Administrative Code) 16.2-3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to ensure clinical information was kept confidential and located in a secure location for 13 of 93 residents who reside in the facility reviewed for confidentiality of records. (Residents 9, Resident 58, Resident 62, Resident 74, Resident 76, Resident 86, Resident 96, Resident 101, Resident 103, Resident 104, Resident 105, Resident 115, Resident 116) Finding includes: On 2/17/26 at 8:20 a.m., resident documents were observed unattended and spread out face up on a low table. The table was located in front of a couch just inside the front entrance of facility between the receptionist's desk and the Executive Director's (ED) office. No staff were visible in the area at the time. The unsecure and unattended documents included, but were not limited to: - Resident 9 (name), room (number), code status do not resuscitate (DNR), medication allergies listed out as follows: aspirin (ASA), Demerol, gemfibrozil, Lasix, Statins-HMG-CoA Reductase Inhibitors, Zetia, consistent carb (carbohydrate) diet, care in pairs, and listed assistance required for aspects of resident's activities of daily living (ADLs). - Resident 58 (name), room (number), code status full code, no known allergies (NKA), check every 2 hours for incontinence, regular diet, and listed assistance required for aspects of resident's ADLs. - Resident 62 (name), room (number), code status DNR/hospice, NKA, listed as a high fall risk with numerous fall interventions, behavioral symptom, Resident will at times become verbally aggressive with peers. Staff will offer the resident earplugs or noise cancelling headphones. Separate residents into different activities., check every 2 hours for incontinence, regular diet with ground meat, was receiving (Name of) Hospice care, and listed assistance required for aspects of resident's ADLs. - Resident 74 (name), room (number), code status full code, medication allergy listed out for codeine sulfate, additional information, Resident may at times place [Resident 74's] wet or soiled clothing in [Resident 74's] closet and not inform staff., and listed assistance required for aspects of resident's ADLs. - Resident 76 (name), room (number), code status full code, NKA, regular diet, wander guard (a device that alarms at exits for residents with high elopement risk) in place, elopement risk, additional information, Resident has a right glass eye, and listed assistance required for aspects of resident's ADLs. - Resident 86 (name), room (number), code status full code, medication and environmental allergies listed out as follows: Clozaril, Soap, regular diet with ground meat double portions, presence of a catheter device, and listed assistance required for aspects of resident's ADLs. - Resident 96 (name), room (number), code status full code, food and medication allergies listed out as follows: Nuts, vancomycin, presence of paraplegia (impairment of motor or sensory function), presence of a catheter device, resident on enhanced barrier precautions, care in pairs, presence of wound on coccyx, and listed assistance required for aspects of resident's ADLs. - Resident 101 (name), room (number), code status full code, NKA, regular diet, and listed assistance required for aspects of resident's ADLs. - Resident 103 (name), room (number), code status full code, NKA, regular diet, on a toileting assistance program, use of compression stockings, and listed assistance required for aspects of resident's ADLs. - Resident 104 (name), room (number), code status full code, medication allergies listed out as follows: amoxicillin-pot clavulanate, diphenhydramine HCL, metformin, Sulfa (Sulfonamide Antibiotics), regular diet, presence of enhanced barrier precautions, presence of a wound to right foot, on a toileting assistance program, and listed assistance required for aspects of resident's ADLs. - Resident 105 (name), room (number), code status DNR, medication allergy drug class listed as follows: Opioid Analgesics (Narcotics/Opiates), regular diet, no male caregivers preference, and listed assistance required for aspects of resident's ADLs. - Resident 115 (name), room (number), code status full code, antibiotic medication allergy listed out as follows: azithromycin, and listed assistance required for aspects of resident's ADLs. - Resident 116 (name), room (number), code status full code, medication allergy listed out as follows: iodine, presence of left below knee amputation, dialysis appointments three times weekly, use of brace to left stump, and listed assistance required for aspects of resident's ADLs. During an interview on 2/17/26 at 8:30 a.m., the Executive Director (ED), indicated that the resident documents should not have been left out on the table. On 2/23/26 at 10:20 a.m., the ED provided a policy titled HIPAA and Privacy Compliance and Complaint Policy, dated October 2018, and indicated it was the policy currently in use by the facility. A review of the policy indicated that the facility is required to maintain the privacy, security, and confidentiality of residents' Protected health Information (PHI) in compliance with state and federal laws and regulations and with ASC Policies.which. includes any information about health status, provision of care, or payment that can be linked to an individual. 3.1-3(o)

Based on observation, interview, and record review, the facility failed to ensure a self-administration of medication assessment was completed for medications left at bedside of 1 of 32 resident rooms. (Resident 79)Finding includes: During initial tour on 2/17/26 at 10:28 a.m., Resident 79 was observed to have a bottle of [NAME] nasal spray and a bottle of Refresh eye drops on the over the bed table. Resident 79's clinical record was reviewed on 2/17/26 at 11:00 a.m. The diagnosis included, but was not limited to, acute respiratory failure. The admission Minimum Data Set assessment, dated 2/7/26, indicated Resident 79 had no cognitive impairment. Resident of 79's clinical record lacked a self-administration of medication assessment. On 2/18/26 at 8:29 a.m., Resident 79 was observed to have a bottle of [NAME] Nasal Spray and a bottle of Refresh eye drops on the over the bed table. During an interview on 2/18/26 at 8:33 a.m., the Director of Nursing indicated Resident 79 did not have a self-administration of medication assessment and should have had one completed. On 2/19/26 at 8:10 a.m., the Director of Nursing provided a policy titled Self Administration of Medications, American Senior Services, with revision date of 1/2015 and indicated that the policy is currently being observed by the facility. A review of the policy indicated if a resident desires to participate in self-administration, the Interdisciplinary Team will assess the competence of the resident to participate by completing the Self-Administration of Medication Assessment observation. 3.1-11(a)

Based on interview and record review, the facility failed to ensure resident care plans were revised to reflect accurate code status for 2 of 22 residents reviewed for care plan accuracy. (Resident 12 and Resident 60)Finding includes:1. The clinical record for Resident 12 was reviewed on 2/17/26 at 2:20 p.m. The diagnoses included, but were not limited to, pressure ulcers and congestive heart failure.An active physician's order, initiated 12/8/25, indicated resident's code status was DNR (Do Not Resuscitate)An Indiana Physician Orders for Scope of Treatment form, or POST form, dated 12/8/25, indicated Resident 12 had elected a DNR code status.A care plan, dated 10/20/25, regarding the resident as a new admission to the facility included an approach with a start date of 10/20/25 which stated, Honor resident wishes including discharge goal: Return to community/possibly long term care, code status: Full.A care plan, dated 12/8/25, indicated resident had a preferred code status of DNR.2. The clinical record for Resident 60 was reviewed on 2/17/26 at 12:05 p.m. The diagnoses included, but were not limited to, acute kidney failure and cerebral infarction (where blood flow to part of the brain is blocked or reduced, also called an ischemic stroke).An active physician's order, dated 1/23/24, indicated resident's code status was DNR.An Indiana Out of Hospital Do Not Resuscitate Declaration and Order form, was signed by the resident and witnessed on 2/15/22 and signed by the physician on 2/16/22.A care plan, dated 1/19/24 regarding the resident as a new admission to the facility included an approach with a start date of 1/19/24 which stated, Honor resident wishes including discharge goal: Remain in Long term, code status: Full.A care plan, dated 1/24/24 indicated resident had a preferred code status of DNR.During an interview on 2/23/26 at 8:50 a.m., the Executive Director (ED) and Director of Nursing Services (DNS) indicated that Resident 12 and Resident 60's care plans indicated both a full code and a DNR code status. Both care plans should have been revised to reflect only the current code status preferences of DNR for each of the two residents.On 2/23/26 at 8:45 a.m., the ED provided a copy of a policy titled IDT Comprehensive Care Plan Policy, and indicated it was the policy currently in use by the facility. A review of the policy indicated that, Care plan problems, goals, and interventions must be reviewed and revised by the interdisciplinary team periodically and following completion of each OBRA MDS assessment.3.1-35(d)(2)(B)

Based on observation, record review, and interview, the facility failed to implement Enhanced Barrier Precaution infection control practices for 1 of 4 residents reviewed for wounds. (Resident 45). Finding includes: On 2/23/26 at 8:25 a.m., Resident 45's clinical record was reviewed. The diagnoses included, but were not limited to, osteomyelitis, left ankle and foot (a slowly progressive bone infection, often lasting over two weeks). An Annual Minimum Data Set assessment, dated 1/23/26, indicated Resident 45 had moderate cognitive impairment. On 2/19/26 at 2:04 p.m., observed License Practical Nurse (LPN) 2 provide wound care. LPN 2 gathered supplies for Resident 45's left ankle. Upon entering Resident 45's room there were no indications that Enhanced Barrier Precautions (EBP) should be followed. Resident 45's wound care was observed including the removal of a light brown crusted covering which exposed a silver metal screw head that protruded from the skin just above the skin surface on Resident 45's left ankle. LPN 2 was observed wearing gloves during the care, but was not observed to wear a gown. During an interview on 2/19/26 at 2:15 p.m., LPN 2 indicated that there were no signs indicating that nursing staff should follow Enhanced Barrier Precautions but would check records to clarify if Resident 45's wound care required Enhanced Barrier Precautions. On 2/19/26 at 2:20 p.m., Resident 45's clinical record was reviewed. A wound assessment, dated 10/24/25, indicated old hardware/screw coming through the skin. The facility lacked an order to follow Enhanced Barrier Precautions. During an interview on 2/19/26 at 2:50 p.m., the Director of Nursing indicated that Resident 45's left ankle wound was from an old surgery, and the skin was not open therefore the Interdisciplinary Team did not feel Resident 45's wound met Enhanced Barrier Precaution criteria. On 2/19/26 at 2:50 p.m., the Administrator provided a copy of policy titled, American Senior Communities Policy Title: Enhanced Barrier Precautions (EBP), revised 3/2025 and indicated it was the current policy in use by the facility, A review of the policy indicated: Enhanced Barrier Precautions are used for: .Resident (s) with chronic wound and or indwelling medical devices regardless of their MDRO status and Resident(s) who have an infection or colonization with a CDC-targeted MDRO when contact precautions do not apply . 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to provide supervision to a resident that resided on the secured memory unit and had a history of exit seeking behaviors, from exiting the facility through a window in his room. The day of the elopement the resident was angry, exit seeking, trying to leave, stated he needed out of there. (Resident B) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on, 4/15/25 at approximately 6:20 p.m., when the facility failed to provide supervision to a cognitively impaired resident, that resided on the memory care unit, to prevent an elopement. The Administrator, Director of Nursing, Assistant Director of Nursing, and the Regional Director of Nursing were notified of the Immediate Jeopardy on 4/24/25 at 2:00 p.m. The Immediate Jeopardy was removed, and the deficient practice corrected, on 4/16/25, prior to the start of the survey and was therefore Past Noncompliance. Findings include: During an interview on 4/24/25 at 9:36 a.m., the Assistant Director of Nursing (ADON) indicated, on 4/15/25 at approximately 7:00 p.m., the ADON saw Resident B walking alone near a store approximately 100 yards from the facility. The ADON returned Resident B to the secured memory care unit. During an interview on 4/24/25 at 10:58 a.m., the Social Service Director (SSD) indicated Resident B started exit seeking as soon as he was admitted to the facility. Resident B had packed his belongings and set them in the dining room on the secured unit several times in the days prior to Resident B climbing out of his window. Resident B told the staff that he believed they were trying to send him to a nursing home and would stand and knock on the back door, the front door, and the courtyard door. Resident B was adamant that he was going home. During an interview on 4/24/25 at 11:31 a.m., RN 1 indicated she was the nurse for the secured memory care unit, on 4/15/25, when Resident B climbed out of his window but was not actually on the unit. There was a Qualified Medication Aide (QMA) that was working on that unit. RN 1 was not aware that Resident B exited the secured memory care unit until he had been brought back to the facility by the DON at approximately 7:30 p.m. that evening. On 4/24/25 at 12:11 p.m., the windows in the room where Resident B exited the secure memory care unit was observed. There were two windows side by side, each approximately 30 inches wide by approximately 48 inches tall (upper and lower windows 24 inches tall each). There were two window locks at the top of the lower window and a small tab at each side of the top of the lower window. There were screws in the window track to block the window from opening vertically and one screw into each of the tabs. There were silver L shaped brackets screwed into the upper and lower windows frames. Immediately outside the window, was an area of dirt and gravel that extended approximately 4 feet out from the window. Then a retaining wall approximately five feet tall dropped down to the parking lot. At that time, the windows were secured shut and the Administrator indicated the tabs on each side of the top of the bottom window can be pressed inward and the bottom window can be pulled inward and laid flat while still inside the frame. Resident B broke the left tab, with the screws in place, and laid the window flat. Then, Resident B climbed out of his window to exit the secured unit. On 4/24/25 at 11:23 a.m., the ADON provided a copy of an incident timeline and indicated this was the timeline of events when Resident B exited the secured unit through his window. A review of the timeline, dated 4/15/25, indicated: - At 5:49 p.m., Resident B finished his meal and spoke with QMA 1 about another cup of juice and stated he was going to go to bed as he said he was tired - At 5:51 p.m., Resident B was observed by staff walking to his room. - At 6:57 p.m., Resident B was observed outside the facility near a store, ambulating on the sidewalk and was immediately accompanied by staff and returned to the facility. The clinical record for Resident B was reviewed, on 4/24/25 at 12:45 p.m. The diagnoses included, but were not limited to, dementia, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and glaucoma-bilateral eyes. A Hospital Discharge Summary, dated 4/10/25, indicated Resident B presented to the emergency department for an unknown reason and was being admitted due to concern for his safety on his own. In the emergency department, Resident B became much more agitated and expressed a desire to leave. However, Resident B was not able to provide hospital staff with a concrete plan for where he would go and how he would get there, which raised concern for Resident B's safety while on his own. Resident B lived alone, and family were concerned he was no longer able to care for himself. Resident B's family was actively pursuing guardianship. An Admission Observation, dated 4/10/25, indicated Resident B was alert to self only. An Elopement Risk Assessment, dated 4/10/25, indicated Resident B was able to move freely and easily which would allow the resident the capability of leaving the facility unassisted, often asked to go home or searched for home, exhibited significant cognitive impairment that impacted the elopement risk, was diagnosed with dementia, and was assigned a security bracelet. Resident B was at risk for an elopement. Progress Notes included, but were not limited to: - On 4/11/25 at 8:51 a.m., Resident B was exit seeking. -On 4/11/25 at 8:54 a.m., Resident B was in the hallway pushing on doors to go outside. - On 4/15/25 at 9:46 a.m., writer observed Resident B in dining room, Resident B was still looking for an exit. - On 4/15/25 at 11:52 a.m., Resident B was oriented to person, was alert, angry, and exit seeking. Resident B had been going door to door trying to leave. Resident B stated he needed out of here. When assisted to the courtyard, he became angry because he couldn't get out of the courtyard area. - On 4/15/25 at 2:39 p.m., Resident B continued to insist that staff let him leave and stated he came to the facility to volunteer and didn't want to stay. Resident B was redirected but was short lived. - On 4/15/25 at 7:49 p.m., spoke with Resident B following return to the facility. He remembered leaving the facility and planned to go home, but he wasn't sure where he was nor where he lived anymore. - On 4/15/25 at 8:00 p.m., Resident B broke the window in his room and jumped out. The Assistant Director of Nursing found Resident B approximately 100 yards from the facility. Resident B still wanted to leave the facility. An Event Note, dated 4/16/25 at 10:11 a.m., indicated on the previous evening Resident B had eaten dinner, other residents were watching television, and Resident B had asked for a juice and shut his door. Resident B opened his window and jumped out. Resident B was redirected back to the building. On 4/24/25 at 1:10 p.m., observed the path from the facility to the store where Resident B was found by the ADON. The store parking lot was approximately 100 yards from the facility with flat terrain and a sidewalk to the parking lot. On 4/24/25 at 11:21 a.m., the ADON provided a copy of a facility policy, dated 10/2020, titled Elopement Prevention and Response Program, and indicated this was the current policy used by the facility. A review of the policy indicated it was the policy of the facility that staff who have residents under their care are responsible for knowing the location of those residents. The past noncompliance Immediate Jeopardy began on 4/15/25. The Immediate Jeopardy was removed and the deficient practice corrected by 4/16/25 after the facility implemented a systemic plan that included the following actions: audits of elopement evaluations and care plans, inservicing staff on elopement procedures, and ongoing monitoring. This citation relates to Complaint IN00457689. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure food was stored in a sanitary manner for 1 of 1 kitchen observations and 1 of 1 pantry observations. Dry food storage room and kitchen were not thoroughly cleaned and food was not labeled and dated. Findings include: 1. During the initial tour of the kitchen, on 3/6/25 from 7:11 a.m. until 7:22 a.m., observed the dry food storage room. Inside the dry food storage room the following was observed: - On the floor, under the metal shelving units, observed a buildup of dust and debris, two unopened 0.75 ounce bags of cheddar crackers and two unopened 4 ounce containers of unsweetened apple sauce. - Five - 16 ounce boxes of corn starch sitting inside a hard plastic bin with a hard plastic lid. On top of the lid, small, black, mouse-like droppings were observed. - A plastic bag of brown powder was opened and wrapped tightly with plastic wrap. The label indicated it was received on 3/4/25 at 6:53 p.m. The wrapping had a hole that appeared to have been chewed through to the powder. Approximately, one ounce of powder was missing from the wrapping and the brown powder was lying on the shelf and on a box on the shelf below. Small, black, mouse-like droppings were observed on top of the plastic wrapped brown powder and mixed with the powder on the box on the lower shelf. - A board, approximately one inch (in.) by four in. by seven foot, ran along the wall approximately three feet from the floor. On the board, small, black, mouse-like droppings were observed. - Under the preparation tables and the warming table in the kitchen, a build-up of dust and debris was observed. During an interview on 3/6/25 at 7:15 a.m., Dietary [NAME] 1 indicated the kitchen and dry food storage area was cleaned at the beginning and end of every shift. Dietary [NAME] 1 was not aware of the small, black, mouse-like droppings in the dry food storage room. The kitchen and dry storage should have been cleaned that morning at the beginning of the shift. During an interview on 3/6/25 at 7:22 a.m., Culinary Aide 2 indicated the kitchen was cleaned every shift. The floor under the food preparation tables and cooking area should have been cleaned. 2. During the initial tour of the facility on 3/6/25 from 7:30 a.m. until 8:11 a.m., observed the unit pantry refrigerator. Inside the refrigerator the following was observed: - A dried brown substance covered the bottom door shelf and the bottom of the refrigerator. - A large clear plastic cup, undated and unlabeled, was tipped over on its side with approximately 15 ml (milliliters) of brown liquid. The cup was on the bottom shelf of the refrigerator door. - Approximately an eight once clear glass container with a plastic lid, that was undated and unlabeled, that contained two strawberries that were cut in half. The strawberries were slimy and turning brown and green. - A square styrofoam container with a plastic fork, corn, mashed potatoes, and meat that was undated and unlabeled. During an interview on 3/6/25 at 8:11 a.m., RN 1 indicated all of the items in the pantry refrigerator should have been dated and labeled with the resident's name. On 3/6/25 at 8:31 a.m., the Administrator provided a copy of a facility policy, titled Food Storage, dated 5/2024, and indicated this was the current policy used by the facility. A review of the policy indicated food was stored to prevent contamination. This citation relates to Complaint IN00454897. 3.1-21(i)(2) 3.1-21(i)(3)

Based on record review and interview, the facility failed to ensure a resident was referred to the State-designated authority contractor for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a new mental illness diagnosis for 1 of 1 resident reviewed for PASRR. (Resident 65) Finding includes: On 1/16/25 at 10:40 a.m., Resident 65's clinical record was reviewed. The diagnosis included, but was not limited to, delusional disorder. Resident 65 was admitted to facility on 12/15/23 with a PASRR Level I completed. On 10/15/24, a new diagnosis of delusional disorder was added without a new Level II PASRR evaluation. A Quarterly Minimum Data Set (MDS) assessment, dated 10/28/24, indicated Resident 65 was severely cognitively impaired. During an interview on 1/16/25 at 11:19 a.m., the Administrator indicated that a PASRR Level II evaluation was not completed for the new diagnosis of delusional disorder for Resident 65. On 1/16/25 at 1:27 p.m., the Administrator provided a copy of an American Senior Communities Indiana PASRR Policy, undated, and indicated that it was the current policy being followed by the facility. The policy indicated a screening was completed to identify residents who had mental illness. 3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

Based on observation, interview, and record review, the facility failed to ensure the area next to the trash dumpster container was free from rubbish for 2 of 2 observations. Findings include: 1. During the initial facility tour with the Dietary Manager (DM), on 1/14/25 from 9:25 a.m. to 9:30 a.m., the dumpster, located at the end of the facility parking lot on the west side of the building, was observed. The following was observed at the dumpster container site: - Three large trash bags were observed laying on the ground next to the dumpster. The untied trash bags were filled with soiled briefs and other unidentifiable debris. - Multiple used plastic gloves and other debris were observed laying on the ground next to the dumpster container. - Two large partially filled clear trash bags were laying on the ground near the dumpster. The trash bags were partially covered with snow. - No staff were visible in the area at that time. During an interview at that time, the DM indicated all trash bags were to be tied and placed into the dumpster container. The ground surrounding the dumpster container was to be kept free of debris. During an interview on 1/14/25 at 9:35 a.m., the Assistant Director of Nursing Services (ADNS) indicated all trash bags were to be tied and placed into the dumpster container. The dumpster area was to be kept free of any debris. 2. During a follow-up observation with the Maintenance Director on 1/16/25 at 2:00 p.m., the dumpster area was observed. Multiple used plastic gloves and other debris were observed on the ground near and around the dumpster area. No staff were visible in the area at that time. During an interview at that time, the Maintenance Director indicated all trash was to be placed inside the dumpster and the area was to be kept free of debris. On 1/16/25 at 3:45 p.m., the Administrator provided a copy of the Trash Removal policy, dated April 2018, and indicated it was the current policy in use by the facility. A review of the document indicated, .always dispense trash in container outside .if the area is getting unsightly, clean it up or alert your supervisor . On 1/17/25 at 2:15 p.m., a review of the Retail Food Establishment Sanitation Requirements - Title 410 IAC 7-24, effective November 13, 2004, indicated, .receptacles and waste handling units for refuse, recyclables and returnables shall be kept covered with tight-fitting lids or doors if kept outside .accumulation of debris .are minimized .effective cleaning is facilitated around .the unit . 3.1-21(i)(2) 3.1-21(i)(5)

Based on observation, interview, and record review, the facility failed to ensure medications were stored in accordance with accepted principles for 1 of 3 medication carts reviewed and two random observations of treatment carts. Medication and treatment carts were unlocked and insulin did not have an open date. (300 Hall Medication Cart, 300 Hall Treatment Cart) Findings include: 1. On 2/19/24 at 8:55 a.m., a treatment cart located near the 300-hall nurse's station was observed to be unlocked. No staff were observed in the immediate area at that time. On 2/19/24 from 10:30 a.m. to 10:33 a.m., a medication cart located in the hall and next to next to the 300-hall nurse's station was observed. The medication cart was observed to be unlocked. Inside the cart were multiple syringes and a variety of resident's medications. On top of the cart was a pair of metal scissors. An unidentified staff person was sitting inside the nurse's station area facing the four foot tall half wall. The staff person was facing the opposite direction from where the medication cart was located. The staff person was working intently on the computer and had not looked up or acknowledged that anyone was nearby during that time. Multiple residents were observed in the therapy room which was located approximately 12 feet from the nurse's station. No other staff were visible in the area. On 2/21/24 at 3:00 p.m., Registered Nurse (RN) 2 was observed to position a medication cart in the 100-hall near room [ROOM NUMBER]. RN 2 retrieved supplies and medication from the medication cart. RN 2 was observed to walk away from the medication cart to enter a resident's room located across the hall from the medication cart. The medication cart was observed to be unlocked. No other staff were visible in the area. During an interview at that time, RN 2 indicated the cart was to be kept locked when left unattended by staff. On 2/21/24 from 3:05 p.m. to 3:13 p.m., a treatment cart located in the 300-hall between rooms [ROOM NUMBERS] was observed. The treatment cart was observed to be unlocked. Inside the unlocked treatment cart were multiple medications and supplies including, but not limited to, santyl ointment (used to remove damaged tissue from chronic skin ulcers); diclofenac sodium topical gel 1% (used to treat pain and swelling caused by osteoarthritis of the knees); and bandages. No staff were visible in the area during that time. During an interview on 2/21/24 at 3:15 p.m., the Director of Nursing Services (DNS) indicated the medication and treatment carts were to be kept locked when unattended by staff. On 2/21/24 at 3:55 p.m., the DNS provided a copy of the LTC (Long Term Care) Facility's Pharmacy Services and Procedures Manual policy, dated 7/21/22, and indicated it was the current policy in use by the facility. A review of the document indicated, .facility should ensure that all meds [medications] and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors . 35099 2. On 2/20/24 at 1:20 p.m., the 300 Hall Medication Cart was observed. The following medications were not labeled indicating a date the medications were opened. - One opened vial of Insulin Lispro (an injectable medication used to treat Diabetes Mellitus) 100 units/ml (milliliter). - One used Insulin Glargine (an injectable medication used to treat Diabetes Mellitus) Flex Pen 100 units/ml. - One Levemir (an injectable medication used to treat Diabetes Mellitus) Flex Pen 100 units/ml. - One Lantus Solostar Insulin (an injectable medication used to treat Diabetes Mellitus) Flex Pen. During an interview at that time, LPN 3 indicated the vials and Pens should have been dated at the time they were opened. On 2/21/24 at 11:40 a.m., the Director of Nursing provided a policy titled, Storage and Expiration Dating of Medications, Biologicals, dated 2/2002, and indicated it was the current policy being used by the facility. A review of the policy indicated 5. Once any medication or biological package is opened; Facility should follow manufacturer or supplier guidelines with respect to expirations dates for open medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened. 3.1-25(j) 3.1-25(m)

Based on observation, interview, and record review, the facility failed to ensure the posted nurse staffing document reflected the actual hours worked for 3 of 3 observations. Findings included. On 2/19/24 at 8:40 a.m., the Staff Posting Report document was observed in the front lobby sitting on a table in a clear frame. The Staff Posting Report was observed to not include the actual hours worked by staff. On 2/20/24 at 8:20 a.m., the Staff Posting Report document was observed in the front lobby sitting on a table in a clear frame. The Staff Posting Report was observed to not include the actual hours worked by staff. On 2/21/24 at 7:55 a.m., the Staff Posting Report document was observed in the front lobby sitting on a table in a clear frame. The Staff Posting Report was observed to not include the actual hours worked by staff. During an interview on 2/21/24 at 11:40 a.m., the Director of Nursing (DON) indicated the front lobby was the only location the posted staffing hours were posted in the facility. The DON was unaware the actual hours worked were to be posted. On 2/21/24 at 3:55 p.m., the DON provided a policy titled Posted Nurse Staffing Data and Retention Requirements, dated July 2023, and indicated it was the current policy being used by the facility. A review of the policy indicated .Procedure: 1.d The total number and actual hours worked by the following categories of licensed and unlicensed staff directly responsible for resident care per shift: i. Registered nurses ii. Licensed practical nurses iii. Certified nurse aides.

Based on record review and interview, the facility failed to ensure a resident was referred for a Level II Pre-Admission Screening Resident Review (PASRR) mental health assessment for mental illness evaluation and determination as indicated by a Level I PASRR evaluation for 1 of 2 resident reviewed for PASRR. (Resident 26) Finding includes: On 5/16/22 at 1:35 p.m., Resident 26's clinical record was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 26's primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A Quarterly Minimum Data Set (MDS) assessment, dated 3/8/22, indicated Resident 26 was cognitively intact. On 5/19/22 at 1:08 p.m., the Administrator provided a screen shot copy of the State's PASRR designated contractor electronic data base system regarding Resident 26's Level I Pre-Admission Screening Resident Review (PASRR) evaluation and determination dated 1/24/17. A review of the document indicated, refer for Level II onsite [comprehensive mental health assessment for mental illness based on the findings of the Level I determination]. On 5/20/22 at 8:35 a.m., the Director of Nursing Services (DON) provided a copy of the Notice of PASRR Level I Screen Outcome, dated 1/24/17. A review of the document indicated Resident 26 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/19/22 at 10:30 a.m., the Administrator indicated the facility was unable to provide a copy of the completed PASRR Level II assessment for Resident 26. The Level I indicated a Level II was required and it had not been completed. On 5/19/22 at 2:20 p.m., the Administrator provided an undated policy titled Indiana PASRR Policy - Summary of PASSR and indicated that it was the currently policy in use by the facility. A review of the policy indicated, .the Level I Screen is completed to identify residents who may have a mental illness (MI) .the [contractor] generated outcome letter will indicate if a Level II is necessary . 3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

Based on observation, interview, and record review, the facility failed to implement interventions to prevent falls for 1 of 5 residents reviewed for falls. (Resident 16) Findings include: During an observation on 5/18/22 at 2:04 until 2:22 p.m., Resident 16 was in his room with no staff visible. The resident was leaning over in the wheel chair and reaching for the floor. The resident's feet were without socks or shoes. During an observation on 5/19/22 at 8:35 a.m. until 8:50 a.m., Resident 16 was in his room with no staff visible. The resident was in his wheelchair and self propelling himself around in his room. The resident's feet were without socks or shoes During an observation on 05/19/22 at 9:33 a.m., facility staff was in Resident 16's room. The staff were assisting the resident. The resident was sitting on the floor and the resident's feet were without socks or shoes. During an interview on 5/19/22 at 10:00 a.m., the Director of Nursing (DON) indicated CNA 4 had reported Resident 16 had fallen at 6 a.m. this morning. The fall was unwitnessed. During an interview on 5/19/22 at 10:20 a.m., CNA 4 indicated she used the CNA task sheet to know if a resident was to wear non-skid socks as part of their care plan. CNA 4 also indicated Resident 16 was not wearing any foot covering when he fell earlier in the shift. On 5/19/22 at 3:00 p.m., the clinical record of Resident 16 was reviewed. The diagnoses included, but were not limited to, repeated falls and dementia with behavioral disturbance. A Quarterly Minimum Data Set (MDS) assessment, dated 2/29/22, indicated Resident 16's cognitive status was moderately impaired. Resident 16 required extensive assist of two or more staff members for all transfers. The resident required extensive assist of one staff member for dressing. The resident was not steady, and only able to stabilize with staff assistance. The resident required substantial/maximum assistance putting on foot wear: (The ability to take off socks and shoes or other footwear that is appropriate for safe mobility ) An Occupational Therapy evaluation, dated 3/15/22, indicated Resident 16 required partial to moderate assistance putting on and taking off footwear. A fall risk assessment, dated 3/25/22, indicated Resident 16 was a high risk for falls. A care plan, dated 8/4/16 and current through 5/23/22, indicated Problem: Falls Resident 16 is at risk for falls due to resident has a history of falls, he [Resident 16] has had a prior fall, he [Resident 16] is incontinent of bladder and bowel. He [Resident 16] has impaired balance, weakness and debility. Goal: Resident 16's fall risk factors will be reduced in an attempt to avoid significant fall related injury. Interventions included, but were not limited to: Non-skid footwear[initiated 8/4/16]. A care plan, dated 8/3/16 and current through 5/23/22, indicated Problem: Resident 16 requires assistance and/or monitoring for Activities of Daily Living (ADL) care. Goal: Residents ADL's will be met. Interventions included, but were not limited to a.m. cares including bathing and dressing. A Certified Nursing Assistant (CNA) task sheet, undated, indicated Resident 16 should wear Non-skid footwear to prevent falls. A progress note, dated 5/8/22 at 6:15 p.m., indicated Resident 16 was in his room and slid to the floor landing on his bottom. A progress note, dated 5/17/22 at 10:42 a.m., indicated Resident 16 had an unwitnessed fall and was found on the floor next to his bed. An interdisciplinary progress note, dated 5/17/22, indicated Date/Time of fall: 05/17/2022 04:52 a.m. Description of incident: res [Resident 16] found on floor next to bed, stating he was attempting to transfer from w/c [wheelchair] to bed. Immediate intervention: res [Resident 16] assisted up from floor and into bed. An interdisciplinary progress note, dated 5/19/22, indicated Date/Time of fall: 5/19/22 at 9:15 a.m., Resident [Resident 16] was in his wheel chair and was attempting to get something out of his bottom drawer and fell in the process. A progress note, dated 5/20/22 at 6:00 a.m., indicated This nurse responded to CNA's call for assistance in resident's room. Resident [Resident 16] was seated on the floor next to his bed with both legs out in front of him. The resident was unable to recount [recall] how he got [fell ] to the floor. On 5/20/22 at 8:34 a.m., the Director of Nursing provided a policy titled Fall Management Program, dated July, 2001, and indicated it was the current policy being used by the facility. A review of the policy indicated Policy: It is the policy of American Senior Communities to ensure residents residing within the facility receive adequate supervision and or assistance to prevent falls 5. Residents who are categorized as moderate to high risk falls should have fall interventions implemented based on resident specific risk factors. 6. The resident specific care requirements will be communicated to the assigned caregiver utilizing resident profile or CNA assignment sheet. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure 2 staff provided in bed activities of daily living care for a resident assessed to require 2 person assistance, which caused a fall from the bed resulting in a fracture of the distal right thigh bone for 1 of 3 residents reviewed for accidents (Resident B). Findings include: On 6/23/21 at 1:00 p.m., Resident B's clinical record was reviewed. Diagnoses included, but not limited to: [CONDITION(S)] (paralysis of lower body), [CONDITION(S)] with right amputated toe, and [CONDITION(S)]. An Admission Minimum Data Set (MDS) Assessment, dated 6/4/21, indicated Resident B was cognitively intact. Bed mobility (turning a resident from side to side positions body while in bed) required a two person assist. Fall history indicated Resident B had a fall in the past month prior to admission. Functional status for activities of daily living (ADL), dated 5/30/2021 to 6/5/2021 (observation period) indicated Resident B required extensive assistance of 2 staff for bed mobility on 4 days (5/30, 5/31, 6/1, and 6/2) and required total assistance with bed mobility on 2 days (6/3 and 6/4). Resident B's admission care plan, dated 6/1/21, indicated Resident B was to be assisted with bed mobility as needed, assist with transfers as needed, and was a moderate fall risk. Factors included, but were not limited to [CONDITION(S)], unsteady gate, and balance. Resident B's care plan lacked documentation to indicate level of care and/or assistance required by staff. Resident B's clinical progress note, dated 6/4/21 at 2:45 p.m., indicated Resident B rolled off her bed while being turned for personal care, having slid to the floor and onto her knees. The resident was assessed by the nurse with no complaint of pain. Resident B did indicate having felt a pop in her knee. X-rays were ordered and Resident B was assisted back into bed using a Hoyer lift. X-ray results, dated 6/5/21 at 8:34 a.m., indicated an acute spiral fracture with displacement distal (lower area) femur (upper leg). The physician was notified and Resident B was transferred to the Resident's personal preference hospital. Incident event documentation, reviewed on 6/23/21 at 2:00 p.m., indicated on 6/4/2 at 2:48 p.m., Resident B was receiving personal care from CNA (Certified Nursing Assistant) 1 and while up on the side of the bed Resident B began to slide off of the bed and CNA 1 was not capable of stopping her. Interview with CNA 1, on 6/23/21 at 1:57 p.m., indicated she was in to do a check and change (in bed ADL care). Resident B rolled to one side, lifted her left leg over the right leg, the sheet started to slip, and Resident B slipped off of the bed. CNA 1 could not catch Resident B from sliding off onto the floor and onto her knees. CNA 1 called for assistance, the nurse came in, and assessed the resident; at which time Resident B indicated she heard a pop when her knees hit the floor. Resident B did not complaint of any pain and was lifted into bed with a Hoyer lift and 4 people. On 6/24/21 at 4:00 p.m., review of local hospital admission for Resident B indicated emergency room chief complaint was leg pain-swelling. Subjective physician review, dated 6/5/21 at 11:31 a.m., indicated Resident B had a past medical history of [CONDITION(S)] due to spine infection and bilateral knee replacements. Resident B reported she was being turned at her facility and she was turned too far and fell off of the bed, in slow motion. No immediate pain, however once back in bed she felt different, although she had minimal to no sensation at baseline. X-rays performed in the emergency room , indicated a mildly displaced spiral fracture of the distal femoral shaft, with no prostatic involvement, requiring surgery. Interview with Administrator (ADM) and Director of Nursing (DON) on 6/23/21 at 1:24 p.m., indicated Resident B was not being transferred, she wanted to sit on the side of bed, and started slipping out if bed. The care plan indicated Resident B was an assist as needed. A request was made to review the profile care plan (pocket care assistance) for CNA 1, dated 6/4/21. The Administrator and DON indicated after a resident is discharged , the resident's profile care is no longer available. This Federal tag relates to Complaint IN 629. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure a resident received a scheduled narcotic pain medication as prescribed by a physician for 1 of 3 residents reviewed for pain management. (Resident B) Findings include: The clinical record for Resident B was reviewed on 11/20/19 at 10:30 a.m. Resident B was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment, dated 10/3/19, indicated Resident B was cognitively intact. A physician's orders [REDACTED]. Resident B also had an order, dated 10/1/19, for Tylenol 1000 mg every six hours, as needed for pain control. A plan of care (P[NAME]), dated 9/27/19 and current through 2/13/19, indicated Resident B was at risk for pain. Interventions included to administer medications as ordered. Review of the Medication Administration Record [REDACTED] 11/8/19 at 6:00 p.m. 11/9/19 at 12:00 a.m. 11/9/19 at 6:00 a.m. Interview, on 11/20/19 at 1:25 p.m., Resident B indicated she had missed three consecutive doses of pain medication one night a few weeks ago. She had asked for her routinely ordered pain medication and was told she had run out and they had to order the medication from pharmacy. Resident B denied being offered any other type of pain medication. She had been in so much pain she was, unable to get out of bed and sit in a wheelchair. She described, feeling miserable. Interview, on 11/21/19 at 10:45 a.m., the Director of Nursing (DON) indicated Resident B should not have run out of her pain medication, as it should have been ordered when there were just a few pills left during regular pharmacy hours. Nurses were to contact the on-call nurse if assistance of any kind was required. A content list of the medications available through the emergency drug kit (EDK) (the EDK consists of a supply of medication, used when a resident runs out of a medication), dated 11/21/19, indicated they had access to the [MEDICATION NAME] 10-325 mg dose in which Resident B had been ordered. Interview, on 11/21/19, at 10:45 a.m., the DON indicated staff could have obtained pain medication for Resident B, on 11/8/19 through 11/9/19, through the EDK. The DON provided a policy titled: Medication Shortages/Unavailable Medications, dated 12/1/07, and indicated it was the current policy being used by the facility. Review of the policy indicated, .3. If a medication shortage is discovered after normal Pharmacy hours: 3.1 A licensed facility nurse should obtain the ordered medication from the Emergency Medication Supply . This Federal tag relates to Complaint IN 752. 3.1-37(a)

Based on interview and record review, the facility failed to ensure residents were free from fear of staff retaliation for 3 of 3 residents reviewed for grievances. (Resident 325, 350, and 375) Findings include: On 10/16/19 at 2:00 p.m., the Administrator provided a copy of Incident Report number 298, that was submitted to the Indiana State Department of Health on 8/13/19. A review of the report indicated, .Resident (375) states that CNA (Certified Nursing Assistant) 5 was rude . The facility's investigation indicated 2 of 16 residents indicated CNA 5 was rude and hateful. The facility investigation questionnaires to residents identified CNA 5's name and listed the resident's responses by their name. Confidential interviews were conducted during the course of the survey. Resident 325 indicated CNA 5 was reported to the facility management staff a while back and since that time, CNA 5 has been rude, vindictive, and refused to speak to him or provide care to him. CNA 5 would answer his call light and stated, your light is on, what do you want? Resident 325 indicated a fear of retaliation from CNA 5 in regard to the reported concerns of having been rude. Resident 350 indicated CNA 5 was, rude and ignored the resident. Resident 350 indicated a fear of retaliation. Resident 375 indicated in a written statement that CNA 5 was rude and talked hateful. Resident 375 indicated a fear of retaliation. The clinical record of Resident 325 was reviewed on 10/11/19 at 9:00 a.m. The quarterly MDS (Minimum Data Set) assessment, dated 8/26/19, indicated Resident 325 was cognitively intact. The clinical record of Resident 350 was reviewed on 10/11/19 at 9:05 a.m. The significant change MDS assessment, dated 9/23/19, indicated Resident 350 was cognitively intact. The clinical record of Resident 375 was reviewed on 10/16/19 at 3:00 p.m. The quarterly MDS assessment, dated 9/11/19, indicated Resident 375 was cognitively intact. On 10/11/19 at 9:44 a.m., the Administrator provided a copy of the Abuse Prohibition, Reporting and Investigation policy, dated (MONTH) (YEAR), and indicated it was the current policy in use by the facility. A review of the policy indicated, .has established policies and procedures which will provide facility personnel with the knowledge and training to further ensure each resident is treated with individual respect and dignity .to provide each resident with an environment that is free from abuse, neglect .this includes but is not limited to verbal abuse .physical abuse .mental abuse .protect residents and staff from retaliation . On 10/15/19 at 2:45 p.m., the Administrator provided a copy of the Resident Concerns and Grievances policy, dated (MONTH) 2019, and indicated it was the current policy in use by the facility. A review of the policy indicated, .resident .concerns/grievances occurring during the resident's stay shall be responded to promptly and without fear of reprisal or discrimination . 3.1-7(a)(1)

Based on interview and record review, the facility failed to ensure a resident was referred to the State-designated authority for a Level II Pre-Admission Screening Resident Review (PASRR) evaluation and determination for 1 of 2 residents reviewed for PASRR. (Resident 46)) Findings include: On 10/11/19 at 2:24 p.m., the clinical record of Resident 46 was reviewed. Resident 46 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) assessment, dated 8/9/19, indicated Resident 46 was cognitively intact. The Notice of PASRR (Pre-Admission Screening Resident Review) Level I Screen Outcome, dated 5/21/19, indicated PASRR Level I Determination: Refer for Level II document-based review . suspected or confirmed PASRR conditions: MH Mental Health Disability .PASRR Level I screens and Level II evaluations are required by Federal Law, 42 U.S.C. 1396r(e)(7) . The clinical record lacked a PASRR Level II mental health assessment for Resident 46. Interview, on 10/11/19 at 2:00 p.m., the Administrator indicated Resident 46's PASRR Level I was completed and determined a PASRR Level II was required. The facility failed to refer for the PASRR Level II - mental health assessment as directed by the PASRR Level I determination. On 10/11/19 at 3:10 p.m., the Administrator provided a copy of the PASRR policy, dated (MONTH) (YEAR), and indicated it was the current policy in use by the facility. A review of the policy indicated, .It the policy of this facility to ensure that any Pre-Admission Screening and Resident Review (PASRR) recommendations which impact those with an intellectual, mental disability or related conditions are completed as prescribed and PASRR assessments are updated .Residents seeking admission to a skilled nursing facility will participate in Pre-Admission Screening as directed in the Indiana PASRR Level I and Level of care Screening Procedures for Long Term Care Services Provider Manual . On 10/11/19 at 4:00 p.m., a review of the Indiana PASRR Level I and Level of Care Screening Procedures for Long Term Care Services Provider Manual, dated 3/8/17, indicated when an outcome of Refer for Level II is rendered, the submitter is responsible for notifying the appropriate mental health or intellectual disability representative (based on region), who will conduct the onsite Level II evaluation . 3.1-16(d)(1)(A)

Based on observation, record review, and interview, the facility failed to develop and implement a comprehensive person-centered care plan for a resident utilizing a life vest and had a biliary drain (Resident 300) and for a resident in need of dental services (Resident 89) for 2 of 24 residents reviewed for devotement of a care plan. Findings include: 1. The clinical record for Resident 300 was reviewed on 10/9/19 at 9:34 a.m. [DIAGNOSES REDACTED]. Recapitulated Physician orders, dated 9/2019, indicated staff should check the function of Resident 300's life vest (external personal defibrillator worn by a resident at risk for sudden [MEDICAL CONDITION]), to ensure battery is charged and operational every shift, and to switch out the battery pack to life vest and place depleted battery on charger base every day. Orders, dated 9/28/19, indicated staff were to change the battery in the life vest daily and to record the biliary drain output three times a day. Resident 300's clinical record lacked a care plan for operation and care of Resident 300's life vest. The clinical record lacked a care plan for care of a biliary drain. Interview, on 10/11/19 at 2:00 p.m., the Administrator indicated Resident 300 did not have a care plan for the care and maintenance of the life vest or the biliary drain. On 10/11/19 at 10:38 a.m , the Administrator provided a policy with the last revision dated 10/2019, titled: IDT Comprehensive Care Plan Policy, and indicated it was the current policy in use by the facility. A review of the policy indicated, .that each resident will have a comprehensive person-centered care plan developed .The care plan will include measurable goals and resident specific interventions based on resident needs and preferences to promote the residents highest level of functioning including medical, nursing, mental, and psychosocial needs. 2. On 10/7/19 at 2:00 p.m., Resident 89 was observed to have her own natural teeth, of which multiple were broken. During an interview, at that time, Resident 89 indicated her teeth have been broken, for a long time and she would like her teeth fixed. The clinical record of Resident 89 was reviewed on 10/10/19 at 8:46 a.m. [DIAGNOSES REDACTED]. The significant change MDS (Minimum Data Set) assessment, dated 7/26/19, indicated Resident 89 had obvious or likely cavity or broken natural teeth. The MDS assessment worksheet-work history indicated, Resident has natural teeth with missing teeth. This places resident at risk for altered nutrition. Resident is observed for difficulty with eating and c/o (complaint of) pain. The clinical record lacked a comprehensive care plan addressing Resident 89's dental health. Interview, on 10/10/19 at 10:00 a.m., the MDS Coordinator indicated the significant change MDS assessment, dated 7/26/19, indicated Resident 89 had broken teeth and triggered for a care plan to be developed addressing the dental issues. No care plan had been developed. Interview, on 10/10/19 at 4:25 p.m., the Director of Nursing indicated, as a result of the 7/26/19's significant change MDS assessment, a dental care plan should have been developed right away for Resident 89. On 10/11/19 at 10:38 a.m., the Administrator provided a copy of the IDT Comprehensive Care Plan Policy, dated (MONTH) 2019, and indicated it was the current policy in use by the facility. A review of the policy indicated, .each resident will have a comprehensive person-centered care plan developed based on comprehensive assessment .to promote the resident's highest level of functioning .care plan problems, goals, and interventions will be updated based on changes in resident assessment/condition . 3.1-35(a)

Based on record review and interview the facility failed to ensure adequate supervision and interventions were used to prevent an accident for 1 of 3 residents reviewed for having adequate accident prevention measures in place in a sample of 14. (Resident #A) Findings included: The record of Resident #A was reviewed on 9/8/11 at 12:00 p.m. [DIAGNOSES REDACTED]. A "Resident Assessment," received from the Executive Director (E.D.) on 9/9/11 at 3:50 p.m., was completed on Resident #A on 6/28/11, prior to her admission to the facility. During an interview at this time the E.D. indicated the assessment was done by the facility's corporate nurse liaison while the resident was still in the hospital. The Resident Assessment indicated "...Current Problems/Reason for Placement...Pt. (patient) (with) Bipolar 2 (diagnosis)...confusion...anxiety. Pt is very impulsive - has sitter & will get up - she is unsteady on feet (at) this time...Medical History...extensive psych (history)...Comprehension-Thinking/Awareness...Alert et oriented to: person...confused...Restraints Y (yes) Type: Sitter...Overestimates abilities Y (yes)...Bed alarm Y(yes) .hallucinations...very impulsive...(increased) fall risk...Pt. gets up on own...Still (with sitter 6/2...(rest of date illegible)..." Resident #A was admitted to the facility on [DATE] at 6:30 p.m. She was discharged to a hospital on [DATE] at 7:40 p.m. Review of a facility "Nursing Admission Assessment," dated 7/1/11 at 6:30 p.m. indicated Resident #A was "friendly," answered questions "readily," was oriented to "person," had "Clear Speech" "Lower Body Weakness" and "Involuntary Movements." Review of a "Fall Risk Assessment" for Resident #A, completed 7/1/11, indicated she had a history of [REDACTED]." Review of a Pain Assessment for Resident #A, completed 7/1/11, indicated she was currently experiencing pain in her left shoulder. This pain was described as moderate, frequent, aching, increased by movement and decreased by "pain meds." (medications) An undated, unsigned "Interim/Admission Nursing Care Plan" indicated a problem of "Fall Risk related to BLE (bilateral lower extremity) weakness and meds." The goal was Resident #A would have no injury related to falls. Interventions included observing for fall risk contributors, reminding to use call light, provide assistance for transfers and providing appropriate assistive devices. The care plan also indicated a problem of pain related to "old L (eft) shoulder injury. A goal was the resident would have no pain. Interventions included "Meds as ordered..." Resident #A's admission medications on 7/1/11 included Seroquel (an antipsychotic medication for treatment of [REDACTED]. 3 times per day and Cymbalta (an antidepressant) 30 mg. per day. Review of nurses' notes for Resident #A for 7/1/11 at 10:30 p.m. indicated the resident was "very confused" and "staff to anticipate wants and needs...PSA (personal safety alarm) in place and functioning...Res(Resident) very restless..." Review of nurses' notes for 7/2/11 at 1:20 a.m. indicated "...very confused...clear speech, unable to clearly voice needs. Res up in w/c (wheelchair) at nurses' station due to resident trying to climb over bolsters in bed...Safety alarms in place and functioning..." Review of nurses' notes for 7/2/11 at 10:00 a.m. indicated "Res very confused, non cooperative, combative (with) care...constantly trying to stand up in chair...res c/o (complains of) pain while res arm was being moved... Review of physician orders [REDACTED]. Review of nurses' notes for 7/2/11 at 10:00 p.m. indicated Resident #A had been up much of the day, was "non cooperative (with) care. New PRN meds have been helpful. Res has taken naps occasionally after PRN Ativan 0.5 mg and Vicodin 5/500 mg given." Review of nurses's notes for 7/3/11 indicated Resident #A "restless. confused. Has activated PSA multiple times...attempted to climb out of bed x 3. In wheelchair at nurse's station at this time. Requiring constant reminders per staff to stay seated." Review of nurses' notes for 7/3/11 at 10:00 a.m. indicated "...Several attempts during hour to get up...Requires 1 on 1 assist or constant attendance at all times (with) toileting, meals or just being around other res (related to) res behavior." Review of nurses' notes for 7/3/11 at 10:00 p.m. indicated "Res woke up, got out of bed and went to toilet in next room. Res was redirected back to her own room..." Review of a nurse's note for 7/4/11 "@ noc" (at night) indicated "Resident is continued on 1:1 care @ nurses' station..." Review of nurses' notes for 7/4/11 at 11:20 a.m. indicated "...Resident restless and confused. Res (up) on night shift and still (up)....was put down 3 different times but refused to stay in bed..." Review of nurses' notes for 7/4/11 at 10:00 p.m. indicated "Has required constant one on one supervision...undressing in hall. Attempting to eat trash from trash can. Touching other residents...orders received...for Haldol (an anti-psychotic medication) 5mg... every 6 hours PRN severe anxiety or agitation; administered...ineffective. Remains at side of staff." Review of nurses' notes for 7/4/11 at 10:45 p.m. indicated "Sat on floor in front of chair. Witnessed per staff. No apparent injuries. Returned to chair without incident...remains agitated..." Review of nurses' notes for 7/5/11 at 3:20 a.m. indicated Resident #A was complaining of chest pain and inability to breathe. The physician was notified and she was sent to a local hospital emergency room . Review of a nursing note written by RN #1 On 7/5/11 at 3:00 p.m. indicated resident returned from the emergency room with no new orders. "Res confused and agitated. Requires 1:1 care...continuously trying to climb out of bed or (wheelchair)...Spouse currently sitting (with) res." There was no documentation in Resident #A's record to indicate she was assessed or medicated for pain, anxiety or agitation after her return from the hospital on [DATE]. Review of nursing note written by RN #1 on 7/5/11 at 7:40 p.m. indicated "Res fell out of (wheelchair) at 7:00 p.m. (with) lap attached. Landed on (right) arm...(right) temple at eye brow swollen et purple...(MD) advised to send to (hospital)..." During an interview with RN #1 on 9/8/11 at 1:35 p.m. she indicated Resident #A was in the "little dining room" around 7:00 p.m. on 7/5/11 in her wheel chair with her lap try on. She indicated no one else was in the dining room. The resident was alone in the dining room. She indicated Resident #A was always "very agitated" and "constantly moving." She indicated the resident "didn't communicate, she just thrashed." RN #1 indicated she (RN #1) was standing outside the dining room "maybe 6 feet away." She turned away and when she looked back at the resident again the wheelchair was tipped over. She indicated the lap tray and the resident were still on/in the wheelchair. She indicated the resident had a lump on the right side of her head. During an interview with the Director of Nursing (DON) on 9/8/11 at 5:30 p.m. she indicated the facility would not have accepted Resident #A if they had known she required 1:1 care because "we don't have staffing for that." She indicated 1:1 care meant someone was with a resident constantly. Further information was requested from the DON at this time regarding a schedule of who was assigned to Resident #A for 1:1 care. She indicated she was not able to provide this information because the assignments were not written out. She indicated Resident #A did not always require 1:1 care, just "sometimes" but she did not have any scheduled assignments for this. Review of a local hospital's records, obtained by the facility and received from the Assistant Director of Nursing on 9/8/111 at 5:00 p.m. indicated after Resident #A was admitted to the hospital on 7/5/11, she had an MRI (x-ray) of the brain on 7/7/11 "which showed a probable contusion involving the high right frontal lobe." A neurology consultation note, dated 7/6/11, indicated the physician had spoken "to 1 of the nurses there (the facility) and she tells me the patient has been quite combative and agitated since she has been there, requiring 1-on-1 care, which they really cannot provide for her....sent to our emergency room after she fell out of her wheelchair, striking her head. The nurse at the extended care facility told me she did not pass out, she did not seize, she was just agitated and trying to get out of her wheelchair when she fell ..." The hospital records indicated Resident #A had to have a feeding tube placed due to poor intake by mouth. A physician consultation note for the feeding tube dated 7/21/11 indicated "...admitted from ECF after she flipped her wheelchair and hit her head. MRI showed a contusion. Subsequently she has had seizures and tremors. She has been encephalopathic. (refers to brain disease) She does not respond except by opening her eyes. She does not follow any commands. She is nonverbal..." During an interview with Resident A's husband on 9/8/11 at 2:00 p.m. he indicated Resident #A passed away on 9/7/11. This federal tag relates to Complaint IN 190. 3.1-45(a)(2)