Every finding on record at Bethany Village

Based on observation, interview, and record review, the facility failed to ensure foods were served in a sanitary and safe manner for 2 of 3 kitchen observations. Staff hair was not covered while in the kitchen food preparation area. (Dietary Aide 7 and Dietary Aide 8) Findings include: 1. During a follow-up kitchen observation, on 9/2/25 from 11:35 a.m. to 11:40 a.m., the following was observed:- Dietary Aide 7 was observed walking through-out the kitchen service area where the noon meal was being prepared and near the steamtable that held the hot foods for the noon meal. Dietary Aide 7 was observed to have facial hair, approximately one-half inch in length, above and below the lip area and at the upper cheek bone area. The facial hair was observed to not be covered.- Dietary Aide 8 was observed walking through-out the kitchen service area where the noon meal was being prepared and near the steamtable that held the hot foods for the noon meal. Dietary Aide 8 was observed wearing a white hair net that covered hair from above the ears and approximately three inches above the neckline area to the top of the head. Below the white hair net, Dietary Aide 8 was observed to have multiple loose hairs approximately 12 to 18 inches in length. Multiple hairs were pulled from behind both ears and were observed resting on his chest area. Multiple hairs were observed hanging from the neckline to the mid shoulder area. The hairs were observed to not be covered.2. During a follow-up kitchen observation, on 9/2/25 from 12:33 p.m. to 12:45 p.m., the following was observed:- Dietary Aide 7 was observed walking through-out the kitchen service area where the noon meal was being plated and near the steamtable that held the hot foods for the noon meal. Dietary Aide 7 was observed to have facial hair, approximately one-half inch in length, above and below the lip area and at the upper cheek bone area. The facial hair was observed to not be covered.- Dietary Aide 8 was observed walking through-out the kitchen service area where the noon meal was being plated and worked at the steamtable that held the hot foods for the noon meal. Dietary Aide 8 was observed wearing a white hair net that covered hair from above the ears and approximately three inches above the neckline area to the top of the head. Below the white hair net, Dietary Aide 8 was observed to have multiple loose hairs approximately 12 to 18 inches in length. Multiple hairs were pulled from behind both ears and were observed resting on his chest area. Multiple hairs were observed hanging from the neckline to the mid shoulder area. The hairs were observed to not be covered.During an interview on 9/2/25 at 1:00 p.m., the Dietary Manager indicated staff's hair was to be kept covered while in the kitchen area. On 9/2/25 at 1:16 p.m., the Executive Director provided a copy of the Culinary Personal Hygiene policy, dated May 2025, and indicated it was the current policy in use by the facility. A review of the policy indicated, .All employees working in the culinary department must wear a clean hair restraint which effectively covers all hair .employees with facial hair, including beards and/or mustaches, must wear a beard restraint that effectively covers all facial all hair .On 9/2/25 at 3:30 p.m., a review of the Indiana Food Establishment Sanitation Requirements, Title 410 IAC 7-26, effective April 16, 2025, indicated, .food employees shall wear hair restraints, such as hats, hair coverings or nets, beard restraints .that are designed and worn to effectively keep their hair from contacting .exposed food .3.1-21(i)(2)3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure potentially hazardous materials were kept secured and behind locked doors to prevent resident's access to the materials potentially affecting 15 self-mobile cognitively impaired residents for 1 of 1 observation. (Housekeeping/Electrical room)Finding includes:On 9/4/25 from 11:00 a.m. to 11:08 a.m., the Housekeeping/Electrical room located near the main dining room and the 300 hall was observed. Posted on the door was a sign that indicated Not An Exit and a keypad lock was observed above the door handle. The door was observed to be open. Visible inside the room were multiple tools, electric wires, cleaning supplies, and various maintenance equipment. No staff were visible in the area during that time.On 9/4/25 at 11:09 a.m., Floor Technician 6 was observed walking from the nurse's station area and past three occupied resident rooms. Floor Technician 6 walked toward the Housekeeping/Electrical room and entered the open room. During an interview at that time, Floor Technician 6 indicated the Housekeeping/Electrical room door was to be kept closed and locked when no staff were in the area. On 9/5/25 at 9:40 a.m., during a facility tour with the Executive Director, the Housekeeping/Electrical room was observed. During an interview at that time, the Executive Director indicated the door was to be kept closed and locked when staff were not present.On 9/5/25 at 11:30 a.m., the Executive Director indicated there were 15 self-mobile cognitively impaired residents who could have accessed the unlocked Housekeeping/Electrical room.On 9/5/25 at 11:30 a.m., the Executive Director provided an undated copy of the Direct Supply Tels: Door's policy and indicated it was the current policy in use by the facility. A review of the document indicated, .doors to hazardous areas shall be self-closing or automatic closing . 3.1-45(a)

Based on observation, interview, and record review, the facility failed to ensure insulin was labeled with an open date for 2 of 2 medication carts of observed. (Rehab Cart, Skilled Cart)Findings include: During an observation on 9/3/25 at 8:35 a.m., the rehab medication cart was observed. An opened and used insulin flex pen 100 units/ml was located in the medication cart. The pen lacked a label indicating the date it was opened. During an interview at that time, LPN 2 indicated there was no label on the insulin and indicated it should have been labeled at the time it was opened. During an observation on 9/3/25 at 8:45 a.m., the medication cart on the skilled unit was observed. An opened and used insulin flex Pen 100 units/ml was observed in the medicine cart. The flex pen lacked a label indicating when the pen was opened. The pen also lacked a label indicating to whom it was prescribed. During an interview at that time LPN 3 indicated the pen in medicine cart had been opened and should have been labeled. During an interview on 9/3/25 at 9:20 a.m., the Director of Nursing Services indicated the flex pens should have been dated at the time they were opened. On 9/3/25 at 9:27 a.m., the Executive Director provided a policy titled, American Senior Communities, Medication Storage and Expiration Policy, and indicated that the policy is the current policy being used by the facility. A review of the policy indicated 10. c, .If a multidose vial of an injectable medication has been opened or accessed (e.g., needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. 3.1-25(j)

Based on interview and record review, the facility failed to follow the current vaccine administration guidelines for both the influenza and pneumococcal vaccinations for 1 of 5 residents reviewed for vaccinations records. (Resident 10)Findings include:On 9/2/25 at 11:00 a.m., Resident 10's clinical record was reviewed and indicated the following:Resident 10's preventative health section in the electronic health record lacked records for any influenza or pneumococcal vaccinations. Resident 10's diagnoses included, but were not limited to, unspecified vascular dementia. Resident 10 had an admission date of 12/4/24 and was [AGE] years old or older.On 9/4/25 at 8:50 a.m., the DON (Director of Nursing) provided influenza and pneumococcal vaccination consent forms indicating Resident 10's guardian had consented for the resident to receive the recommended vaccinations for both influenza and pneumococcal vaccines. During an interview on 9/4/25 at 9:00 a.m., the DON indicated that there were not any records for Resident 10's influenza or pneumococcal vaccinations and that Resident 10 should have received them as recommended and requested with the guardian's signed consent. On 9/2/25, the ED (Executive Director) provided a policy titled Title: Influenza (Flu) Vaccination (Resident), reviewed 8/2021, and indicated it was the policy currently in use. The policy indicated that newly admitted residents who consented to receive the influenza vaccine during flu season, or while influenza was still actively circulating locally, should be offered and receive influenza vaccinations. On 9/2/25, the ED provided a policy titled Title: Pneumococcal Vaccination, reviewed 12/2024, and indicated it was the policy currently in use. The policy indicated that newly admitted residents who had consented to receive pneumococcal vaccinations would be offered and receive the appropriate PCV (pneumococcal conjugate vaccine) and/or the PPSV (pneumococcal polysaccharide vaccine) doses as indicated for each resident's criteria.On 9/5/25 at 9:30 a.m., a review of the CDC guidelines at the following website for influenza guidelines (https://www.cdc.gov/flu/hcp/acip/index.html), updated 8/28/25, indicated one dose annually of influenza vaccinations are recommended for all individuals 6 months of age or older, and that adults [AGE] years of age or older are particularly vulnerable to the influenza virus. On 9/5/25 at 9:45 a.m., a review of the CDC guidelines at the following website for pneumococcal guidelines (https://www.cdc.gov/vaccines/hcp/imz-schedules/adult-notes.html#note-pneumo), updated 7/2/25, indicated that adults [AGE] years of age or older should have the recommended pneumococcal vaccinations, and for an individual over [AGE] years of age whose vaccination record is unknown, a dose of PCV 20 or PCV 21 is recommended. 3.1-13(a)

Based on interview and record review, the facility failed to follow the current vaccine administration guidelines for Covid-19 vaccinations for 1 of 5 residents reviewed for vaccination records. (Resident 10)Finding includes:On 9/2/25 at 11:00 a.m., Resident 10's clinical record was reviewed and indicated the following:Resident 10's preventative health section in the electronic health record lacked records for any recent Covid-19 booster vaccinations; Resident 10 last had a historical vaccine on record in 2022 from a previous facility, but no subsequent vaccinations were administered. Resident 10's diagnoses included, but were not limited to, unspecified vascular dementia. Resident 10 had an admission date of 12/4/24 and was [AGE] years old or older.On 9/4/25 at 8:50 a.m., the DON (Director of Nursing) provided a Covid-19 vaccination consent form indicating Resident 10's guardian had consented for the resident to receive the recommend vaccinations and boosters for Covid-19. During an interview on 9/4/25 at 9:00 a.m., the DON indicated that Resident 10 should have received at least one booster dose of Covid-19 after being admitted to facility based on his immunization records. On 9/2/25, the ED (Executive Director) provided a policy titled Policy Title: Resident Covid-19 Vaccination, dated 12/2020, and indicated it was the policy currently in use. The policy indicated that upon admission, residents will be offered Covid-19 vaccinations based on their Covid-19 vaccination history and they should be offered and receive all additional doses and/or boosters to current consenting residents. On 9/5/25 at 9:30 a.m., a review of the CDC guidelines at the following website for Covid-19 guidelines (https://www.cdc.gov/vaccines/hcp/imz-schedules/adult-age.html), updated 7/2/25, indicated that adults [AGE] years of age or older were to receive two of more doses of the 2024-2025 vaccination boosters. 3.1-13(a)

Based on interview and record review, the facility failed to ensure dialysis medical records were shared between the facility and the dialysis center for 2 of 2 residents reviewed for dialysis. (Resident 2 and Resident 13) Finding includes:1.During an interview on 9/2/25 at 10:49 a.m., Resident 2 indicated he had been using dialysis services for years. He was transported to dialysis on Tuesday, Thursday, and Saturday. Resident 2 indicated he had not taken any facility paperwork to the dialysis center, nor did he return to the facility with any paperwork from the dialysis center.On 9/2/25 at 11:00 a.m., the clinical record for Resident 2 was reviewed. The diagnoses included, but were not limited to, end stage renal disease and dependence on renal dialysis.The Quarterly Minimum Data Set (MDS) assessment, dated 8/11/25, indicated Resident 2 was cognitively intact and required dialysis services.During an interview on 9/4/25 at 10:55 a.m., Licensed Practical Nurse (LPN) 5 indicated Resident 2 was not sent with any facility paperwork and the resident did not return with any paperwork from the dialysis center.On 9/5/25 at 10:00 a.m., the Director of Nursing (DON) provided a copy of Resident 2's current physician orders which included, but were not limited to, Resident 2 was to be transferred to the dialysis center every Tuesday, Thursday, and Saturday for dialysis services, effective 2/19/25 with no end date noted. On 9/8/25 at 10:15 a.m., the DON provided a copy of Resident 2's August of 2025 - Appointment Administration History document. A review of the document indicated that staff documented that Resident 2 was transported to the dialysis center 13 times during the month of August of 2025. The document indicated Resident 2 received dialysis services every Tuesday, Thursday, and Saturday during the month of August.On 9/8/25 at 10:15 a.m., the DON provided a copy of Resident 2's September of 2025 - Appointment Administration History document. A review of the document indicated that staff documented that Resident 2 was transported to the dialysis center three times during the month of September of 2025. The document indicated Resident 2 received dialysis services on Tuesday, Thursday, and Saturday during the month of September.The clinical record lacked dialysis health related documentation that indicated communication between the facility and the dialysis center had been shared between the providers.2. On 9/4/25 at 12:44 p.m., the clinical record for Resident 13 was reviewed. The diagnoses included, but were not limited to, end stage renal disease and dependence on renal dialysis.The admission MDS assessment, dated 6/4/25, indicated Resident 13 was cognitively intact and required dialysis services.During an interview on 9/5/25 at 8:20 a.m., Resident 13 indicated he was transported to dialysis on Tuesday, Thursday, and Saturday. Resident 13 indicated he had not been given any facility paperwork to be given to the dialysis center, nor had the dialysis center provided any paperwork to be returned to the facility.On 9/5/25 at 10:00 a.m., the DON provided a copy of Resident 13's current physician orders which included, but were not limited to, Resident 13 was to be transferred to the dialysis center every Tuesday, Thursday, and Saturday for dialysis services, effective 5/29/25 with no end date noted. On 9/8/25 at 10:15 a.m., the DON provided a copy of Resident 13's August of 2025 - Appointment Administration History document. A review of the document indicated that staff documented that Resident 13 was transported to the dialysis center 12 times during the month of August of 2025. The document indicated Resident 13 received dialysis services every Thursday and Saturday and three of four Tuesdays during the month of August.On 9/8/25 at 10:15 a.m., the DON provided a copy of Resident 13's September of 2025 - Appointment Administration History document. A review of the document indicated that staff documented that Resident 13 was transported to the dialysis center three times during the month of September of 2025. The document indicated Resident 13 received dialysis services on Tuesday, Thursday, and Saturday during the month of September.The clinical record lacked dialysis health related documentation that indicated communication between the facility and the dialysis center had been shared between the providers.During an interview on 9/5/25 at 9:45 a.m., the DON indicated the facility lacked any written communication between the facility and the dialysis center for Resident 2 and Resident 13. Nursing staff were to complete the dialysis communication binders, and it was supposed to be sent to dialysis with the residents. Then while at dialysis, the center was to update the communication binders and send them back with the residents. The binders were to be the communication vehicle to ensure both the facility and center were kept updated on the resident's health status. On 9/2/25 at 9:35 a.m., the Executive Director provided a copy of the Long-Term Care Facility Outpatient Dialysis Services Coordination Agreement, dated 8/23/21, and indicated it was the current dialysis agreement in use by the facility and dialysis provider. A review of the document indicated, .Mutual Obligations: Collaboration of Care.Both parties shall ensure that there is documented evidence of collaboration of care and communication between the Long-Term Care Facility and [End Stage Renal Disease] Dialysis Unit. On 9/4/25 at 2:10 p.m., the DON provided a copy of the Dialysis Care policy, dated November 2017, and indicated it was the current policy in use by the facility. A review of the document indicated, .Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.The nurse in charge at time of transfer to dialysis will provide the resident with all appropriate paperwork.The nurse in charge at time of return will review paperwork for new orders and/or notes accompanying the resident.The facility will employ a method of communication between the facility and the dialysis center to rely changes in condition and response to treatment.3.1-37(a)

Based on interview and record review, the facility failed to ensure a resident's medical record was complete and accurate when the resident discharged against medical advice for 1 of 3 residents reviewed for discharges. (Resident B) Findings include:During an interview on 7/24/25 at 10:56 a.m., Resident B indicated, on 6/18/25, he left the facility with his sister against medical advice. Resident B was unhappy with his care since his admission the previous night. Resident B had been made aware of the risk of discharging against medical advice but didn't care.The clinical record for Resident B was reviewed on 7/24/25 at 11:10 a.m. The diagnoses included, but were not limited to, acute osteomyelitis, acquired absence of right leg below knee, and diabetes.A progress note, dated 6/17/25 at 10:15 p.m., indicated Resident B arrived at the facility and was transferred to bed. Resident B did not have any complaints of pain.The clinical record lacked a progress note describing the details of Resident B's discharge against medical advice.During an interview on 7/24/25 at 11:32 a.m., the Director of Nursing (DON) indicated, on 6/18/25 at approximately 10:00 a.m., Resident B left the facility with his sister against medical advice. Resident B and his sister notified the staff and the DON as they were leaving the facility. The nurse should have entered a progress note in Resident B's medical record when he left the facility against medical advice. On 7/24/25 at 12:07 p.m., the DON provided a copy of a facility policy, titled Discharge Against Medical Advice, dated 7/2025, and indicated this was the current policy used by the facility. A review of the policy indicated when a resident chooses to discharge against medical advice, documentation in the resident's medical record should indicate the facility staff attempted to provide other options to the resident and informed the resident of the potential risks of leaving against medical advice.This citation relates to Complaint 1685013.3.1-50(a)(1)3.1-50(a)(2)

Based on interview and record review, the facility failed to ensure the resident trust accounts were safeguarded to prevent misappropriation for 6 of 6 residents reviewed for misappropriation of property. Cash was withdrawn from resident trust accounts and was unaccounted for. (Resident B, Resident C, Resident D, Resident E, Resident F, Resident G) Findings includes: 1. During an interview on 1/28/25 at 9:04 a.m., Resident B indicated he thought there had been a discrepancy in his trust account but couldn't remember the details of the discrepancy. On 1/28/25 at 9:30 a.m., the Administrator provided a copy of an incident report, dated 12/19/24 at 3:01 p.m., with three withdrawal slips. A review of the incident report and withdrawal slips indicated money was withdrawn from Resident B's account as follows: - On 11/30/24, Resident B withdrew fifty dollars from his account. The money was disbursed by an unknown person (signature illegible) and the witness signature indicated Qualified Medication Aide (QMA) 3. The withdrawal slip was numbered 272023. - On 12/15/24, Resident B withdrew twenty dollars from his account. The money was disbursed by LPN 2. The withdrawal slip was numbered 272060. - On an unknown date Resident B withdrew fifty dollars. The money was disbursed by the Business Office Manager and the witness signature indicated Licensed Practical Nurse (LPN) 3. The withdrawal slip was numbered 201268. Resident B's signature did not match on any of the three slips. An undated written statement indicated LPN 3 did not sign the withdrawal slips, dated 11/30/24, 12/15/24, nor the undated withdrawal slip. Signed by LPN 3. The clinical record for Resident B was reviewed on 1/28/25 at 10:02 a.m. The diagnoses included, but were not limited to, hemiplegia and hemiparesis, osteoporosis, and epilepsy. A quarterly Minimum Data Set (MDS) assessment, dated 11/5/24, indicated Resident B was cognitively intact. The facility was unable to identify the person who signed the withdrawal slips. 2. On 1/28/25 at 9:30 a.m., the Administrator provided a copy of an incident report, dated 12/19/24 at 3:01 p.m., with three withdrawal slips. A review of the incident report and withdrawal slips indicated money was withdrawn from Resident C's account as follows: - On 11/19/24, Resident C withdrew fifty dollars from her account. The money was disbursed by an unknown person (illegible signature) and the witness signature indicated QMA 3. The withdrawal slip was numbered 271993. - On 11/30/25, Resident C withdrew ten dollars from her account. The money was disbursed by an unknown person (illegible signature). The withdrawal slip was numbered 272025 - On 12/12/24, Resident C withdrew fifty dollars from her account. The disbursed by signature indicated QMA 3 and an unknown witness (illegible signature). The withdrawal slip was numbered 272064. Resident C's signatures did not match on the slips. A written statement from QMA 3, dated 12/19/24, indicated QMA 3 never gave money to Resident C, signed by QMA 3. During an interview on 1/28/25 at 11:00 a.m., the Administrator indicated, on 12/18/24, Resident C's family member notified the facility that Resident C received a delinquency letter regarding her resident trust account, and she didn't think that was correct. The facility was unable to identify the person who signed the withdrawal slips. 3. On 1/28/25 at 9:30 a.m., the Administrator provided a copy of an incident report, dated 12/19/24 at 3:01 p.m., with a withdrawal slip. A review of the incident report and withdrawal slips indicated money was withdrawn from Resident D's account as follows: - On 12/8/24, Resident D withdrew fifty dollars from his account. The money was disbursed by an unknown person (illegible signature) and an unknown witness (illegible signature). The withdrawal slip was numbered 272061. The resident/representative signature was illegible. The facility was unable to identify the person who signed the withdrawal slips. 4. On 1/28/25 at 9:30 a.m., the Administrator provided a copy of an incident report, dated 12/19/24 at 3:01 p.m., with a withdrawal slip. A review of the incident report and withdrawal slips indicated money was withdrawn from Resident E's account as follows: - On 12/14/24, Resident E withdrew twenty-five dollars from his account. The disbursed by signature indicated LPN 2 and an unknown witness (illegible signature). The withdrawal slip was numbered 272059. During an interview on 1/28/25 at 11:20 a.m., LPN 2 indicated she did not sign the withdrawal slip, dated 12/14/24, for Resident E's twenty-five dollar withdrawal. The facility was unable to identify who signed the withdrawal slip. 5. On 1/28/25 at 9:30 a.m., the Administrator provided a copy of an incident report, dated 12/19/24 at 3:01 p.m., with two withdrawal slips. A review of the incident report and withdrawal slips indicated money was withdrawn from Resident F's account as follows: - On 11/6/24, Resident F withdrew fifty dollars from his account. The money was disbursed by the Business Office Manager with an unknown witness (illegible signature). - On 12/8/24, Resident F withdrew fifty dollars from his account. The money was disbursed by an unknown person (illegible signature) with an unknown witness (illegible signature). Resident F's signatures did not match on the slips. The facility was unable to identify who signed the withdrawal slips. 6. On 1/28/25 at 9:30 a.m., the Administrator provided a copy of an incident report, dated 12/19/24 at 3:01 p.m., with two withdrawal slips. A review of the incident report and withdrawal slips indicated money was withdrawn from Resident G's account as follows: - On 12/14/24, Resident G withdrew fifty dollars from her account. The disbursed by signature indicated LPN 2 with an unknown witness (illegible signature). The withdrawal slip was numbered 272058. The facility was unable to identify who signed the withdrawal slips. During an interview, on 1/28/25 at 11:00 a.m., the Administrator indicated during an investigation into the resident trust accounts, the facility identified 6 residents with withdrawals from their resident trust accounts that didn't seem right. The staff who's signatures are on the withdrawal slips were interviewed and each of them indicated the signatures were forged. The money was replaced by the facility because it was unaccounted for. On 1/28/25 at 1:34 p.m., the Administrator provided a copy of a facility policy, titled Abuse Prohibition, Reporting, and Investigation, dated 6/2023, and indicated this was the current policy used by the facility. A review of the policy indicated it was the policy of the facility to provide an environment that was free from misappropriation of resident property. This deficient practice was corrected on 12/23/24 after the facility implemented a systemic plan of correction that included the following actions: all staff were educated to ensure process and policy for dispensing resident funds was followed with ongoing monitoring and audits. This citation relates to Complaint IN00449665. 3.1-28(a)

Based on observation, interview, and record review, the facility failed to ensure the facility was free from accident hazards for 1 of 1 observation, potentially affecting 36 of 56 self-mobile residents residing in the facility. A rubber hose used for fish tank maintenance was located on the floor in the middle of a walkway area that was used by the residents. (500 hall) Finding includes: During an observation, on 9/6/24 from 9:00 a.m. to 9:13 a.m., the following was observed on the 500-hall floor space between the resident pantry and the resident lounge area: - A dark colored rubber hose, approximately one inch in diameter and approximately 25 feet in length, was observed in the middle of the walkway that ran from the resident pantry room (on the left side of the hall) to the resident lounge (on the right side of the hall) of the 500-hall. - Approximately ten feet from the lounge area, the dark colored rubber hose was observed to be curled onto itself which raised the hose approximately two inches from the floor. - Approximately eight feet from the lounge area, the dark colored rubber hose was raised above the floor approximately three inches from the floor. - Multiple residents were observed watching television in the resident lounge. - No staff were visible in the area where the dark colored rubber hose was located. - No caution signs were visible in the hallway near where the dark colored rubber hose was located. On 9/6/24 at 9:14 a.m., LPN 2 was observed walking from the lounge area toward the nurse's station located across from the resident pantry room. During an interview at that time, LPN 2 indicated she was unsure if any caution signs should have been placed near the rubber hose to alert residents of a potential trip hazard. During an interview on 9/6/24 at 9:50 a.m., the Administrator indicated the rubber hose should not have been placed in the middle of the walkway on the 500-hall. The hallway was to be kept clear of any potential tripping hazards. Caution signs should have been in place to alert residents of a potential tripping hazard. On 9/6/24 at 1:44 p.m., the Director of Nursing Services provided a document that indicated there were 36 of 56 self-mobile (ability to move independently without staff assistance) residents who had access to the 500-hall. On 9/6/24 at 2:16 p.m. the Administrator provided a copy of the American Senior Communities General Health and Safety Policies, dated 12/2023, and indicated it was the current policy in use by the facility. A review of the policy indicated, .all recognized safety and health hazards shall be eliminated or controlled as quickly as possible .must be kept free and clean of extraneous materials that could create a health hazard or cause an accident . 3.1-45(a)(1)

Based on interview and record review, the facility failed to ensure that written notification was provided to the Office of the State Long-Term Care Ombudsman for 1 of 4 residents reviewed for written transfer and discharge notification. (Resident 39) Finding includes: On 9/5/24 at 1:05 p.m., Resident 39's clinical record was reviewed. The diagnoses include, but were not limited to, delusional disorder, severe dementia with agitation, and mood disturbance. The Quarterly Minimum Data Set (MDS) assessment, dated 8/1/24, indicated Resident 39 was severely cognitively impaired. 1. The ASC (American Senior Communities) Hospital ER (emergency room /Department) Transfer Form, dated 3/18/24, indicated Resident 39 was transferred to the hospital Emergency Department on 3/18/24 at 8:06 a.m. The transfer was a facility-initiated transfer. 2. The ASC Hospital ER Transfer Form, dated 3/19/24, indicated Resident 39 was transferred to a psychiatric hospital on 3/19/24 at 2:30 p.m. The transfer was a facility-initiated transfer. 3. The ASC Hospital ER Transfer Form, dated 4/27/24, indicated Resident 39 was transferred to a psychiatric hospital on 4/27/24 at 7:40 p.m. The transfer was a facility-initiated transfer. 4. The ASC Hospital ER Transfer Form, dated 5/22/24, indicated Resident 39 was transferred to the ER and then transferred to a psychiatric facility on 5/22/24 at 2:30 p.m. The transfer was a facility-initiated transfer. The clinical record lacked documentation that the Office of the State Long-Term Care Ombudsman was notified, in writing, that Resident 39 had been transferred to another facility in March 2024, April 2024, and May 2024. During an interview on 9/10/24 at 12:31 p.m., the Social Service Director indicated Resident 39's transfer to the Emergency Department and to a psychiatric facility was a facility-initiated transfer. The Office of the State Long-Term Care Ombudsman had not been notified of Resident 39's facility-initiated transfers to another facility in March 2024, April 2024, and May 2024. During an interview on 9/10/24 at 1:00 p.m., the Administrator indicated the facility lacked a specific policy regarding the Office of the State Long-Term Care Ombudsman notification of a resident's facility-initiated transfer to another facility. 3.1-12(a)(6)(A)

Based on observation, interview, and record review, the facility failed to ensure reasonable accommodation of needs for 1 of 8 residents observed. A call light was not within reach. (Resident 86) Finding includes: On 9/10/24 at 1:45 p.m., observed Resident 86 in bed. Resident 86's call light was hanging over the bed and was on the floor next to the residents bed, out of the reach of the reach of the resident. During an interview at that time, the Assistant Director of Nursing (ADON) indicated the call light should have been within the reach of the resident. On 9/10/24 at 11:52 a.m., the DON provided a policy titled Resident [NAME] of Rights, dated 12/2017, and indicated it was the current policy being used by the facility. A review of the policy indicated, .(b. the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the community . 3.1-3(v)(1)

Based on interview and record review, the facility failed to ensure an accurate Minimum Data Set (MDS) assessment was completed for 2 of 4 residents reviewed for accuracy of MDS assessments. Falls were not coded correctly. (Resident 35, Resident 92) Findings include: 1. The clinical record of Resident 35 was reviewed on 9/5/24 at 1:45 p.m. The diagnoses included, but were not limited to, Parkinson's disease, unsteadiness on feet, repeated falls, generalized muscle weakness, syncope and collapse, and difficulty in walking not. A Fall Event, dated 7/9/24, indicated an unwitnessed fall. Resident 35 had left shoulder pain that required x-rays to rule out fracture. A Quarterly MDS assessment, dated 8/7/24, indicated Resident 35 had not had any falls since their prior MDS assessment, a Quarterly MDS assessment, dated for 5/10/24. During an interview on 9/9/24 at 10:50 a.m., the MDS Coordinator indicated the MDS assessment, dated 8/7/24, should have indicated Resident 35 had experienced falls. 2. The clinical record of Resident 92 was reviewed on 9/5/24 at 1:03 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, unspecified dementia, generalized muscle weakness, and age-related physical debility. A Fall Event, dated 7/7/24, indicated a witnessed fall where Resident 92 stood and fell close to a nursing station. A Fall Event, dated 7/13/24, indicated a witnessed fall where Resident 92 stood from her chair and fell . A Fall Event, dated 7/21/24, indicated an unwitnessed fall where Resident 92 was found by staff sitting on the floor of their room. A Significant Change MDS assessment, dated 7/22/24, indicated Resident 92 had not had any falls since their prior MDS assessment, a Significant Change assessment, dated for 5/19/24. During an interview on 9/9/24 at 9:46 a.m., the MDS Coordinator indicated the MDS assessment, dated 7/22/24, should have indicated Resident 92 had experienced falls. During an interview on 9/9/24 at 10:50 a.m., the MDS Coordinator indicated the facility followed RAI (Resident Assessment Instrument) guidelines for MDS assessments. 3.1-31(d)

Based on observation, interview, and record review, the facility failed to provide services to a resident with an ulcer on her right heel for 1 of 3 residents reviewed for pressure ulcers. (Resident 86) Finding includes: On 9/6/24 at 10:15 a.m., observed Resident 86's right heel to have an uncovered wound. The area was not wrapped with gauze (a protective covering). On 9/9/24 at 9:33 a.m., observed Resident 86's right heel. The wound on the right heel was observed to be uncovered. On 9/9/24 at 11:22 a.m., observed the wound on Resident 86's right heel to not be wrapped in gauze. On 9/10/24 at 10:30 a.m., the clinical record for Resident 86 was reviewed. The diagnosis, included but was not limited to, type II Diabetes Mellitus. A Quarterly Braden Score (a risk assessment tool that predicts the likelihood of developing pressure ulcers), dated 8/15/24 indicated Resident 86 had a very high risk for pressure ulcers. A Physicians Order, dated 8/27/24, indicated cleanse right heel with normal saline, pat dry, apply collagen to wound bed, cover with board gauze every three days. During an interview on 9/9/24 at 11:25 a.m., the Assistant Director of Nursing indicated the wound on Resident 86's heel should have been wrapped and was unsure why it was not wrapped during the observations. On 9/8/24 at 3:45 p.m., the Executive Director provided a policy titled Skin Management Program, dated 5/2022, and indicated it was the current policy being used by the facility. A review of the policy indicated Purpose: To promote the prevention of pressure ulcers/injury development; promote the healing of existing pressure ulcers and prevent development of additional pressure ulcer injury.4. preventative measures and treatments will be implemented as appropriate. 3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a treatment cart was locked and secured for 1 of 1 random observations. (Memory Care Treatment Cart) Findings include: On 9/6/24 from 9:00 a.m. to 9:15 a.m., during medication administration pass observation, on the memory care unit, observed an unlocked treatment cart with no staff present in the area. Multiple residents were observed wandering around the unit. The treatment cart was easily opened. Inside the unlocked cart, the following medicated treatments, included but were not limited to: - Two tubes containing 30 grams of Nystatin Topical Cream (a medicated cream was used to treat fungal or yeast infections on your skin). The tube of medicated cream indicated .keep out of reach . - One tube containing one ounce of vagisil cream (anti-itch medication). The label on the tube of medicated cream indicated .keep out of reach . - One fourteen ounce jar of Aquaphor healing ointment. The label on the ointment indicated .keep out of reach . During an interview on 9/6/24 at 9:10 a.m., LPN 3 indicated the treatment cart should have been locked. During an interview on 9/6/24 at 9:39 a.m., the Executive Director indicated the treatment cart should have been locked. On 9/6/24 at 1:44 p.m., the DON provided a document that indicated there were 20 of 25 cognitively impaired self-mobile residents residing on the Memory Care Unit. On 9/6/24 at 9:52 a.m., the Director of Nursing provided a policy titled Storage and Expiration Dating of Medications and Biologicals, dated 8/1/24, a review of the policy indicated .5. Facility should ensure that all 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. 3.1-25(m)

Based on observation, record review, and interview, the facility failed to ensure a homelike atmosphere for 1 of 8 rooms observed for a homelike setting. Drywall was missing. (room [ROOM NUMBER], Resident 86) Finding included: During a tour of the facility on 9/4/24 at 10:30 a.m., observed a six inch by six inch hole in room [ROOM NUMBER]. The hole was in the drywall above the residents room light. The hole was observed to have exposed wires. During an interview at that time, the Resident 86 who resided in that room was unaware of how long the hole with exposed wires had been there. On 9/5/24 at 9:00: a.m., observed the same. On 9/6/24 at 10:30 a.m., observed the same. On 9/9/24 at 9:57 a.m., observed the same. During an interview on 9/9/24 at 10:01 a.m., the Executive Director indicated she was not aware of the hole in room [ROOM NUMBER]. The Executive Director indicated the facility did not currently have a maintenance director. 3.1-19(f)

Based on observation, interview, and record review, the facility failed to provide care and services to a resident with a suprapubic catheter (a urinary catheter that is inserted through the skin and advanced to the bladder to drain urine) for 1 of 3 residents reviewed. (Resident C) Finding includes: During an interview on 11/29/23 at 9:41 a.m., Resident C indicated the catheter bag should have been hung under the wheelchair. At that time, observed the top half of a urinary drainage bag sticking out of a tight pocket on the back of Resident C's wheelchair. The bottom half of the drainage bag appeared to have been stuffed into the pocket so the urine only be emptied into the top half of the drainage bag. The top half of the drainage bag appeared to be full and was connected to a dense, clear plastic tube that extended from the catheter drainage bag on the back of the wheelchair, down and under the wheelchair and to Resident C's left pant leg. The length of the plastic tube from the drainage bag to Resident C's left pant leg was also full of yellow fluid. Resident C was not sure how long ago the catheter bag was placed in the back pocket of the wheelchair but could remember it was placed there by staff that provided assistance earlier that morning. Resident C was not able to remember if she had been treated for a urinary tract infection recently but was tested for a urinary tract infection. During an interview on 11/29/23 at 10:04 a.m., QMA 1 (Qualified Medication Aide) indicated Resident C's catheter bag should have been placed below the Resident C's bladder. QMA 1 was not sure how long the catheter bag was in the back pocket of Resident C's wheelchair. During an interview on 11/29/23 at 10:05 a.m., CNA 1 (Certified Nursing Aide) indicated Resident C's catheter bag was placed in the back pocket of the wheelchair by night shift. Night shift ended at 7:00 a.m. The catheter bag was like that when CNA 1 came on to work. The clinical record for Resident C was reviewed on 12/1/23 at 10:28 a.m. The diagnoses included, but were not limited to, breast cancer, neurogenic bladder, and atrial fibrillation. A quarterly MDS (Minimum Data Set) assessment, dated 10/29/23, indicated Resident C was severely cognitively impaired and had a urinary catheter. A progress note, dated 11/7/23 at 11:49 a.m., indicated new orders for a urinalysis with culture and sensitivity was ordered. A nurse practitioner progress note, dated 11/8/23 at 5:48 a.m., indicated on 11/7/23, a urinalysis with culture and sensitivity was ordered due to behaviors. A social services note, dated 11/8/23 at 9:48 a.m., indicated Resident C was putting feces on her face, hair, and mouth, and cursing and yelling at staff. Attempted to clean Resident C three times and was successful. Resident has order for a urinalysis to check for infection. The clinical record lacked a urinalysis being collected on 11/7/23. A progress note, dated 11/10/23 at 1:35 p.m., (3 days after the urinalysis was initially ordered) indicated collected urine correctly by foley catheter. A lab result, dated 11/13/23 at 5:38 a.m., indicated a urinalysis was collected on 11/10/23. Three or more organisms were identified suggesting contamination at collection. Suggest repeat culture. Verified 11/11/23 at 2:07 p.m. The lab was first printed at the facility on 11/13/23 at 5:38 a.m. A lab result, dated 11/16/23 at 5:19 a.m., indicated a urinalysis was collected on 11/14/23 (7 days after the urinalysis was initially ordered). Three or more organisms were identified suggesting contamination at collection. Suggest repeat culture. Verified on 11/15/23 at 10:51 a.m. The lab was first printed at the facility on 11/16/23 at 5:19 a.m. A physician's order initiated on 11/17/23, indicated repeat urinalysis with culture and sensitivity. The physician's order had not been completed or discontinued as of 12/1/23. On 12/1/23 at 1:10 p.m., the facility was unable to provide a policy by survey exit. This tag relates to Complaint IN00416420. 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to provide care and services for a resident that required continuous g-tube (gastric tube that is inserted into the skin and advanced to the stomach used to provide nutrients) feedings for 1 of 2 residents reviewed. (Resident B) Finding includes: On 11/29/23 at 9:49 a.m., observed Resident B laying in bed with the head of bed elevated. Next to Resident B's bed, at the top of a pole approximately 6 feet tall, was a hard plastic bottle with approximately 900 ml (milliliters) of tan liquid. The label on the plastic bottle indicated Glucerna 1.5 (a tube feeding used for residents with diabetes), dated 11/28/23 at 8:30 a.m., (approximately 25 hours before observation), and administer 50 ml per hour. The hard plastic bottle held 1000 ml of feeding. Next to the bottle was a clear plastic bag approximately half full with clear liquid. The label on the clear bag indicated Resident B and 45 ml per hour. There was a thin tube coming from the bottom of the plastic bag and plastic bottle that came together and down into a g-tube pump (mechanical pump that administers tube feeding and water flushes at a rate and in intervals ordered by the physician. The pump is set by the nurse). The pump's screen indicated the feeding rate was set to 50 ml per hour and the water flush was set to 45 ml per hour. A thin tube coming from the bottom of the pump extended under Resident B's blanket. On 11/29/23 at 10:59 a.m., Resident B was lying in bed with the head of the bed elevated. Resident B's g-tube feeding was turned on and feeding was being administered. CNA 1 (Certified Nursing Aide) used the bed control and laid Resident B to a flat position. At that time, CNA 2 was standing approximately 5 feet from Resident B, and indicated Resident B's g-tube feeding should have been placed on hold before she was laid flat. Then CNA 1 indicated a nurse had to put the g-tube feeding on hold. With Resident B still lying flat, CNA 1 stood next to Resident B's bed and CNA 2 left the room to get a nurse. After approximately 60 seconds, CNA 2 returned with the ADON (Assistant Director of Nursing). The ADON indicated Resident B's g-tube feeding should have placed on hold before laying the bed to a flat position. The ADON walked to the g-tube pump to place the g-tube feeding on hold. Then, the ADON pressed a button, on the pump, to flush the feeding tube with water. After approximately 15 seconds, the flush completed. The ADON placed the pump on hold and disconnected the feeding tube from Resident B's g-tube. At that time, the ADON indicated Resident B should not have received a water flush while she was lying flat. The feeding should have been placed on hold. The ADON was not sure why the date on the plastic bottle indicated the bottle was opened and hung for approximately 25 hours and only 100 ml of feeding was used from the bottle. According to the administration rate the bottle would have ran out approximately 5 hours ago. The feeding bottle and bag of water flush should have been labeled with Resident B's name, the date and time the bottle was opened and hung on the pole, what was being administered, the prescribed feeding rate, and the nurse that hung the bottle should have initialed the label. The ADON indicated she would ask the nurses who hung the feeding bottle. On 11/29/23 at 11:21 a.m., the ADON entered Resident B's room carrying a new bottle of tube feeding, a new clear bag with the thin tubes and indicated she could not find any nurse that opened and hung Resident B's bottle of tube feeding, dated 11/28/23 at 8:30 a.m., the ADON opened and hung a new bottle of tube feeding and bag of water flush. On 12/1/23 at 8:20 a.m., observed Resident B's g-tube feeding bottle that was hung on a pole next to the bed. The bottle, dated 12/1/23 at 6:45 a.m. (approximately 1.5 hours prior to observation), indicated Glucerna 1.5 administered at 50 ml per hour. The tube feeding bottle was full with 1000 ml tan fluid. Next to the hard plastic bottle of tube feeding was a clear plastic bag, dated 12/1/23 at 6:45 a.m. The bag was filled to the lid with clear fluid. The tube feeding pump was turned on and tube feeding was moving down the tube toward Resident B. A piston syringe (large syringe used to administer water flushes and medication though the g-tube) was sitting on Resident B's bedside table. The piston syringe was not dated. At that time, LPN 1 (Licensed Practical Nurse) entered Resident B's room. LPN 1 was not able to explain why Resident B's g-tube feeding was opened and hung, on 12/1/23 at 6:45 a.m., but the bottle of feeding and water flush bag were both full according to the manufacturer's label on the bottle. LPN 1 indicated according to the date and time the bottle was opened and hung, the bottle should have had approximately 925 ml remaining in the bottle. LPN 1 brought an unopened bottle of Glucerna 1.5 to compare the amount of feeding in the opened bottle with the unopened bottle. When LPN 1 compared the bottles next to each other, both bottles appeared to be filled with the same amount of fluid. LPN 1 was not sure if or when the g-tube feeding pump had been serviced to ensure the pump worked properly. The clinical record for Resident B was reviewed, on 11/29/23 at 12:14 p.m. The diagnoses included, but were not limited to, subarachnoid hemorrhage, diabetes, aphasia (difficulty communicating effectively), and dysphagia (difficulty swallowing effectively). A quarterly MDS (Minimum Data Set) assessment, dated 10/20/23, indicated Resident B was severely cognitively impaired and received tube feeding. A current physician's order initiated, on 10/9/23, indicated Glucerna 1.5 administered at 50 ml per hour. A current physician's order initiated, on 10/9/23, indicated flush g-tube with 45 ml every hour. A current physician's order initiated, on 7/26/23, indicated Resident B could not have anything by mouth. On 11/30/23 at 8:30 a.m., the DON (Director of Nursing) provided a copy of a facility document, titled Enteral Tube Procedure, dated 1/2010, and indicated this was the current skills competency for a licensed nurse. A review of the document indicated maintain the head of the bed at 30 degrees at all times. 3.1-44(a)(2)

Based on observation, interview, and record review, the facility failed to ensure that a glucometer (machine used to test a resident's blood sugar by blood drop), that was used for multiple residents, was disinfected before entering a resident's room to test the resident's blood sugar for 1 of 1 observations. (Resident B, QMA 1) Finding includes: On 11/29/23 at 1:07 p.m., observed QMA 1 (Qualified Medication Aide) take a glucometer, test strip (a small strip inserted into the glucometer where a blood drop is applied so the glucometer can give a blood sugar result), alcohol wipe, and a lancet (small device used to puncture the skin so a blood drop can be collected) out of the medication cart on the 100 hall. QMA 1 gathered the supplies and walked away from the cart toward resident rooms. QMA 1 entered Resident B's room and indicated she entered Resident B's room to check Resident B's blood sugar with the supplies she carried. QMA 1 indicated she last disinfected the glucometer around 9:00 a.m. when she checked the last blood sugar. QMA 1 then exited Resident B's room and walked back to the medication cart on 100 hall. QMA 1 opened a germicidal bleach wipe and wiped the glucometer until the entire glucometer was wet. QMA 1 set the glucometer down directly on the medication cart surface without a barrier. After waiting approximately 4 minutes (appropriate waiting time for the germicidal bleach wipe), QMA 1 indicated she was ready to check Resident B's blood sugar now. The glucometer that QMA 1 took to Resident B's room to check Resident B's blood sugar was used for all the residents, on the 100 hall, that required a finger to be punctured to collect a blood drop. At that time, the ADON (Assistant Director of Nursing) indicated the glucometer should have been placed on a clean barrier after the glucometer was disinfected with the germicidal bleach wipe, the glucometer should have been disinfected before QMA 1 walked into Resident B's room when QMA 1 was initially going to check Resident B's blood sugar. During an interview on 11/30/23 at 11:47 a.m., the DON (Director of Nursing) indicated there were 4 residents that resided on the 100 hall that required a finger stick, with a lancet, to collect the drop of blood for the glucometer reading. On 11/30/23 at 8:30 a.m., the DON provided a copy of a document, titled Blood Glucose Meter Cleaning/Disinfecting and Testing, dated 7/2011, and revised, on 10/17/23. A review of the document indicated place a paper towel, plastic cup, or other clean barrier on a hard surface. Wipe entire surface of the glucometer with a germicidal wipe approved for use on a glucometer and allow the surface to remain wet for 3 minutes. Place cleaned glucometer on the paper towel, in the plastic cup, or on the clean barrier. Allow the glucometer to completely dry. This tag relates to Complaint IN00416420. 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to date and label oxygen tubing for 4 of 5 residents reviewed for oxygen. (Resident 148, Resident 63, Resident 36, Resident 146) Finding includes: 1. During an interview on 9/26/23 at 8:55 a.m., Resident 148 indicated he constantly needed the oxygen delivery from the machine and nasal cannula. On 9/26/23 at 11:00 a.m., Resident 148 was observed in bed in his room receiving 2 liters of oxygen via a nasal cannula from an oxygen concentrator machine (a machine that takes in air from the room to filter out nitrogen in order to provide higher amounts of oxygen for oxygen therapy). The oxygen humidifier bottle and oxygen tubing were not labeled with a time or date. On 9/27/23 at 8:20 a.m., Resident 148 was observed in his room receiving 2 liters of oxygen via a nasal cannula from an oxygen concentrator. The oxygen humidifier bottle and oxygen tubing were not labeled with a time or date. On 9/28/23 at 1:30 p.m., Resident 148's clinical record was reviewed. The physician's orders included, but were not limited to: - 2 liters oxygen per nasal cannula, dated 9/5/23. - Change oxygen tubing and humidity, clean concentrator and filter, once a day on Sunday, dated 9/6/23. 2. On 9/26/23 at 12:19 p.m., Resident 63 was observed in his. The resident was sitting in his wheelchair, receiving 2 liters of oxygen via a nasal cannula from an oxygen concentrator, The oxygen humidifier bottle and oxygen tubing were not labeled with a time or date. On 9/27/23 at 8:30 a.m., Resident 63 was observed in room receiving 2 liters of oxygen via a nasal cannula from an oxygen concentrator. The oxygen humidifier bottle and oxygen tubing were not labeled with a time or date. 3. On 9/26/23 at 1:35 p.m., Resident 36 was observed in bed in his room receiving 2 liters of oxygen via a nasal cannula from an oxygen concentrator machine. The oxygen humidifier bottle and oxygen were not labeled with a time or date. On 9/27/23 at 8:44 a.m., Resident 36 was observed in his room receiving 2 liters of oxygen via a nasal cannula from an oxygen concentrator. The oxygen humidifier bottle and oxygen tubing were not labeled with a time or date. 4. On 9/26/23 at 1:53 p.m., Resident 146 was observed in bed in his room receiving 2 liters of oxygen via a nasal cannula from an oxygen concentrator machine. The oxygen humidifier bottle and oxygen tubing were not labeled with a time or date. On 9/27/23 at 8:15 a.m., Resident 146 was observed in his room receiving 2 liters of oxygen via a nasal cannula from an oxygen concentrator, The oxygen humidifier bottle and oxygen tubing were not labeled with a time or date. On 9/27/23 at 9:00 a.m., Resident 146's clinical record was reviewed. The physician orders included, but were not limited to: - Oxygen at 2 liters per nasal cannula, every shift, dated 9/14/23. - Change oxygen tubing and humidity, clean concentrator and filter, once a day on Sundays, dated 9/14/23. On 9/27/23 at 8:40 a.m., License Practical Nurse (LPN) 2, indicated she did not see a date on oxygen tubing for Resident 146 and Resident 148, but it was changed every Sunday. On 9/28/23 at 11:20 a.m., the Director of Nursing (DON) indicated the oxygen tubing should have been labeled. On 9/28/23 at 10:20 a.m., the Director of Nursing, provided a copy of facilities Oxygen Therapy and Devices policy, undated, and indicated it was the currently used by the facility. A review of policy indicated, .Nasal Cannula, Change out weekly and PRN [as needed] . Place in a labeled bag when not in use . 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to ensure a resident centered comprehensive care plan was developed for 1 of 3 residents reviewed for wanderguards and 1 of 5 residents reviewed for oxygen therapy. A care plan for wanderguards and C-PAP machine use was not developed. (Resident 78, Resident 83) Findings include: 1. On 9/27/23 at 11:41 a.m., Resident 78 was observed in the activity room. Resident 78 was observed wearing wanderguard device (a device allows an individual the freedom to move about the unit yet remain safe if they attempt to leave the area) on his right ankle. On 9/27/23 at 12:54 p.m., Resident 78's clinical record was reviewed. The diagnosis included, but was not limited to, dementia. Physician orders included, but were not limited to, wanderguard .start date: 8/4/23 and no end date noted. The August 2023 MAR/TAR (Medication Administration Record/Treatment Administration Record) indicated starting on 8/4/23 Resident 78's wanderguard was in position on a daily basis. The September 2023 MAR/TAR indicated Resident 78's wanderguard was in position on a daily basis. The Admission Minimum Data Set (MDS) assessment, dated 7/28/23, indicated Resident 78 was severely cognitively impaired. The clinical record lacked a care plan related to Resident 78's wanderguard. Resident 78's Elopement Risk Assessment, dated 8/7/23, indicated Resident 78 was assigned a wanderguard. During an interview on 9/28/23 at 3:45 p.m., the Memory Care Coordinator indicated Resident 78 had been exhibiting exit seeking behaviors. On 8/4/23, the physician ordered a wanderguard monitor for Resident 78. The care plan should have been updated at the time of the physician's order for the placement of the wanderguard. 2. On 9/26/23 at 10:34 a.m., Resident 83 was observed in his room and resting on his bed. A C-PAP machine (continuous positive airway pressure therapy system) was observed at the bedside. The machine was turned to the on position with the tubing going from the machine to the C-PAP mask. The C-PAP mask was in place on Resident 83's face. On 9/26/23 at 11:16 a.m., the same was observed. On 9/28/23 at 3:43 p.m., Resident 83's clinical record was reviewed. The diagnoses included, but were not limited to, dementia, sleep apnea (potentially serious sleep disorder in which breathing repeatedly stops and starts), and asthma. Physician orders included, but were not limited to, C-PAP machine, setting at 11.0, on at bedtime and off in the morning, start date: 7/19/23 and no end date noted. The July 2023 MAR/TAR (Medication Administration Record/Treatment Administration Record) indicated starting on 7/19/23 Resident 83 utilized the C-PAP treatment on a daily basis. The August 2023 MAR/TAR indicated Resident 83 utilized the C-PAP treatment on a daily basis. The September 2023 MAR/TAR indicated Resident 83 utilized the C-PAP treatment on a daily basis. The Quarterly Minimum Data Set (MDS) assessment, dated 9/12/23, indicated Resident 83 was moderately cognitively impaired. The clinical record lacked a care plan related to Resident 83's C-PAP use. During an interview on 9/28/23 at 3:50 p.m., Resident 83 indicated he had used the C-PAP machine for a long time and was able to independently put the mask on and take it off as needed. During an interview on 9/28/23 at 3:55 p.m., the Memory Care Coordinator indicated Resident 83's physician ordered the C-PAP machine on 7/19/23 due to sleep apnea. Resident 83 had been using the C-PAP machine since that time. Resident 83 was able to independently put the C-PAP mask on and take it off. The care plan should have been updated when the physician ordered the C-PAP machine. On 9/28/23 at 4:00 p.m., the Memory Care Coordinator provided a copy of the IDT (Interdisciplinary team) Comprehensive Care Plan Policy, dated August 2023, and indicated it was the current policy in use by the facility. A review of the policy indicated, .the care plan must include measurable goals and resident specific interventions based on resident needs and preferences to promote the resident's highest level of functioning including medical, nursing, mental, and psychosocial well-being .care plan problems, goals, and interventions musts be reviewed and revised by the interdisciplinary team periodically . 3.1-35(a)

Based on record review and interview, the facility failed to ensure a resident was free being pushed down by an angry resident which resulted in a fall and a [MEDICAL CONDITION] for 1 of 3 residents who met the criteria for review of abuse. (Resident 60) Findings include: The clinical record of Resident 60 was reviewed on 7/27/17 at 10:33 a.m. [DIAGNOSES REDACTED]. She was admitted to the facility on [DATE]. An admission Minimum Data Set assessment dated [DATE], indicated Resident 60 was severely impaired in her ability to make decisions. A care plan for the resident, dated 5/31/17 and current through 8/31/17, indicated Resident 60 experienced short and long-term memory deficit with impaired decision making. Nurses' notes indicated the following: 5/31/17 at 11:41 a.m., Resident adjusting well to new environment, pleasant, socializing with staff and other residents. 6/1/17 at 11:36 a.m., Resident moved to a different room due to to needing to be closer to the nurses' station. 6/5/17 at 4:30 p.m., Resident adjusting well and is getting along well with her new roommate (Resident 53). 6/8/17 at 11:46 a.m., Resident's niece stated that the resident seemed increasingly confused and that she stated that she believed staff was in her room taking photos of her belongings . 6/8/17 at 2:16 p.m., Experiencing some confusion with hers and roommate's side of room. Res(ident) is redirected to her side and belongings . 6/8/17 at 7:00 p.m., Resident was found lying on floor on back in room. Res(ident) stated she had been pushed down by roommate (Resident 53) .Res(ident) complained of hip pain and stated she was not able to move leg. Res(ident) stated she could not walk or bear weight exhibiting guarding behavior to left leg .resident sent out to hospital . 6/12/17 at 11:54 p.m., Resident arrived to the facility via ambulance .alert to self and place able to verbalize pain and some needs surgery 3 days ago for Lt (left) femur fx (fracture) .on comfort care only (related to) [MEDICAL CONDITION]. 6/21/17 at 9:42 a.m., Res(ident) has had significant decline in condition in last 16 hrs (hours) 6/21/17 at 2:58 p.m., Res(ident) RHC'd (respirations have ceased) at 2:48 p.m. The clinical record of Resident 53 was reviewed on 7/28/17 at 9:08 a.m. [DIAGNOSES REDACTED]. A Minimum Data Set Assessment, dated 4/24/17, indicated Resident 53 was moderately impaired in her ability to make decisions and had had no behaviors during the assessment period. A nurse's note, dated 6/8/17 at 9:03 p.m., indicated, Res(ident) in room with roommate the aids stated they heard yelling and when entered the room found other resident (Resident 60) lying on back on floor. When roommate (Resident 60) asked how she fell she stated she had been pushed. Resident stated, 'Well she shouldn't have been getting in my closet' . On 6/9/17, the facility filed an Incident Report (Incident Number 109) with the Indiana State Department of Health. The report indicated, .(Resident 60) was going through the closet of (Resident 53). (Resident 53) then became agitated and pushed (Resident 60) causing her to fall. (Resident 60) was confused regarding the incident and stated that she was pushed and fell at the same time. (Resident 53) would not speak much of the incident other than to say that the other resident should not be going through her belongings .(Resident 60) complained of leg pain. MD notified and order to send resident to ER (emergency room ) for further evaluation .psych notified . A physician's note, dated 6/9/17 at 11:51 a.m., indicated, This provider was contacted in regards to recent episode of aggression and agitation. History of agitation is noted, but episodes are infrequent. Aggression appears to be an isolated incident at this time . On 7/24/17 at 11:00 a.m., the Executive Director provided a policy dated 11/2016, titled Abuse Prohibition, Reporting, and Investigation, and indicated it was the policy currently used by the facility. The policy indicated, It is the policy of (name of facility corporation) to protect residents from abuse including physical abuse .Definitions of Abuse Physical Abuse - a willful act against a resident by another resident, staff or other individuals. Examples: .shoving .Policy/Procedure: 1. (name of facility corporation) will not permit residents to be subjected to abuse by anyone, including .other residents . 3.1-27(a)(1)

Based on observation, interview, and record review, the facility failed to ensure 2 residents who entered the facility without a pressure ulcer did not develop a pressure ulcer, in that a resident did not receive pressure relief to the heels and developed unstageable deep tissue injuries (Resident #108) and a resident was not turned and repositioned and developed a pressure ulcer on the right hip (Resident #40) for 2 of 2 residents reviewed for pressure ulcers. Findings include: 1. The clinical record review of Resident #108, completed 5/29/15 at 1:08 p.m., indicated the resident had [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE], following repair of a fractured left hip. An Admission Nursing Assessment completed 9/20/14, assessed the resident as having lower leg weakness and no pressure ulcers. A written care plan dated 9/26/14, with a goal date of 6/26/15, indicated the resident was at risk for skin breakdown due to impaired/decreased mobility, diabetes, [MEDICAL CONDITION], and medication side effects. Interventions dated 9/26/14, included but were not limited to, assess and document skin condition weekly and as needed, pressure reducing/redistribution cushion in chair/wheelchair and mattress on the bed, and turn and reposition at least every 2 hours. A Quarterly Minimum Data Set (MDS) assessment completed 2/19/15, assessed the resident as requiring extensive assistance of 2 or more staff members for bed mobility and transfers. The resident was assessed as having a BIMS (Brief Interview for Mental Status) of 15 out of 15, indicating no cognitive impairment, having a risk for the development of pressure ulcers, and having an unstageable pressure ulcer. Section M, Skin Conditions, of the MDS assessment did not indicate the resident was receiving a turning and repositioning program and did not indicated pressure ulcer care was being provided. A physician's orders [REDACTED]. The special instructions in the physician's orders [REDACTED]. A New Skin Event, started on 1/22/15 at 8:50 a.m., indicated the resident had a new open area on the right heel measuring 0.4 x 2.0 x < (less than) 0.1. The form indicated the measurements were L (length) x W (width) x D (depth) and were recorded in centimeters. The wound was described as white in color with a dusky wound bed and had a clear odorless drainage. A physician's orders [REDACTED]. Re-eval (re-evaluate) in 1 week. The web site smith-nephew.com, accessed on 6/4/15 at 10:50 a.m., indicated skin prep was a liquid film-forming dressing which provides a protective interface and may reduce friction during the removal of tape, may reduce irritation from contact with body wastes, and should only be used on intact skin. The next documented evaluation or observation of the open area was on 1/26/15, 4 days after the open area was first noted, by the IDT (Interdisciplinary Team). The IDT progress note indicated the open area was on the left heel, had a moderate amount of serosanguineous (yellow with small amounts of blood) drainage, and the surrounding skin was moist and white. The progress note indicated the resident had increased swelling in both legs and was repositioned with legs elevated and pillows for pressure relief. The progress note indicated the physician would be contacted for further orders. The Pressure Wound Skin Evaluation Report dated 1/26/15 at 2:41 p.m., indicated the wound measured 0.3 x 2.0 x 0.1. The area was staged as a Stage II, described as partial thickness loss of skin layers that presents clinically as an abrasion, blister or shallow crater. The most severe tissue type was described as slough (yellow or white tissue adhering to the ulcer bed), had a minimum amount of serosanguineous drainage, and no odor. A physician's orders [REDACTED]. Apply silver alginate (an agent used to debride, remove, dead or dying tissue) to open area, protect w/Allevyn Heel Foam (a foam dressing used to absorb drainage from wounds), secure with kerlix (rolled gauze) daily and PRN (as needed) soilage/dislodgement. A nursing progress note dated 1/31/15 at 9:49 a.m., indicated the resident was up in the main dining room eating a meal. .Dressing to LT (left) heel OA (open area) CDI (clean dry intact The progress notes lacked documentation of the implementation of pressure relieving measures. A Pressure Wound Skin Evaluation Report dated 2/2/15 at 7:55 a.m., indicated the wound, present since 1/22/15, to the right heel, was now considered unstageable as a deep tissue injury was suspected. The National Pressure Ulcer Advisory Panel (NPUAP) described a deep tissue injury as, a pressure related injury to subcutaneous tissues under intact skin. The measurements of the wound were 3.2 x 0.8 x 0.5, with tunneling (tissue destruction underlying intact skin along wound margins using a clock method to describe direction) of 0.5 cm located at 6 o'clock. The measurements indicated an increase in length and depth from the measurements on 1/26/15. The wound was described as purple/maroon intact skin on Achilles, having purulent drainage, foul odor, and the area around the wound was described as soft and mushy and warm to touch. The IDT progress note for 2/2/15, indicated the physician was notified of the wound on the right heel having signs and symptoms of infection. The notes indicated the resident complained of pain during the treatment to the heel and received pain medication as needed. The swelling of the lower legs was noted to be decreased, and the resident was repositioned with legs elevated and pillows for pressure relief. A written plan of care dated 2/2/15, 11 days after the pressure ulcer was first noted, indicated the resident had a pressure ulcer described as a deep tissue injury to the right heel. Interventions included assess for pain and treat as needed, notify physician of unrelieved/worsening of pain, assess wound weekly documenting measurements and description, notify physician of worsening or no change in wound or for signs of infection, encourage resident to eat 75% (percent) of meals, pressure reducing/redistribution cushion in chair, wound healing vitamins as ordered, and observe for signs of infection including redness, pain, malodorous drainage, fever, or increase in size/depth of wound. The care plan lacked repositioning with legs elevated and pillows for pressure relief. A physician's orders [REDACTED]. apply (sic) foam heel support wrap with kerlix and secure with tape. Change daily and PRN (as needed) for soilage and dislodgement. The resident was seen on 2/5/15, in the facility by the physician and an order was received to soak the wound (not designated as the left or right heel) in warm soapy water for 15-20 minutes, cleanse with N/S, apply Santyl, apply a non-adherent [MEDICATION NAME] pad, and wrap with kerlix daily and as needed. The physician's progress note indicated the wound started as a pressure blister on 1/22/15 and had developed into a deep tissue injury with [MEDICAL CONDITION] (an potentially serious bacterial skin infection). A physician's orders [REDACTED]. A Pressure Wound Skin Evaluation Report dated 2/9/15 at 4:21 p.m., indicated the wound, present since 1/22/15, to the right heel, was now considered unstageable and had necrotic (dead) tissue in the wound bed. The measurements were 4.1 x 7.4 and depth was indeterminate. The wound bed was described as purple/black and had minimal serosanguineous drainage with a slight odor. The area around the wound was described as intact and a dusky white color. A Pressure Wound Skin Evaluation Report dated 2/16/15 at 1:44 p.m., indicated the wound to the right heel measured 7 x 6 and the depth was indeterminate. The wound was described as black in color, had a moderate amount of serosanguineous drainage with a moderate odor, and the area around the wound was moist, mushy, and a dull pink color. No change in treatment was recommended. The IDT note dated 2/17/15 at 1:48 p.m., indicated the resident had pain during the treatment of [REDACTED]. The note indicated the resident refused to lay down between meals and was educated in the need to relieve pressure. The note indicated the resident agreed to elevate the right leg when up in the wheelchair and have the heel float off the end of the wheel chair instead of resting on the leg rests. A Pressure Wound Skin Evaluation Report completed 2/23/15 at 4:52 p.m., indicated the wound measured 6.2 x 5.9 and the depth was indeterminate. The wound bed was described as necrotic tissue, having minimal serosanguineous drainage with a slight odor, and the tissue surrounding the wound was mushy, pale/white in color. The IDT note on 2/24/15, indicated the wound continued to self debride, was less mushy and boggy, and the wound bed was necrotic tissue. The note indicated the resident required cueing to float heel when up in wheel chair for pressure relief. No changes were recommended to the treatment. The care plan was updated on 2/26/15, to include foot cushion to be worn while up in wheelchair and at bedtime. The care plan did not indicate which foot or feet for the cushion. The Pressure Wound Skin Evaluation Report dated 3/2/15 at 2:31 p.m., indicated the wound to the right heel measured 5.7 x 5.3 and the depth was indeterminate. The color of the wound was described as necrotic purple/black with a moderate amount of serous foul smelling drainage. The area around the wound was described as macerated, moist, and mushy. The resident was seen on 3/2/15, in the facility by the nurse practitioner. The progress notes of the nurse practitioner indicated the resident had bilateral (both) unstageable heel wounds. The right heel wound was described as macerated with escar (dark brown or black tissue) and odorous yellow drainage. The left heel ulcer was described as dry escar. The nurse practitioner orders included stopping the warm soaks to the right heel, continuing the use of the Santyl to the right heel, starting [MEDICATION NAME] ([MEDICATION NAME]-iodine) to the left heel 2 times a day, starting an antibiotic for the drainage, keeping pressure off of the wounds, and consulting with a wound clinic. The nursing progress notes lacked documentation regarding the wounds on the right and left heel. A Pressure Wound Evaluation Report dated 3/3/15 at 10:01 a.m., indicated the resident had a deep tissue injury on the left heel measuring 1.2 x 1.3 with the depth being indeterminate. The report indicated the wound was first observed on 3/2/15. The wound was described as purple in color with no drainage and the recommended treatment was [MEDICATION NAME]-iodine and a foot cushion. The IDT progress note for 3/3/15 at 1:44 p.m., indicated the resident had deep tissue injuries to both heels. A new mattress was ordered for the resident's bed, an antibiotic was going to be started for a wound infection in the right heel, and the the resident was to be in bed between meals for 30 minutes. The root cause of the pressure ulcers was noted to be related to the resident resting feet on the foot rests of the wheelchair when up in the chair. The note indicated the resident would continue to be positioned with legs elevated and pillows underneath the legs for pressure relief and would have foot cushions to both feet at all times when up in the chair. The care plan for pressure ulcers was updated 3/3/15, to include foot cushions to both feet when up in wheelchair and in bed and resident to be in bed between meals for at least 30 minutes. On 3/5/15, the resident went to the wound clinic for evaluation. The resident was sent from the wound clinic to the hospital for treatment of [REDACTED]. The resident was admitted to the hospital and returned to the facility on [DATE], with 3 intravenous (IV) antibiotics and a negative pressure dressing to the wound on the right heel. The wound to the right heel was observed during a dressing change on 5/28/15 at 1:00 p.m. The resident had been up in the wheelchair for breakfast and lunch. After lunch, the resident was taken to the room for treatment of [REDACTED].#3 pushed the resident into the room and removed the leg rests from the wheel chair. The resident was observed to not have either foot elevated prior to the transfer and did not have cushions on either foot. The resident transferred with the assistance of 2 staff into the bed. Once in bed the resident's feet were placed on pillows on the bed. The old dressing had a moderate amount of serosanguineous drainage on it. The wound covered approximately 3/4 of the resident's heel and was approximately 1/4 of the side of the foot. The bottom edge of the resident's heel was missing. Part of the wound bed was beefy red with slough covering approximately 25% of the wound. An area of necrotic tissue covered the top half of the wound. The area surrounding the wound was red in color. No odor was noted. The resident denied complaints during the dressing change. Once the dressing change was completed, the resident transferred back into the wheelchair with the assistance of the staff. On 5/29/15 at 2:30 p.m., the resident was observed propelling in the hallway in a wheelchair. Neither of the foot rests were elevated on the wheelchair and foot cushions were not in place. The resident stated, I can't stay in bed. I want to be up in my chair. During an interview with the Director of Nursing Services (DNS) and the Clinical Education Coordinator (CEC) on 6/2/15 at 1:30 p.m., the DNS indicated the treatment orders on 1/26/15, for an ulcer on the left foot and the IDT note on 1/26/15, were documentation errors and should have indicated the open area was on the right heel. The DNS indicated the staff knew which heel needed the treatment and the treatment had been completed to the right heel from 1/26/15, through 2/2/15, when the order was changed. The DNS indicated the staff had attempted to treat the heel ulcer in house and referred the resident to the wound clinic when the area continued to show a lack of improvement with changing of the treatments. The CEC provided an invoice dated 3/3/15, indicating the specialty mattress had been applied to the resident's bed on 3/3/15, for additional pressure relieving while in bed. During a review of the Treatment Administration Record (TAR) for January 2015 on 6/3/15 at 12:45 p.m., the TAR contained staff initials for the dates 1/26, 1/27, 1/28, 1/29, 1/30, 1/31, and 2/1/15, indicating the treatment, Cleanse Lt (left) heel w/NS (with normal saline), Gently pat dry, apply skin prep to wound edges and heel. Apply silver alginate (an agent used to debride, remove, dead or dying tissue) to open area, protect w/Allevyn Heel Foam (a foam dressing used to absorb drainage from wounds), secure with kerlix (rolled gauze) daily and PRN (as needed) soilage/dislodgement, had been completed as ordered. The TAR and the nursing progress notes lacked documentation to indicate the wheelchair legs had been elevated and lacked documentation to indicate the heels had been elevated while in bed. During an interview with the DNS, the Executive Director (ED), and the Corporate Clinical Consultant on 6/3/15 at 10:30 a.m., the DNS indicated the resident's wheelchair did not have adaptive equipment to the leg rests for pressure relief, but did have elevating leg rests. The DNS indicated the resident was encouraged to elevate the legs of the chair, but was not always compliant with elevating them. The DNS indicated the facility did not document turning and repositioning every 2 hours and did not have documentation indicating when the resident had pillows under the legs for pressure relief. 2. The clinical record of Resident #40 was reviewed on 6/1/15 at 11:00 a.m. [DIAGNOSES REDACTED]. An annual Minimum Data Set assessment, dated 5/5/15, and a quarterly ((MDS) dated [DATE], indicated Resident #40 was independent in her ability to make decisions, needed extensive assistance of 2 staff for bed mobility, transferring and toileting, and was frequently incontinent. A New Skin Event, dated 5/7/15, indicated Resident #40 had developed a Stage 1 non-blanchable pressure ulcer on her right hip. A stage 1 pressure ulcer is a defined area of discolored, usually pink or red, intact skin on a surface which endures pressure. Non-blanchable means when pressure is applied, the area does not lose its color, as normal skin does. The Skin Event indicated this new stage 1 pressure ulcer measured 10.0 centimeters (cm) x 9.0 cm by < (less than) 0.1 cm. An Event, dated 5/11/15, indicated the right hip stage 1 pressure ulcer measured 13.0 cm. x 9.0 cm. x <0.1 cm. An Event dated 5/18/15, indicated the right hip stage 1 pressure ulcer measured 10 cm. x 8 cm. x <0.1 cm. An event dated 5/26/15 indicated the right hip stage 1 pressure ulcer measured 13 cm. x 9.0 cm x <0.1 cm. An event dated 6/1/15, indicated the right hip stage 1 pressure ulcer measured 12 cm. x 9 cm. x <0.1 cm. An observation on 6/2/15 at 10:45 a.m., indicated a large, pinkish, red, and darker red area around the right buttock fold, upper thigh, hip area. A discontinued care plan, dated 6/22/14, indicated Resident #40 was at risk for skin breakdown. Interventions in place at the time the stage 1 pressure area was noted on 5/7/15, included turning and repositioning the resident at every 2 hours. A current care plan, created 5/13/15, indicated the resident being at risk for skin breakdown. Interventions including turning and repositioning at least every 2 hours. A current care plan, created 2/24/15, indicated Resident #40 had impaired skin integrity .stage I to right hip as of 5/6/15. Interventions included turning and repositioning every 2 hours. An observation on 6/2/15 between 11:10 a.m. and 1:40 p.m. (2 1/2 hours), indicated Resident #40 was sitting in her wheelchair. It appeared she was sitting directly on the stage I pressure area on her right buttock, upper thigh, hip area. There were no observations of attempts to reposition the resident during the 2 1/2 hour period. On 6/2/15 at 1:40 p.m., Certified Nursing Assistant (CNA) #1 indicated Resident #40 stays up in the wheelchair after lunch and likes to stay in the wheelchair all afternoon. The CNA indicated the resident will call if she is incontinent of stool, and sometimes the resident's urinary catheter bag gets emptied, but otherwise the staff doesn't do anything with the resident. On 6/2/15 at 3:30 p.m., the Clinical Education Coordinator (CEC)/wound nurse indicated Resident #40 refused to go back to bed during the day and didn't want to be repositioned. No documentation was found in the resident's record which indicated staff was repositioning the resident while up in the wheelchair. The CEC indicated at that time the resident's refusal to return to bed or be repositioned in the wheelchair was not care planned with alternative interventions for pressure relief. On 6/1/15 the Director of Nursing Services provided a policy titled, Skin Management Program, dated 2/2015, and indicated it was the policy currently used by the facility. The policy indicated, .The facility assigned wound nurse will complete further evaluation of the wounds identified and complete the appropriate skin evaluation event on the next business day, Direct care givers will be notified of skin alterations and specific care needs, A plan of care will be initiated to include resident specific risk factors with appropriate interventions .A care plan will be developed specific to the resident's needs including prevention interventions Direct care givers will be notified of the resident's specific prevention interventions . 3.1-40(a)(1) 3.1-40(a)(2)