Every finding on record at Brickyard Healthcare - Brandywine Care Center

Based on interview and record review, the facility failed to file a grievance for a resident expressed concerns about not getting timely assistance with toileting for 1 of 1 resident reviewed for grievances (Resident F). Findings include:During an interview with the Social Service Director (SSD) on 3/12/26 at 11:28 a.m., the SSD indicated she did not file a grievance for Resident F when the resident expressed care concerns during a care plan meeting on 2/26/26. The SSD was unsure if nursing had done anything for the resident, because Unit Manager 1 was also present during the care plan meeting. During an interview with Unit Manager 1 on 3/12/26 at 11:32 a.m., the Unit Manager indicated she did not file a grievance for Resident F after the resident expressed concerns in her care plan meeting on 2/26/26 about not getting timely assistance with her toileting needs. Review of the clinical record of Resident F, on 3/13/26 at 1:25 p.m., indicated the resident's diagnoses included, but were not limited to, fracture of sacrum (bone at the base of the spine), muscle weakness, fracture of the right rib and reduced mobility. The admission Minimum Data Set (MDS) assessment for Resident F, dated 2/25/26, indicated the resident was cognitively intact for daily decision making. The resident was consistent and reasonable. The resident was dependent on staff for toileting. The care plan meeting for Resident F, dated 2/26/25 at 11:47 a.m., indicated the resident had concerns with getting assistance to use the bathroom, the resident indicated it took an hour for staff to assist her to use the restroom. During an interview with the Regional Director Of Clinical Operations on 3/16/26 at 1:10 p.m., indicated it was the responsibility of all the staff present during Resident F's care plan meeting on 2/26/26 to file a grievance for the resident after she expressed care concerns with timely assistance. The Regional Director Of Clinical Operations indicated any staff member could fill out a grievance form for residents. The grievance policy provided by the Executive Director on 3/16/26 at 8:53 a.m., indicated the facility would support each resident and family member to voice grievances without discrimination, reprisal, or fear of discrimination. The facility would acknowledge a complaint/grievance and actively work toward a solution of the complaint/grievance. A resident may voice grievances with respect to care and treatment which had been furnished as well as that which had not been furnished. The staff member receiving the grievance would record the nature and specifics of the grievance on the designated grievance form, take any immediate action needed to prevent further potential violations. All staff involved in the grievance investigation or resolution should make prompt efforts toward a resolution. The written decision would include at a minimum the date the grievance was received, steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns and any corrective action taken or to be taken by the facility as a result of the grievance. This citation relates to intake 2795030. 410 IAC (Indiana Administrative Code) 3.1-7(a)(2)

Based on interview and record review, the facility failed to follow the provider's ordered wound care for a resident's wound care treatment for 1 of 4 resident reviewed for Quality of Care. (Resident E) Findings include:The clinical record for Resident E was reviewed on 3/12/26 at 9:33 a.m. His diagnoses included, but were not limited to, diabetes, hypertension, and lymphedema (abnormal accumulation of protein-rich fluid in soft tissues, resulting in swelling, usually in the arms or legs). The wound care provider note, dated 10/21/25, indicated the treatment plan for the non-pressure chronic ulcer to Resident E's left perineum was to cleanse the area with sterile water and the peri-wound (area of skin surrounding a wound, essential for healing by serving as a protective barrier) area with soap and water. The peri-wound skin treatment was SurePrep (water-base, non-stinging polymer barrier film used in medical settings to protect intact or damaged skin from friction, bodily fluids and adhesive stripping) protective wipes. The primary dressing was Hydrofera Blue Ready (a non-cytotoxic, antibacterial foam dressing). The secondary dressing was Allevyn Gentle Border (a advanced wound care dressing, specifically a type of hydrocellular sillicone gel adhesive foam dressing). The treatment was to be done three times per week for one week. The treatment at the wound care center was the first of the three treatments. The ulcer was not debrided. The progress note, dated 10/21/25, indicated Resident E returned from the wound clinic with updated wound orders. The medication administration record (MAR) was updated with the new orders. His next appointment was the following Tuesday on 10/28/25. The wound care provider note, dated 10/28/25, indicated the resident's non-pressure chronic ulcer to his left perineum was debrided. The treatment plan for the resident's ulcer was to cleanse the area with Anasept (antimicrobial skin and wound care product used to kill a broad spectrum of bacteria, fungi, viruses, and spores, while removing biofilms and assisting in the management of infected wounds, burns, and skin infections) and the peri-wound area with soap and water. The primary dressing was Mepilex Ag (soft silicone foam dressing designed for wound care to manage exudate [fluid]. maintain a moist wound environment). The treatment was to be done three times per week for one week. The treatment at the wound care center was the first of the three treatments. The October and November, 2025 MARs indicated the facility did not update to the new wound care treatment orders from 10/28/25 and continued to provide the same treatment as indicated in the 10/21/25 wound care center note on 10/30/25 and 11/1/25. The wound care provider note, dated 11/4/26, included the dressing orders for the facility due to a missed appointment on 11/4/26. The treatment orders for the resident's ulcer to his perineum were to cleanse the area with Anasept or saline as a substitute. The November, 2025 MAR indicated the facility did not update to the resident's new wound care treatment orders from 11/4/25 and continued to provide the same treatment as ordered on the 10/21/25 wound care center note. An interview was conducted with the Registered Nurse from the wound care provider on 3/13/26 at 12:18 p.m. She indicated typically an order to cleanse an ulcer was changed from sterile water to Anasept, because the ulcer smelled and bacteria needed killed. Anasept cleansed bacteria more effectively and was stronger than sterile water. The primary dressing order also changed to Mepilex on 10/28/25, because Resident E probably did not need the Hydrofera anymore. Mepilex and Hydrofera were two very different dressings. They expected the facility to follow the wound care center orders for Resident E's wound care treatment. The Wound Management policy was provided by the ED (Executive Director) on 3/13/26 at 8:50 p.m. The policy indicated, Wound treatments will be provided in accordance with physician's orders, including the cleansing method, type of dressing, and frequency of dressing change. This citation relates to Intake 2657216. 410 IAC (Indiana Administrative Code) 3.1-37(a)

Based on observation, interview, and record review, the facility failed to timely develop individualized plans of care for residents who displayed behaviors, document behavioral incidents in the clinical record, document effectiveness of interventions used to manage behaviors, review behaviors with an interdisciplinary team, and provide adequate supervision resulting in increased behaviors and resident-to-resident altercations. (Resident C, D, G, H, and J)Findings include: 1a. The clinical record for Resident D was reviewed on 11/12/25 at 11: 15 a.m. The resident's diagnosis included, but was not limited to, dementia and anxiety disorder.A physician's order, dated 8/18/25, indicated behavior monitoring for Depression every day and night shift for depression.A Quarterly MDS Assessment, completed 8/29/25, indicated she had severe cognitive impairment. She had exhibited physical and verbal behaviors directed toward others one to three days during the seven day look back period. She had displayed behaviors not directed toward others one to three days during the seven day look back period. She was able to walk with supervision for at least 150 feet. A care plan, last revised on 9/6/25, indicated Resident D was at risk for elopement and wandering related to being disoriented to place and impaired safety awareness. She wanders aimlessly and will wander into other resident rooms. The goal was for her safety to be maintained and that she would not leave the facility unattended. The interventions included to distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Offer interventions as appropriate. Intervene as appropriate. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes.A care plan, initiated 9/26/25, indicated Resident D could experience being physically aggressive, grabbing others, lunging at others, express frustration, anger at others, screaming at others, and disruptive sounds. The goal was for her to demonstrate decreased frequency on any of the behaviors. The interventions were to ensure safety of resident, staff and others by removing others from the area and maintaining a safe distance, to speak in a soft, calm tone, and provide reassurance, and to use non-threatening body language and remain calm avoiding sudden movements. A care plan, initiated 9/26/25, indicated Resident D might experience becoming sad and tearful. The goal was for her to verbalize when she is feeling sad and tearful. The interventions were to acknowledge and validate emotions, encourage resident to verbalize feelings rather than only expressing through crying, and to offer privacy when desired, but check in frequently to ensure safety and support.The September 2025 Medication Administration Record (MAR) did not contain information that Resident D had displayed any behaviors related to depression during the month of September. A general progress note, dated 10/6/25 at 5:06 p.m., indicated Resident D was having increased anxiety. Resident was crying and saying things like I don't know what to do and it's about my kids what should I do. Staff attempted redirection with snacks, activities, and one on one attention. Resident D remained tearful. Will continue to try redirection. A Psychiatric Progress Note, dated 10/8/25, indicated Resident D had been seen due to increased depressive symptoms. Over the past couple of weeks, staff report worsening depressive symptoms. Resident D had been increasingly tearful and emotionally labile. On that date, she was observed sitting in a chair crying and stated she just wishes God would take her. Staff report that Resident D becomes easily overwhelmed by other residents, loud noises, or excessive commotion, which often triggers crying and shut down episodes. During these times, she appears withdrawn and anxious, and her crying and anxiety levels become significantly exacerbated. Staff report that she becomes upset when another resident enters the area and began to hit herself in the head, saying I am stupid. When the other resident was removed and environment was quieted, Resident D calmed, stopped crying, and began joking with staff. The assessment/plan was to increase Resident D's sertraline (anti-depressant medication) to 75 milligrams (MG) daily, continue close monitoring for self-injurious behavior or suicidal ideations, provide calm, reassuring redirection during episodes of overstimulation, and to maintain supervision in common area to ensure safety. The non-pharmacological interventions were to implement environmental modifications to reduce over stimulation (quiet areas, limited crowding, and noise), and to encourage participation in structured, calming, and social activities as tolerated.The non-pharmacological interventions listed in the Psychiatric Progress Note were not added to Resident D's plan of care. Resident D's clinical record did not contain a care plan that addressed self-harm.A care plan, initiated 10/17/25, indicated Resident D had aggressive behaviors as evidenced by throwing water on another resident related to dementia. The goal was for her not to have any episodes of throwing water at others. The interventions were to assess her for pain, discomfort, thirst or need to toilet. Talk calmly with resident and allow her time to express her feelings. When resident becomes agitated calmly remove resident from area.Resident D's clinical record contained a behavior charting note, dated 10/15/25, that indicated Resident D had started to lunge for a Certified Nursing Assistant (CNA) while the CNA was trying to pass trays. The nurse had intervened, and Resident D indicated she was looking for her daughter and that her daughter had been stolen. The nurse had taken Resident D to her room to redirect her. When Resident D and the nurse got to the room, Resident D lunged at the nurse. The intervention was not effective.The clinical record did not contain information that an Interdisciplinary Team (IDT) had reviewed Resident D's behavior documented 10/15/25. A physician's order, dated 10/15/25, indicated Resident D was to receive Depakote delayed release tablet 125 mg by mouth two times daily for dementia. This dose was discontinued on 10/22/25.Resident D's clinical record contained a behavior charting note, dated 10/16/25 at 6:21 p.m., that indicated Resident D threw water on another resident. When asked why she threw the water, Resident D indicated the other resident had been talking about her dead daughter. Resident D does not have a daughter who passed away. Resident D continued to be agitated and was very difficult to redirect. Resident D was able to calm down after staff sat with her in her room for about 15 minutes. Resident D was placed on 15-minute observations. The intervention attempted was to separate Resident D to a calm area while staff talked with her. The intervention was effective.A care plan, initiated 10/21/25, indicated Resident D had a history of trauma that affects her negatively. Resident experienced her grandchild's father kicking in a door and taking the granddaughter. Triggers that have the potential to retraumatize her include (blank). The goal was for staff to assist her in avoiding triggers. The interventions included encourage her to be as independent as possible, encourage relationships with her family and friends that support her, her triggers are (blank), observe my mental health, and provide her with meaningful activities.A social services general note, dated 10/22/25 at 3:17 p.m., indicated Resident D had been provided one on one psychosocial support due to Resident D showing signs and symptoms of psychosocial distress related to a murdered baby. Resident D was making statements regarding experienced violence toward children and concerns about going to jail. Resident D was able to be redirected for short times, however quickly returned to the topic of distress. The Psychiatric Nurse Practitioner was notified.The clinical record did not contain information that the IDT team had reviewed the behavior of distress related to violence toward children and concern of going to jail.A physician's order, dated 10/22/25, indicated Resident D was to receive Depakote delayed release 125 mg, tablets 2 tablets twice daily related to dementia.A Psychiatric Progress Note, dated 10/23/25, indicated Resident D was seen due to anxiety delusions and agitation, dementia, Post Traumatic Stress Disorder (PTSD), and depression. Staff recently learned Resident D was present when her granddaughter was kidnapped 30 plus years ago (granddaughter was returned home). She frequently talks fearfully of men and police coming. Increased delusions, with some improvement with addition of Depakote low dose, this day however increased delusions and agitation with another resident. Will increase Depakote to 250 mg twice daily. Resident D's clinical record did not contain documentation of increased delusions and agitation with another resident or intervention attempted to redirect Resident D during these delusions and agitation. A social services general note, dated 10/28/25 at 4:21 p.m., indicated one on one psychosocial support was provided to Resident D. She was crying stating someone was going to kill her. Resident was crying and indicating they took the baby. Resident D indicated she was going to knock the **** out of them but could not indicate who she was going to knock the **** out of. Resident D was offered reassurance and redirected for a short time but then returned to talking about hurting others and being hurt.A Psychiatric Progress Note, dated 10/29/25, indicated Resident D was seen due to anxiety delusions and agitation, dementia, PTSD, and depression. She had increased delusions, recently increased Depakote dose, continued delusions, hallucinations, and agitation/aggression with another residents. Will add Risperdal (anti-psychotic medication) 0.5 mg at 1:00 p.m. daily. Her cognition was impulsive / safety concerns. She was not a danger to self or others at that time.Resident D's clinical record did not contain documentation of increased agitation/aggression with other residents or interventions attempted to redirect Resident D during these episodes.A physician's order, dated 10/29/25, indicated she was to receive Risperdal 0.5 mg by mouth one time a day for psychosis.The October 2025 MAR did not contain information that Resident D had displayed any behaviors related to depression during the month of October.The Point of Care (POC) Behavior Monitoring and Interventions did not include any documentation of behaviors being displayed by Resident D from 10/15/25 through 10/31/25.Resident D's clinical record contained a behavior charting note, dated 11/3/25 at 2:11 p.m. The behavior charting note indicated Resident D had hit a housekeeper on the wrist while the housekeeper was cleaning a room. Resident D had been walking down the hallway when she was seen shaking a housekeeping cart. The housekeeper asked Resident D to stop shaking the cart and Resident D then slapped the housekeeper on the wrist. The interventions attempted were the nurse asked the housekeeper if she was hurt or in pain. The housekeeper indicated she was fine and not hurting. The effectiveness of the intervention indicated that a few minutes later the housekeeper approached the nurse and complained of burning in her hand. The housekeeping supervisor was notified. The clinical record did not contain information of interventions attempted with Resident D related to the behavior of hitting a housekeeper or if the interventions were effective.Resident D's clinical record contained a general note, dated 11/3/25 at 6:20 p.m. The general note indicated a CNA had come to get the nurse due to Resident D slapping another resident. Another CNA indicated Resident D had also attempted to choke the other resident. Resident D came to sit in the dining room. Resident D was smiling, laughing, and talking to other residents in the dining room. Resident D could not give an answer when asked what had happened. 1b. The clinical record for Resident C was reviewed on 11/12/25 at 11:10 a.m. The resident's diagnosis included, but were not limited to, dementia and diabetes.A Quarterly Minimum Data Set (MDS) Assessment, completed 8/25/25, indicated she had severe cognitive impairment. She had not displayed behavioral symptoms during the seven day look back period. She was able to walk at least 150 feet with supervision. Resident C's clinical record contained a general note, dated 11/3/25 at 5:33 p.m. The general note indicated a Certified Nursing Assistant (CNA) had come to get the nurse due to another resident slapping Resident C. The other resident also attempted to choke Resident C. The residents were separated. Resident C was sitting in her room. Resident C had redness to her right cheek and right side of her neck. Resident C stated the other resident had only slapped her and she did not think the choking had happened, but it all happened so fast. Resident C indicated she was okay and felt safe.During an interview on 11/12/25 at 2:35 p.m., the Memory Care Director (MCD) indicated approximately two weeks before Resident D was sent to the inpatient psychiatric hospital, she started getting more aggressive with staff and other residents. Resident D had sporadic thoughts and disoriented thinking. The MCD would try to redirect her by giving her fake names and addresses to work with, and have her sort construction paper to redirect when she was having behaviors. Resident D's behaviors would ramp up about 1:00 p.m. each day. The Psychiatric Nurse Practitioner saw Resident D weekly.During an interview on 11/12/25 at 2:40 p.m., the Social Services Director (SSD) indicated the behavior documentation was done in POC and the nurses used behavior charting to document behaviors. Resident D displayed behaviors almost daily.During an interview on 11/12/25 at 2:51 p.m., Activity Aide (AA) 6 indicated that around 3 weeks ago, she had done a one-on-one activity with Resident D for two hours one afternoon, flipping through pages of a magazine and talking with her about the pictures. She had done the one-on-one with Resident D because she was focusing on a baby being missing. Resident D's behaviors would vary from hour to hour and day to day. Resident D would become frustrated with redirection. When Resident D was first admitted to the facility in August, she would jump at every little noise but seemed to get used it the noises as her stay progressed.During an interview on 11/12/25 at 3:30 p.m., the Director of Nursing (DON) indicated she was not on the Dementia Care Unit often, so she was unsure about Resident D's behaviors, but she was aware of the incident between Resident D and Resident C that caused Resident D to be sent out. Behaviors were reviewed in morning meetings and care plans were updated when the behaviors were reviewed. The behaviors were charted in the progress note using behavior notes and the CNAs could document behaviors in the POC system. During an interview on 11/13/25 at 2:43 p.m., CNA 5 indicated she had witnessed Resident D slap Resident C on 11/3/25. CNA 5 had been standing next to the unit shower room, looking down the hallway. Resident C and another resident were standing outside of the doorway to Resident C's room. Resident D had walked up to Resident C and began verbally arguing. Resident D then slapped Resident C on the right cheek. CNA 5 was able to hear the slap from where she was standing. CNA 5 had not witnessed Resident D attempting to choke Resident C. Another CNA had separated the residents while CNA 5 went to get the nurse. Resident D displayed behaviors daily. Resident D would wander into other resident's rooms almost daily. CNA 5 would attempt to redirect Resident D by taking her to her room and go through family pictures with her, which was helpful but not for long. CNA 5 worked primarily on the dementia care unit. Approximately 2 weeks ago, CNA 5 had made the MCD and the DON aware that there were not enough staff to provide supervision for the residents of the dementia unit. The unit had been hectic and overwhelming for the last couple of weeks. There were 2 CNA's and a nurse working the evening of 11/3/25. She believed that if there had been 3 CNA's, the incident between Resident D and Resident C may have been avoided, because there would have been more staff available to supervise the residents.2. The clinical record for Resident H was reviewed on 11/13/25 at 9:55 a.m. The resident's diagnosis included, but was not limited to, dementia. She was admitted to the facility on [DATE].A care plan, initiated 11/6/25, indicated she was at risk for falls related to gait and balance problems. The goal was for her to be free from falls. The interventions included to anticipate and meet the resident's needs, physical therapy to evaluate and treat, and request a wheelchair for locomotion from hospice.On 11/13/25 at 9:55, Resident H was observed sitting in the dining room with a square water filled sensory mat sitting in front of her on the table. She was dressed in a hospital gown and had one nonskid sock on her left foot. A visitor was sitting next to her. Resident H was attempting to stand, and the visitor was cueing her to sit back down. Resident H was attempting to open the sensory water mat, and the visitor was redirecting her. Resident H then attempted to stand and walk away. There were no staff present in the dining room. The visitor stood and attempted to redirect Resident H from walking because she only had one nonskid sock on. The visitor was able to find a CNA walking in the hallway and requested the CNA to assist Resident H. A nonskid sock was put on Resident H's right foot, and the CNA began to walk with Resident H down the hallway. Resident H was walking very quickly and attempting to enter other residents' rooms. The CNA redirected Resident H from entering other residents' rooms. 3.a. The clinical record for Resident J was reviewed on 11/13/25 at 10:15 a.m. The resident's diagnosis included, but were not limited to, dementia and bipolar disorder.A Psychiatric Progress Note, dated 9/17/25, indicated staff reported Resident J sometimes used demeaning language toward others and had instances of verbal aggression toward others.Resident J's clinical record did not contain a care plan to address the behavior of verbal aggression toward others3.b. The clinical record for Resident M was reviewed on 11/13/25 at 10:10 a.m. The resident's diagnosis included, but were not limited to, vascular dementia and anxiety. He was admitted to the facility on [DATE].Resident M's clinical record contained a Behavior Charting note, dated 11/10/25 at 11:46 a.m., that indicated Resident M was constantly taking his clothes off in the dining room. He would go to the sink, turn on the water and splash water everywhere. He would not stop no matter how many times he was redirected. The interventions attempted were to offer drinks and snacks, putting his clothes back on, and taken to the bathroom. There was no improvement in his behaviors, he continued to get worse and worse.A Behavior Charting Note, dated 11/12/25 at 1:00 p.m., indicated Resident M's family member informed management staff that Resident M had a curtain wrapped around his body, not his neck. Resident M has indicated he was trying to kill himself. He had felt this way for a few years. One on one supervision was initiated, and environment was checked for safety. On 11/13/25 at 10:12 a.m., Resident M was observed walking in the hallway with a grey sweatshirt and an incontinence brief on. CNA 10 was walking beside him and attempting to redirect him back to his room. Resident M began yelling loudly and cursing at CNA 10 and continued to walk down the hallway. Housekeeper (HK) 11 gave CNA 10 a gown out of the linen closet and CNA 10 put the gown on Resident M while he was standing in the hallway. Resident M continued to walk up and down the hallway with CNA 10 following him, until he was redirected into his room. Registered Nurse (RN) 3 brought the medication cart to the entrance of Resident M's room. Resident M exited his room with CNA 10 following him. CNA 10 and RN 3 obtained Resident M's height, using a tape measure, while Resident M was standing in the hallway. Resident M then began to pace the hallway again with CNA 10 following him. Resident M turned around and yelled at CNA 10 that she was getting on his nerves and continued to pace the hallway. A [NAME] map (vital signs machine) was sitting in the middle of the hallway and Resident M kicked it while he was walking and yelled out an expletive. Resident H was pacing in the hallway at the same time Resident M and CNA 10 were walking up and down the halls. Resident H was attempting to enter other residents' rooms and being redirected by RN 3 and CNA 8. On 11/13/25 at 1:13 p.m. through 1:53 p.m., continuous observations were conducted on the facility dementia unit. Resident M was standing in the unit dining room with no shirt on, multiple skin tears were present on both arms. Unit Manager (UM) 7 was sitting in a chair next to resident M and attempting to redirect him. UM 7 was attempting to redirect Resident M and to assist him with putting his shirt back on. Resident J was sitting at a table a crossed from where Resident M was standing. Resident J yelled at Resident M, calling him a f**** man. UM 7 stood up to attempt to help Resident M to put his shirt back on when Resident M became angry and attempted to punch UM 7, losing his balance and falling into another resident sitting in a wheelchair and knocking her drink onto the floor. CNA 8 caught Resident M's arm and kept him from falling to the floor. CNA 8 then attempted to redirect Resident M out of the dining room. The dining room had multiple residents present. Resident M went to the sitting area and sat down. Resident H then began pacing in the hallway and UM 7 went to walk with her and redirect her from going into other's rooms. Resident M reentered the dining room without a shirt on. Resident J yell out for Resident M to keep his shirt on and called Resident M a dirty old man. There were multiple residents in the area walking around the tables and sitting in the dining room. The television was on with a game show. A male resident was sitting at a table and asking to go to go home because he had young children. HK 11 attempted to calm him. CNA 9 was attempting to pick up lunch trays in the dining room. At 1:41 p.m., the MC came to the dining room area and assisted Resident M to her office to call his family. CNA 9 stood at a dining cart and placed her head in her hand. At 1:46 p.m., a male resident hit one of the dining room tables and started to yell curse word. HK 11 attempted to redirect the male resident and calm him down. Resident H continued to pace in the hallway followed by UM 7. During an interview on 11/13/25 at 1:41 p.m., CNA 9 indicated the memory care unit was normally staffed with two CNA's, at times there were three CNA's assigned to the unit. When asked if two CNAs could meet all the residents' needs, CNA 9 shook her head and walked away.During an interview on 11/13/25 at 1:42 p.m., RN 3 indicated the dementia unit was normally staffed with two CNA's, but the staff would like three CNAs. The unit currently had 29 residents, the most he had worked with on the unit. He had worked at the facility for 4 years. When residents displayed behaviors things on the unit could escalate quickly. A confidential interview was conducted during the course of the survey. They indicated they visited the dementia unit almost daily. The CNAs on the unit are always running. They tried to talk with the residents on the dementia unit and help them with what they could. Sometimes the residents needed things when the aides were busy with other residents. If both the aides were in rooms caring for residents, there was no one around to help the other residents. There had been an incident recently when a new resident was in the dining room, running water in the sink and the water had overflowed onto the floor. There were no staff members around and some of the other residents in the dining room had gotten up and were attempting to walk to the area where there was water on the floor. They had redirected the residents from the area with the water because they were afraid someone would get hurt. A staff member finally came back to the dining room and assisted to redirect the new resident and clean up the water. During an interview on 11/13/25 at 2:00 p.m., the DON indicated the Dementia Care Unit was normally staffed with one nurse and two CNAs due to the census being low. She felt that there was enough staff for the unit. During an interview on 11/13/25 at 2:43 p.m., CNA 5 indicated Resident J frequently had behaviors of screaming, yelling, and picking on other residents in the dining room. Resident J also displayed the behavior of grabbing staff between the staff's legs when incontinent care was provided. The nurses and the MC had been made aware of the behaviors. Resident H was a heavy wanderer and a screamer. Resident H would start screaming in the middle of the night and wake the other residents. The staff would attempt to redirect her when they caught her going into other residents' rooms. There were not enough staff to provide supervision to keep residents from wandering into other rooms. The last couple of weeks had been overwhelming. When one resident started displaying behaviors, it was like a [NAME] effect, other residents would start having behaviors as well. Sometime the unit was overstimulating with too much noise. The CNA's were to chart behaviors in the POC system. On 11/12/25 at 3:38 p.m., the DON provided the current Behavioral Health Services policy that read . It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning and well- being. 3. The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety.5. Behavioral health care and services shall be provided in an environment that is conducive to mental and psychosocial well-being. 7.f. Assess and develop a person-centered care plan for concerns identified in the resident's assessment. G. share concerns with the interdisciplinary team [IDT] to determine underlying causes of mood and behavior changes, including differential diagnosis. h. Accurately document the changes, including the frequency of occurrences and potential triggers in the resident's record.k. evaluate resident and care plan routinely to ensure the approaches are meeting the needs of the resident.11. Facility staff will implement person-centered care approaches designed to meet the individual goals and needs of each resident, which includes non-pharmacological interventions. 3.1-37

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for 1 of 3 resident's reviewed for abuse. (Resident C)Findings include: 1.a. The clinical record for Resident C was reviewed on 11/12/25 at 11:10 a.m. The resident's diagnosis included, but were not limited to, dementia and diabetes.A Quarterly Minimum Data Set (MDS) Assessment, completed 8/25/25, indicated she had severe cognitive impairment.Resident C's clinical record contained a general note, dated 11/3/25 at 5:33 p.m. The general note indicated a Certified Nursing Assistant (CNA) had come to get the nurse due to another resident slapping Resident C. The other resident also attempted to choke Resident C. The residents were separated. Resident C was sitting in her room. Resident C had redness to her right cheek and right side of her neck. Resident C stated the other resident had only slapped her and she did not think the choking had happened, but it all happened so fast. Resident C indicated she was okay and felt safe.1.b. The clinical record for Resident D was reviewed on 11/12/25 at 11: 15 a.m. The resident's diagnosis included, but were not limited to, dementia and anxiety disorder.A Quarterly MDS Assessment, completed 8/29/25, indicated she had severe cognitive impairment. A care plan, initiated 9/26/25, indicated Resident D could experience being physically aggressive, grabbing others, lunging at others, express frustration, anger at others, screaming at others, and disruptive sounds. The goal was for her to demonstrate decreased frequency on any of the behaviors. The interventions were to ensure safety of resident, staff and others by removing others from the area and maintaining a safe distance, to speak in a soft, calm tone, and provide reassurance, and to use non-threatening body language and remain calm avoiding sudden movements. Resident D's clinical record contained a behavior charting note, dated 10/16/25 at 6:21 p.m., that indicated Resident D threw water on another resident. Resident D continued to be agitated and was very difficult to redirect. Resident D was able to calm down after staff sat with her in her room for about 15 minutes. Resident D was placed on 15-minute observations. The intervention attempted was to separate Resident D to a calm area while staff talked with her. Resident D's clinical record contained a general note, dated 11/3/25 at 6:20 p.m. The general note indicated a CNA had come to get the nurse due to Resident D slapping another resident. Another CNA indicated Resident D had also attempted to choke the other resident. Resident D came to sit in the dining room. Resident D was smiling, laughing, and talking to other residents in the dining room. Resident D could not give an answer when asked what had happened. On 11/12/25 at 1:38 p.m., the Executive Director (ED) provided a copy of an incident report, sent to the Indiana Department of Health on 11/3/25. The incident report indicated that on 11/3/25 at 5:40 p.m., Resident D had slapped Resident C while in the hallway. Resident D had also placed her hands around Resident C's neck. The immediate action taken was that the residents were separated by the staff. The ED, Director of Nursing, physician, and families were notified. Resident D was placed on 15-minute checks while asleep and one on one care when awake. The process was started for Resident D to be transferred to an inpatient hospital. The preventative measures taken were for psychiatric services to be provided to both residents and the care plans would be updated as needed. The follow up, dated 11/11/25, indicated Resident D remained at an inpatient psychiatric hospital. The facility would review and implement recommendations when Resident D readmitted and care plans would be updated as needed. During an interview on 11/13/25 at 2:43 p.m., CNA 5 indicated she had witnessed Resident D slap Resident C on 11/3/25. CNA 5 had been standing next to the unit shower room, looking down the hallway. Resident C and another resident were standing outside of the doorway to Resident C's room. Resident D had walked up to Resident C and began verbally arguing. Resident D then slapped Resident C on the right cheek. CNA 5 was able to hear the slap from where she was standing. CNA 5 had not witnessed Resident D attempting to choke Resident C. Another CNA had separated the residents while CNA 5 went to get the nurse. On 11/13/25 at 1:22 p.m., the Director of Nursing (DON) provided the current Abuse, Neglect and Exploitation policy, that read It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions .Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment .This citation relates to Intake 26597183.1-27(a)(1)

Based on interview and record review the facility failed to assess a resident's vitals and lung sounds after routine breathing treatments were administered for 1 of 3 residents reviewed for respiratory care. (Resident B)Findings include:The clinical record for Resident B was reviewed on 11/12/25 at 11:30 a.m. The diagnoses included, but were not limited to, hypertension (high blood pressure), atherosclerotic (plaque buildup in arteries) heart disease, Chronic Obstructive Pulmonary Disease (COPD), and stroke. A Quarterly Minimum Data Set (MDS) assessment, dated 6/19/25, indicated Resident B was cognitively intact. A care plan, dated 3/26/25, indicated the resident had COPD due to smoking. The interventions included but were not limited to the following: bronchodilators as ordered, monitor effectiveness, and head of bed elevated.A care plan, dated 3/26/25, indicated the resident had COPD due to smoking. The interventions included, but were not limited, administer aerosol or bronchodilators as ordered. Monitor and document any side effects and effectiveness, resident's head of bed elevated to relieve shortness of breath while lying flat related to COPD.A physician order, dated 7/18/25, indicated Resident B was to receive 3 milliliters of ipratropium-albuterol nebulizer treatment three times a day. The October 2025 Medication/Treatment Record (MAR/TAR) indicated Resident B had received the 3 milliliters of ipratropium-albuterol nebulizer treatments. The MAR lacked respiratory assessments, nor vitals obtained after the routine nebulizer treatments were administered. A physician order, dated 7/18/25, indicated the resident was to receive 2 puffs of 108 micrograms of an albuterol inhaler every 6 hours as needed (PRN) for wheezing and shortness of breath. The MAR indicated Resident B received 2 puffs of the PRN 108 micrograms albuterol inhaler on 10/19/25 at 7:00 a.m. The medication was documented as being effective for the PRN beathing treatment. An interview was conducted with the DON on 11/12/25 3:49 p.m. She indicated the staff should be conducting respiratory assessments after administration of all nebulizer treatments. An interview was conducted with Resident B's Representative on 11/13/25 at 9:08 a.m. He indicated Resident B was unavailable, but he recalled the resident's stay in the nursing facility. The breathing treatment and the inhaler were not working anymore. An interview was conducted with Nurse Practitioner (NP) 1 on 11/13/25 at 1:47 p.m. She indicated she had seen Resident B at the beginning of October. She was made aware of Resident B's complaints of shortness of breath on 10/19/25. She had spoken to the resident about smoking cessation. The resident was not compliant. The resident was assessed, and her vitals were stable at that time. NP 1 did have documentation, a facility staff member, had notified the on-call provider on 10/21/25 at 2:46 a.m., about Resident B with complaints of shortness of breath. The resident received an additional dose of the albuterol inhaler. NP 1 was notified later that morning by staff of Resident B's shortness of breath. Monitoring and Documentation of Respiratory Services/Response Staff should document, based on current professional standards of practice, the assessment and monitoring of the resident's respiratory condition, including response to therapy provided, and any changes in the respiratory condition. Depending on the type of respiratory services the resident receives, physician orders and the individualized respiratory care plan, documentation should include, as appropriate: Vital signs, including the respiratory rate; Chest movement and respiratory effort, and the identification of abnormal breath sounds; Signs of dyspnea, cyanosis, coughing, whether position affects breathing, characteristics of sputum, signs of potential infection, or the presence of behavioral changes that may reflect hypoxia including anxiety, apprehension, level of consciousness; and Instructions for the resident on how to participate/assist in the respiratory treatments as appropriate. The attending practitioner must be immediately notified of significant changes in condition, and the medical record must reflect the notification, response and interventions implemented to address the resident's condition. Also, refer to S483.10(g)(14) F580 for notification of physician, family of significant changes. Modalities/Respiratory Therapy/Care/Services A variety of respiratory therapy modalities and care may be provided in the nursing home, including coughing/deep breathing, therapeutic percussion/vibration and postural drainage, aerosol/nebulizers, humidification, and therapeutic gas administration, BiPAP or CPAP, tracheostomy care and tracheal suctioning, and mechanical ventilation and oxygenation support. Coughing/deep breathing, therapeutic percussion/vibration and bronchopulmonary drainage If a resident has written orders for postural drainage, chest percussion, and vibration to increase the mobility of pulmonary secretions, the care plan must include, based upon the resident's assessments and identified needs, the type of exercise, including when and how often provided. The resident's record should reflect how staff are monitoring the condition of the resident prior to, during and after the treatments, and, as appropriate, vital signs including the respiratory rate, pulse oximetry, presence of dyspnea, and/or signs of infection. The record should reflect the resident's response to the treatment and notification of the practitioner if necessary for a change in the resident's condition or as necessary, the need to revise or alter the respiratory care provided. Refer to S483.10(g)(14) F580 for notification of physician of significant changes. Respiratory medications via aerosol generators There are three common types of aerosol generators used for inhaled drug delivery: A small-volume nebulizer (SVN); A pressurized metered-dose inhaler (pMDI); and A dry-powder inhaler (DPI). A nebulizer therapy policy was provided by the DON on 11/13/25 at 9:12 a.m. It indicated, .Policy: It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions.Care of the Resident.6. Obtain resident's vital signs, and perform respiratory assessment to establish a baseline.Documentation. Record the following information in the resident's medical record: 1. Date, time, and duration of therapy. 2. Type and amount of medication. 3. Oxygen flow, if administered. 4. Resident vital signs and respiratory assessment. 5. Resident's response to treatment. 6. Any resident teaching provided and the resident's understanding of the treatment. This citation relates to Intakes 2659041 and 2649985. 3.1-47(a)(6)

Based on interview and record review, the facility failed to consistently document the pain status of 1 of 3 residents revived for receipt of pain medications during a time period of five days when the resident was without their physician ordered and routinely scheduled opioid pain medication. (Resident B) Findings include: The clinical record of Resident B was reviewed on 6-26-25 at 12:24 p.m. The diagnoses included, but were not limited to, polyosteoarthritis, unspecified severe dementia and late onset Alzheimer's disease. His most recent Minimum Data Set assessment, dated 6-12-25, indicated his cognition was severely impaired, he received routine or scheduled pain medication and received hospice services. An observation of Resident B on 6-26-25 at 10:16 a.m., revealed his speech was unclear, not in response to situation and with no discernable speech pattern. Resident B did not display any signs of pain or discomfort at that time. During the entrance conference with the Executive Director on 6-25-25, she indicated she was unaware of any medication errors since she arrived to the facility in early [DATE]. On 6-25-25 at 2:50 p.m., the Executive Director provided a written statement which indicated, No med error from [DATE] to current 6-25-25. In an interview on 6-25-25 at 3:30 p.m., with the Director of Nursing and the Assistant Director of Nursing, each indicated they were unaware of any issues with any residents not having their scheduled pain medication for several days last month. A review of Resident B's [DATE] Medication Administration Record (MAR) denoted he did not receive his physician-ordered medication of Norco (an opioid combination product of hydrocodone and acetaminophen) 5-325 milligrams (mg) four times daily for pain and discomfort of left ankle fracture from the morning dose of 5-21-25, through the evening/bedtime dose on 5-26-25. The order for this medication also included an entry to include an assessment for the resident's pain level, at the time of the medication's administration. During the time period of 5-21-25 through 5-26-25 when the medication was not available for administration, the entry box for the pain assessment was blocked out with a computer-generated x, which did not allow an assessment to be entered into the MAR. During this same time period, Resident B did receive two doses of morphine sulfate concentrate of 20 mg/milliliter (ml) with instructions to administer 0.25 ml (or 5 mg) by mouth every two hours as needed for pain and shortness of breath. The doses were administered, on 5-21-25 at 8:58 a.m. and 5-24-25 at 10:05 a.m., with the pain level indicated to be at a level of 4 out of 10, with follow-up documentation the medication had been effective. A review of the nursing progress notes, during the time period of 5-21-25 through 5-26-25, reflected the administration of the above mentioned morphine sulfate, and indicated both doses were effective. No other notations regarding Resident B's pain status were located in the nursing progress notes. In an interview with the Corporate Nurse, on 6-26-25 at 2:25 p.m., she indicated the facility nursing staff, charts by exception, so there wouldn't be a note unless there was an issue about his pain. On 6-26-25 at 3:01 p.m., the Corporate Nurse provided a copy of a policy entitled, Pain Management, with a copyright date of 2025. This policy indicated, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences .The facility will utilize a systemic approach for recognition, assessment, treatment and monitoring of pain .The facility will use a pain assessment tool, which is appropriate for the resident's cognitive status, to assist staff in consistent assessment of a resident's pain . This citation relates to Complaint IN00462164. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure 1 of 3 residents reviewed for receipt of pain medications received their medications as ordered by the physician and failed to ensure an investigation was conducted into the issue of the lack of receipt of scheduled pain medication for five days. (Resident B) Findings include: The clinical record of Resident B was reviewed on 6-26-25 at 12:24 p.m. The diagnoses included, but were not limited to, polyosteoarthritis, unspecified severe dementia and late onset Alzheimer's disease. His most recent Minimum Data Set assessment, dated 6-12-25, indicated his cognition was severely impaired, he received routine or scheduled pain medication and received hospice services. An observation of Resident B, on 6-26-25 at 10:16 a.m., revealed his speech was unclear, not in response to situation and with no discernable speech pattern. During the entrance conference with the Executive Director on 6-25-25, she indicated she was unaware of any medication errors since she arrived to the facility in early May 2025. On 6-25-25 at 2:50 p.m., the Executive Director provided a written statement which indicated, No med error from May 1, 2025 to current 6-25-25. In an interview on 6-25-25 at 3:30 p.m., with the Director of Nursing and the Assistant Director of Nursing, each indicated they were unaware of any issues with any residents not having their scheduled pain medication for several days last month. A review of Resident B's May 2025 Medication Administration Record (MAR) denoted he did not receive his physician-ordered medication of Norco (an opioid combination product of hydrocodone and acetaminophen) 5-325 milligrams (mg) four times daily for pain and discomfort of left ankle fracture from the morning dose of 5-21-25, through the evening/bedtime dose on 5-26-25. It did indicate Resident B did receive the third dose of the day on 5-26-25. The corresponding nurse's notes for this time period indicated the following: 5-21-25 at 8:24 a.m., and 11:58 a.m., med not available. 5-21-25 at 3:09 p.m. med not available; talk to hospice for refill. 5-22-25 at 7:27 a.m. and 11:28 a.m., reordered. 5-22-25 at 5:12 p.m. and 9:31 p.m., on order. 5-23-25 at 11:13 a.m., 11:16 a.m., 4:39 p.m. and 9:23 p.m., on order. 5-24-25 at 10:05 a.m., and 12:03 p.m., drug item unavailable. 5-24-25 at 4:42 p.m., and 7:22 p.m., on order. 5-25-25 at 7:50 a.m., and 12:18 p.m., no information documented. 5-25-25 at 9:02 p.m., on order. 5-26-25 at 12:16 p.m., and 3:52 p.m., no information documented. 5-26-25 at 10:26 p.m. on order. The associated narcotic record for Resident B's Norco 5-325 mg four times daily for pain and discomfort of left ankle fracture indicated there were no doses signed out by the facility's nursing staff after 5-20-25 at 12:00 p.m. (noon) until the next dose signed out on 5-27-25 at 12:00 p.m. The narcotic record indicated fifty-six (56) tablets of this medication were received from the contracted pharmacy, on 5-26-25, with no time indicated of the medication's receipt. The nursing progress notes during the time period of 5-21-25 to 5-27-25 did not reflect any notifications of Resident B's responsible party being made aware of the lack of scheduled pain medication. The only notation of communication to the medical provider of the lack of the scheduled pain medication was as indicated above on 5-21-25, nor was the status of obtaining the medication indicated during the same time period. In an interview with the Corporate Nurse, on 6-26-25 at 1:05 p.m., she indicated she was unable to locate any of the documentation from May 21st to May 26, 2025, that addresses anything about letting hospice or the attending physician know this resident was out of his Norco but will keep looking. In talking with the attending physician and pharmacy, I discovered some of the staff had reached out to them for a new script, but since he was a hospice resident, they [hospice] were responsible for the order. The staff did reach out to hospice for the new script. On 6-26-25 at 1:22 p.m., the Corporate Nurse provided a copy of a policy entitled, Medication Errors, with a copyright date of 2025. This policy indicated, It is the policy of this facility to provide protections for the health, wealth, and rights of each resident by ensuring residents receive care and services in an environment free of significant medication errors. 'Medication error' means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order .or accepted professional standards and principles which apply to professionals providing services .The facility shall ensure medications will be administered as follows: According to physician's orders .Medication errors, once identified, will be evaluated to determine if considered significant or not by utilizing the following three general guidelines: Resident's Condition .Drug Category .Frequency of Error .The facility will consider factors indicating errors in medication administration, including, but not limited to the following: Medication administered not in accordance with the prescriber's order .If a medication error occurs, the following procedures will be initiated .Monitor and document the resident's condition .Document actions taken in the medical record. Once the resident is stable, the nurse reports the incident to the appropriate supervisor and completes the incident or occurrence report . On 6-26-25 at 1:30 p.m., the Corporate Nurse provided a copy of a policy entitled, Unavailable Medications, with a copyright date of 2025. This policy indicated, The facility shall use uniform guidelines for unavailable medications. The facility maintains a contract with a pharmacy provider to supply the facility with routine, prn [as needed or requested], and emergency medications. A STAT [immediate or emergent] supply of commonly used medications is maintained in-house for timely initiation of medications. The facility shall follow established procedures for ensuring residents have a sufficient supply of medications. Medications may be unavailable for a number of reasons. Staff shall take immediate action when it is known that the medication is unavailable: Determine reason for unavailability, length of time medication is unavailable, and what efforts have been attempted by the facility or pharmacy provider to obtain the medication; Notify physician of inability to obtain medication upon notification or awareness that medication is not available. Obtain alternative treatment orders and/or specific orders for monitoring resident while medication is on hold .If a resident misses a scheduled dose of the medication, staff shall follow procedures for medication errors, including physician/family notification . This citation relates to Complaint IN00462164. 3.1-25(a) 3.1-25(b)(3) 3.1-25(b)(9)

Based on observation, interview, and record review, the facility failed to timely notify the attending physician, hospice provider, and the resident's representative of a lack of pain medication and continued status of the medication's unavailability for 1 of 3 residents reviewed for pain medication receipt. (Resident B) Findings include: The clinical record of Resident B was reviewed on 6-26-25 at 12:24 p.m. The diagnoses included, but were not limited to, polyosteoarthritis, unspecified severe dementia and late onset Alzheimer's disease. His most recent Minimum Data Set assessment, dated 6-12-25, indicated his cognition was severely impaired, he received routine or scheduled pain medication and received hospice services. An observation of Resident B, on 6-26-25 at 10:16 a.m., revealed his speech was unclear, not in response to situation and with no discernable speech pattern. A review of his May 2025 Medication Administration Record (MAR) denoted he did not receive his physician-ordered medication of Norco (an opioid combination product of hydrocodone and acetaminophen) 5-325 milligrams (mg) four times daily for pain and discomfort of left ankle fracture from the morning dose of 5-21-25, through the evening/bedtime dose on 5-26-25. It did indicate Resident B received the third dose of the day on 5-26-25. The corresponding nurse's notes for this time period indicated the following: 5-21-25 at 8:24 a.m., and 11:58 a.m. - med not available. 5-21-25 at 3:09 p.m. - med not available; talk to hospice for refill. 5-22-25 at 7:27 a.m. and 11:28 a.m. - reordered. 5-22-25 at 5:12 p.m. and 9:31 p.m. - on order. 5-23-25 at 11:13 a.m., 11:16 a.m., 4:39 p.m., and 9:23 p.m. - on order. 5-24-25 at 10:05 a.m., and 12:03 p.m. - drug item unavailable. 5-24-25 at 4:42 p.m., and 7:22 p.m. - on order. 5-25-25 at 7:50 a.m., and 12:18 p.m. - no information documented. 5-25-25 at 9:02 p.m. - on order. 5-26-25 at 12:16 p.m., and 3:52 p.m. - no information documented. 5-26-25 at 10:26 p.m. - on order. The associated narcotic record for Resident B's Norco 5/325 mg four times daily for pain and discomfort of left ankle fracture indicated there were no doses signed out by the facility's nursing staff after 5-20-25 at 12:00 p.m. (noon) until the next dose signed out on 5-27-25 at 12:00 p.m. The narcotic record indicated fifty-six (56) tablets of this medication were received from the contracted pharmacy on 5-26-25, with no time indicated of the medication's receipt. The nursing progress notes, during the time period of 5-21-25 to 5-27-25, did not reflect any notifications of Resident B's responsible party being made aware of the lack of scheduled pain medication. The only notation of communication to the medical provider of the lack of the scheduled pain medication was as indicated above on 5-21-25, nor was the status of obtaining the medication indicated during the same time period. During an interview with the Corporate Nurse on 6-26-25 at 1:05 p.m., she indicated she was unable to locate any of the documentation from May 21st to May 26, 2025, that addresses anything about letting hospice or the attending physician know this resident was out of his Norco but will keep looking. In talking with the attending physician and pharmacy, I discovered some of the staff had reached out to them for a new script, but since he was a hospice resident, they [hospice] were responsible for the order. The staff did reach out to hospice for the new script. I did not see any documentation that addressed the resident's responsible party was made aware of the situation. On 6-26-25 at 1:22 p.m., the Corporate Nurse provided a copy of a policy entitled, Notification of Changes, with a copyright date of 2024. This policy indicated, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification .Circumstances requiring notification include .Circumstances that require a need to alter treatment. This may include: New treatment. Discontinuation of a current treatment due to: Adverse consequences. Acute condition. Exacerbation of a chronic condition . On 6-26-25 at 1:30 p.m., the Corporate Nurse provided a copy of a policy entitled, Unavailable Medications, with a copyright date of 2025. This policy indicated, The facility shall use uniform guidelines for unavailable medications . Staff shall take immediate action when it is known that the medication is unavailable: Determine reason for unavailability, length of time medication is unavailable, and what efforts have been attempted by the facility or pharmacy provider to obtain the medication; Notify physician of inability to obtain medication upon notification or awareness that medication is not available. Obtain alternative treatment orders and/or specific orders for monitoring resident while medication is on hold .If a resident misses a scheduled dose of the medication, staff shall follow procedures for medication errors, including physician/family notification . This citation relates to Complaint IN00462164. 3.1-5(a)(2)

Based on interview and record review, the facility failed to ensure care plan meetings were held quarterly for 4 of 5 residents reviewed for care planning. (Resident G, Resident 22, Resident 39, and Resident 80) Findings include: 1. The clinical record for Resident G was reviewed on 3/19/25 at 2:58 p.m. The diagnoses included, but were not limited to, dementia, anxiety disorder, insomnia, vertigo, and neoplasm of uncertain behavior of skin. An Annual Minimum Data Set (MDS) assessment, dated 1/16/25, indicated Resident G was severely cognitively impaired. An interview conducted with a family member of Resident G, on 3/19/25 at 11:25 a.m., indicated she was the power of attorney (POA) for Resident G and the facility was not good with communication. There had not been a care plan meeting for a long time. A progress note titled Care Plan Meeting Minutes, dated 10/11/24, indicated a quarterly care plan meeting was held with the family member of Resident G. There were no further indications of a care plan meeting being held with the family member of Resident G since 10/11/24. 50436 2. During an interview with Resident 39 on 3/19/25 at 11:02 a.m., they indicated they could not recall having care plan meetings. The clinical record for Resident 39 was reviewed on 3/19/25 at 2:23 p.m. The diagnoses included, but were not limited to, polyneuropathy and major depressive disorder. The Electronic Health Record (EHR) indicated Resident 39 had a care plan meeting on 6/7/24. The EHR indicated no care plan meetings were held after 6/7/24. The Annual MDS assessment, dated 2/26/25, indicated Resident 39 was cognitively intact. The MDS indicated it was very important to Resident 39 to have family, or a close friend involved in discussion about their care. During an interview with the Social Service Director (SSD) on 3/20/25 at 1:10 p.m., they indicated Resident 39 had not had a care plan meeting since 6/7/24. The SSD indicated the facility should have care plan meetings for residents quarterly and as needed. The SSD also indicated it was social services who were responsible for holding care plan meetings for residents and she did not know why the previous SSD did not have any further meetings for Resident 39. 25054 3. During an interview with Resident 22 on 3/19/25 at 11:13 a.m., he indicated he did not have care plan meetings. Resident 22 indicated last year there was one scheduled and he was sick, and no one rescheduled it. Resident 22 indicated that was the only time he had been invited to one. During an interview with the SSD on 3/20/25 at 1:05 p.m., she indicated the facility was supposed to have care plan meetings with residents every three months and on admission. Review of the clinical record of Resident 22, on 3/20/25 at 1:40 p.m., indicated the diagnoses included, but were not limited to, chronic obstructive pulmonary disease, morbid obesity, diabetes, asthma, pulmonary hypertension, anxiety disorder, atrial fibrillation, agitation, and post-traumatic stress disorder. The Quarterly MDS assessment, dated 1/7/25, indicated the resident was cognitively intact for daily decision making. The resident was reasonable and consistent. A care plan meeting for Resident 22, dated 6/6/24, indicated the resident advised to invite no family and the resident declined to attend. A care plan meeting for Resident 22, dated 12/10/24, indicated the resident declined to come. These were the only two care plan meetings for 2024. The resident had no documented care plan meetings in 2025. 4. During an interview with Resident 80 on 3/19/25 at 11:30 a.m., she indicated she had never been invited to a care plan meeting since she was admitted to the facility. Review of the record of Resident 80, on 3/20/25 at 2:10 p.m., indicated the diagnoses included, but were not limited to, bipolar disorder, anxiety disorder, morbid obesity, hypertension, muscle weakness and insomnia. The Admission MDS assessment for Resident 80, dated 12/26/24, indicated the resident was cognitively intact for daily decision making. The resident was consistent and reasonable. The resident was admitted to the facility on [DATE]. The resident's clinical record indicated the resident had not had any care plan meetings since admission to the facility. During an interview with the SSD on 3/20/25 at 1:05 p.m., she indicated the facility was supposed to have care plan meetings with residents every three months and on admission. The care planning resident participation policy provided by the Corporate Nurse, on 3/21/25 at 12:05 p.m., indicated the facility supports the resident's right to be informed of, and participate in, his or her care planning and treatment. The facility would notify the resident and/or the resident representative in advance. The facility would honor the resident's right to participate in establishing the expected goals and outcome of the care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. The facility would discuss the plan of care with the resident and/or the representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes. The facility would make an effort to schedule the conference at the best time of the day for the resident and/or resident representative. The facility would obtain a signature from the resident and/or resident representative after discussion or viewing of the care plan. 3.1-35(d)(2)(B)

Based on observation, interview, and record review, the facility failed to ensure a resident was assisted with eating timely that resulted in the resident taking food and drinks from other residents (Resident 67), ensure a resident was assisted with changing his clothes and assisted with shaving (Resident G), ensure a resident was provided showers as preferred (Resident J), and ensure assistance with transfer/ambulation (Resident 190) for 4 of 6 residents reviewed for activities of daily living (ADLs). Findings include: 1. The clinical record for Resident 67 was reviewed on 3/21/25 at 11:49 a.m. The diagnoses included, but were not limited to, schizophrenia, alcohol-induced persisting dementia, and anxiety disorder. A Quarterly Minimum Data Set (MDS) assessment, dated 1/30/25, indicated severe cognitive impairment and supervision with one staff person for eating. An ADL care plan, revised 10/24/24, indicated Resident 67 was able to eat with setup assistance of one staff person. An observation was conducted of lunch meal service in the Alzheimer's Care Unit (ACU) on 3/19/25 from 12:15 p.m. to 12:55 p.m. During the observation, Resident 67 was sitting at a dining table with Resident 21. The Dementia Care Director gave Resident 21 a cup of coffee. Resident 67 then asked for a cup of coffee and the Dementia Care Director stated, hold on. Resident 67 reached for Resident 21's coffee and was redirected by staff not to reach for Resident 21's coffee. Resident 67 reached for Resident 21's coffee, again, and was able to get a hold of the coffee and she drank the remainder of the coffee in Resident 21's cup, that was previously consumed by Resident 21. Resident 21 stated that's mine when Resident 67 got a hold of the coffee cup and proceeded to drink it. Resident 67 later proceeded to reach for Resident 21's food off her tray that was set in front of her. Resident 21 stated to Resident 67 get away from mine. Resident 21 put her hand up while commenting to Resident 67, but no physical contact was made. The nursing staff proceeded to take Resident 67 to another table, at 12:45 p.m., where Resident 82 was sitting and consuming his lunch. Resident 67 still had not received her meal tray at that time. Resident 67 reached over to Resident 82's tray and took a plastic container of cake that was not open and was able to open it. Resident 82 noticed Resident 67 had opened his container of cake and Resident 82 grabbed the plastic container to retrieve the cake. Facility staff intervened and let Resident 67 keep the plastic container of cake and got Resident 82 another piece of cake. While the staff were retrieving another piece of cake for Resident 82, Resident 67 reached towards Resident 82's cup of coffee and proceeded to drink the remainder of the coffee. The facility staff assisted Resident 67 to another table, brought her food tray over, and she proceeded to consume her lunch without any further issues. An interview conducted with Certified Nurse Aide (CNA) 2, on 3/20/25 at 9:00 a.m., indicated Resident 67 can be grabby at times with food, especially sweets. The goal was to provide Resident 67 with her entree first and then give her dessert when she finished the entree. If she were to see the dessert first, she would only want to focus on the dessert and not her entire meal. There were times that Resident 67 will just sit there and not even attempt to feed herself and other days she will be fully capable of feeding herself. The staff try to sit Resident 67 places, not by herself, but in positions to where she cannot grab others food. 2. The clinical record for Resident G was reviewed on 3/20/25 at 2:04 p.m. The diagnoses included, but were not limited to, dementia, anxiety disorder, and need for assistance with personal care. An Annual MDS assessment, dated 1/16/25, indicated supervision with set up assistance for shower/bathing, upper and lower body dressing, and personal hygiene. An ADL care plan, revised 1/25/25, indicated Resident G had an ADL self-care performance deficit related to confusion and dementia. The interventions included, but were not limited to, shower with supervision of one staff member, supervision of one staff member for dressing, supervision of one staff member for personal hygiene, and resident prefers long hair and a beard (initiated 10/24/24). An observation was conducted of Resident G, on 3/19/25 at 10:05 a.m., of him wearing a white shirt with brown spots scattered on the shirt. There was stubble to his face. An observation was conducted of Resident G, on 3/19/25 at 12:15 p.m., of him wearing the same white shirt with brown spots scattered on the shirt. Resident B approached the staff and showed them a razor that was broken in half. The resident indicated he wanted to shave but couldn't shave due to the razor being broken. The nursing staff removed the razor and told the resident they will assist with shaving him later. The stubble remained to his face. An observation was conducted of Resident G, on 3/19/25 at 2:50 p.m., of him wearing the same white shirt with brown spots scattered on the shirt. The stubble remained to his face. An observation and interview were conducted of Resident G, on 3/20/25 at 12:08 p.m., of him lying in bed wearing the same white shirt, from 3/19/25, with brown spots scattered on the shirt. Resident G indicated he had not been shaved, and the stubble remained on his face. He indicated the razor he had was broken and he no longer had one to shave himself and indicated I need to put it up, got some marks on it, when asked about his white shirt with brown spots on it. There were no care plans to indicate Resident G refused care. Shower documentation for March 2025 indicated the following showers/baths for Resident G: 3/10/25 - refused, 3/13/25 - shower completed, 3/17/25 - refused shower, and 3/20/25 - shower completed. A policy entitled Activities of Daily Living, dated August 2024, was provided by the Corporate Nurse on 3/21/25 at 9:50 a.m. The policy indicated the facility would provide care and services for bathing, dressing, grooming, oral care, transfer and ambulation, toileting, and eating to include meals and snacks. 45291 3. The clinical record for Resident J was reviewed on 3/21/2025 at 12:45 p.m. The medical diagnoses included respiratory failure and diabetes. A Quarterly Minimum Data Set assessment, dated 2/7/2025, indicated Resident J was cognitively intact and did not exhibit behaviors. A care plan, revised 11/13/2024, indicated Resident J needed assistance of one staff member for showers. A CNA task sheet, provided on 3/21/2025 at 2:00 p.m., indicated Resident J was scheduled for showers every Tuesday and Friday on the evening shift. During an interview on 3/19/2025 at 12:12 p.m., Resident J indicated staff do not shower him as often as he would like. He stated he would like showers every other day, but he was lucky to get one a week. He stated in the last month; he had missed showers more than he received them. Review of the shower documentation indicated Resident J received a partial bed bath, on 2/25/2025, instead of a shower and no refusal was recorded along with no documentation, for 3/7/2025, regarding his scheduled shower. During an interview on 3/21/2025 at 1:57 p.m., Resident J indicated he was given his nighttime care of washing his hands and face, on 2/25/2025, but the staff did not offer him a bath. He stated, on 3/7/2025, the staff did not offer to give him a shower. 4. The clinical record for Resident 190 was reviewed on 3/24/2025 at 2:30 p.m. The medical diagnoses included pain and anxiety. A nursing assessment, dated 3/13/2025, established Resident 190's functional status at admission. Resident 190 utilized supervision or touch assistance for walking 10 and 50 feet with a walker. During an interview on 3/19/2025 at 10:33 a.m., Resident 190 was noted to stand up from his wheelchair in the common room with his walker next to him. Registered Nurse (RN) 13 immediately came to Resident 190 and assisted him in the toilet. Resident 190 was brought back to the common room in his wheelchair. Resident 190's walker was placed out of his reach. Within a few minutes, Resident 190 attempted to stand from his wheelchair. RN 13 and CNA 11 assisted Resident 190 with standing. CNA 11 retrieved Resident 190's walker and gave it to him. CNA 11 stood next to Resident 190 for less than a minute before walking way to attend to another resident. Resident 190 began to walk around the common room without staff assistance. During an interview on 3/19/2025 at 10:39 a.m., RN 13 indicated they did not know Resident 190's transfer or ambulation status. During an interview on 3/19/2025 at 10:42 a.m., CNA 11 indicated she believed Resident 190 was able to be up on his own. A policy entitled, Resident Showers, was provided by the Director of Nursing Services on 3/24/2025 at 9:52 a.m. The policy indicated, .Residents will be provided showers as per request or as per facility schedule . A policy entitled, Safe Resident Transfer/Handling, was provided by the Director of Nursing Services on 3/24/2025 at 9:52 a.m. The policy indicated, .All residents require safe handling when transferred to prevent or minimize the risk for injury . This citation is related to Complaints IN00454664 and IN00454943. 3.1-38(a)(2)(A) 3.1-38(a)(2)(B) 3.1-38(a)(3)(A) 3.1-38(a)(3)(D)

Based on interview and record review, the facility failed to promote dignity for 2 of 4 residents reviewed for quality of care. (Resident B and Resident H) Findings include: 1a. The clinical record for Resident B was reviewed on 3/20/2025 at 11:30 a.m. The medical diagnoses included dementia and anxiety. A Quarterly Minimum Data Set assessment, dated 12/20/2024, indicated Resident B was cognitively impaired, did not have behaviors of rejecting care, was incontinent of bowel and bladder, and dependent on staff for toileting needs. An incontinence care plan, revised 2/2/2025, indicated Resident B had functional bladder incontinence. Resident B needed interventions of checking and changing incontinent products as needed. A grievance form, dated 2/26/2025, indicated a concern was filed regarding Resident B being left sitting in his chair for an extended period and regarding the last time he was assisted with toileting needs. 1b. The clinical record for Resident F was reviewed on 3/19/2025 at 2:04 p.m. The medical diagnosis included anxiety disorder. A Quarterly Minimum Data Set assessment, dated 1/7/2025, indicated Resident F was cognitively intact. During an interview on 3/19/2025 at 11:30 a.m., Resident F indicated he was very concerned about how the staff treat Resident B because staff will often get Resident B out of bed, around 9:30 a.m., and do not change Resident B until they lay him down for bed around 9:30 p.m. Resident F recalled a specific time instance that Resident B was taken to sit in front of the television in the common room, at 9:30 a.m., and was not brought back to the room until 9:30-10:00 p.m. Resident B was noted to be soaking wet with urine. Resident F felt it was disrespectful and ridiculous for Resident B to be left up all day and be urine soaked. 2. The clinical record for Resident H was reviewed on 3/21/2025 at 11:30 a.m. The medical diagnoses included diabetes and chronic obstructive pulmonary disease. An Admission Minimum Data Set assessment, dated 2/10/2025, indicated Resident H was cognitively intact, did not reject care, and was frequently incontinent of bowel and bladder. Care plans, revised 2/24/2025, indicated Resident H had incontinence of bowel and bladder, requiring the need for assistance with incontinence care. During an interview with Resident H on 3/18/2025 at 1:45 p.m., she indicated there were times her call light went off for an extended period. Resident H provided handwritten notes of how long her call light was on before it was answered. During this time frame, Resident H indicated she had episodes of bladder and bowel incontinence, but one specific incident resulted in her becoming incontinent of a bowel movement and sitting in her waste for over an hour. This made Resident H feel disgusting and humiliated. Review of the handwritten notes provided by Resident H indicated the following times she waited over thirty minutes to have her call light answered: 3/10/2025 - call light turned on at 6:20 p.m. and answered at 7:10 p.m., 3/11/2025 - call light turned on at 6:25 p.m. and answered at 7:30 p.m., 3/15/2025 - call light turned on at 1:19 p.m. and answered at 2:25 p.m., 3/16/2025 - call light turned on at 11:00 a.m. and answered at 11:45 a.m., 3/16/2025 - call light turned on at 2:20 p.m. and answered at 3:10 p.m., and 3/16/2025 - call light turned on at 8:15 p.m. and answered at 9:15 p.m. During an interview with the Director of Nursing Services on 3/24/2025 at 2:05 p.m., she indicated it was the expectation for all residents to be treated with dignity and respect. 3.1-3(a) 3.1-3(t)

Based on interview and record review, the facility failed to timely follow up on a resident's request to be transferred to the hospital for treatment regarding scrotal swelling and pain for 1 of 2 residents reviewed for choices. (Resident J) Findings include: The clinical record for Resident J was reviewed on 3/21/2025 at 12:45 p.m. The medical diagnoses included respiratory failure and diabetes. A Quarterly Minimum Data Set assessment, dated 2/7/2025, indicated Resident J was cognitively intact and did not exhibit behaviors. A care plan, revised 11/15/2023, indicated Resident J had depression and a psychotic disorder. Interventions were listed to allow and encourage choices. During an interview on 3/19/2025 at 12:12 p.m., Resident J indicated earlier this month he had swelling to his scrotum. He requested to go to the emergency room , but the nurse came in and told him to take some pain medicine. He stated he took the pain medicine and then asked to go to the ER [emergency room ], but she wouldn't send him. The next day, the pain to his scrotum continued. Around evening into night shift change, on 3/3/2025, per Resident J, he asked to go to theER on ce more, but the nurse wouldn't send him. He stated he waited a few more hours, but the pain was getting too severe, so he asked to be transferred to the ER again, but the nurse wouldn't send him. He indicated he then called emergency services to be transferred to the hospital. A physician order, dated 10/25/2024, indicated for Resident J to utilize Norco (narcotic pain medication) 10/325 mg (milligrams) every six hours as needed for severe pain. A nursing progress note, dated 3/2/2025 at 3:26 a.m., indicated the nurse was called to Resident J's room for scrotal swelling, redness, and pain. The nurse called the on-call provider and received an order to elevate the areas of swelling and administer pain medication. A nursing progress note, dated 3/3/2025 at 2:42 a.m., indicated the nurse was alerted to the police department responding to Resident J's call to emergency services related to wanting to go the hospital for severe groin pain. The nurse notified the on-call provider and placed a call to emergency services. A nursing progress note, dated 3/3/2025 at 2:54 a.m., indicated Resident J was transferred to the hospital via emergency services. Review of the March 2025 Medication Administration Record (MAR) indicated Resident J utilized Norco twice, on 3/2/2025, for pain rated 8 out of 10 (severe pain). During an interview on 3/21/2025 at 11:09 a.m., Certified Nurse Aide (CNA) 14 indicated she remembered working with Resident J when he had a swollen scrotum. Resident J had requested, around 10:00 - 11:00 p.m., to go the hospital, but she could not remember if it was the first (3/2/2025) or the second (3/3/2025) night she worked with him. She stated she then went and told the nurse, but he was not sent out right away. She doesn't remember the police department coming, but she remembered in the middle of the shift Resident J was transferred to the hospital. During an interview on 3/21/2025 at 1:30 p.m., Registered Nurse (RN) 15 indicated she worked with Resident J on 3/3/2025 and 3/4/2025. She stated she never heard Resident J request to go to the hospital and nothing was unusual with the shift. When progress notes were read back to RN 15, she stated he had requested to go to the hospital, but the on-call provider wanted to give as needed pain medication. She stated she worked with him the next night as well, the lady that works at the end of the hall told her Resident J wanted to go to the hospital, but she was unsure of the time. She went to assess resident, and he had scrotal swelling, continuing from the night before. She did not send him to the hospital. During an interview on 3/20/2025 at 11:30 a.m., the Assistant Director of Nursing indicated he was the one that sent Resident J to the hospital on 3/3/2025. He stated RN 15 told him Resident J wanted to go to the hospital, so he started the transfer, but the police department showed up during that time as well. He had not heard anything prior to this about Resident J wanting to go to the hospital, but it was the expectation of the facility that if a resident was alert, oriented, and made their own decisions, staff would send them to the hospital per their request. During an interview on 3/25/2025 at 11:30 a.m., the Director of Nursing Services indicated she could not locate any assessments or notes other than the listed progress notes for Resident J between 3/2/2025 and 3/3/2025. Hospital paperwork, dated 3/6/2025, indicated Resident J was admitted to the local hospital from 3/3/2025-3/6/2025 for scrotal swelling, urinary retention, and hematuria (blood in the urine). Resident J was treated with continuous bladder irrigation, diuretics (water pills), and antibiotics. A policy entitled, Resident Rights, was provided by the Director of Nursing Services on 3/24/2025 at 9:52 a.m. The policy indicated, .The facility will ensure that all direct care and indirect care staff members .are educated on the right of residents and the responsibility of the facility to properly care for its residents . 3.1-3(n)(3)

Based on interview, observation, and record review, the facility failed to ensure a grievance was forwarded to the grievance official and failed to implement a resolution of a grievance for 2 of 2 residents reviewed for grievances. (Resident H and Resident B) Findings include: 1a. The clinical record for Resident H was reviewed on 3/21/2025 at 11:30 a.m. The medical diagnoses included diabetes and chronic obstructive pulmonary disease. An Admission Minimum Data Set assessment, dated 2/10/2025, indicated Resident H was cognitively intact, did not reject care, and was frequently incontinent of bowel and bladder. Care plans, revised 2/24/2025, indicated Resident H had incontinence of bowel and bladder and required the need for assistance with incontinence care. During an interview with Resident H on 3/18/2025 at 1:45 p.m., she indicated she filled out two grievances since she had been in the facility. She believed one grievance was filled out at the end of February, the other was filled out about two weeks ago, and both were given to Qualified Medication Aide (QMA) 9. Review of the grievance log, on 3/21/2025 at 12:40 p.m., indicated Resident H had filed a grievance on 2/28/2025. There were no other grievances on file at that time for Resident H. During an interview with Resident H on 3/21/2025 at 1:45 p.m., she indicated no one ever followed up with her about her grievances. She stated, [The Administrator] came down to talk to me about the first one, but she got called away. I don't know what they're supposed to do to help, or anything, but no one ever talked to me about it. 1b. The clinical record for Resident 68 was reviewed on 3/24/2025 at 11:55 a.m. The medical diagnosis included chronic obstructive pulmonary disease. An Admission Minimum Data Set assessment, dated 1/21/2025, indicated Resident 68 was cognitively intact. An interview conducted with Resident 68, on 3/21/2025 at 1:40 p.m., indicated she was present when Resident H provided both grievances to QMA 9. 2a. The clinical record for Resident F was reviewed on 3/19/2025 at 2:04 p.m. The medical diagnosis included anxiety disorder. A Quarterly Minimum Data Set assessment, dated 1/7/2025, indicated Resident F was cognitively intact. During an interview on 3/19/2025 at 11:30 a.m., Resident F indicated he was very concerned about how the staff treat Resident B because staff will often get Resident B out of bed, around 9:30 a.m., and do not change Resident B until they lay him down for bed around 9:30 p.m. Resident F indicated he reported these concerns in the form of a grievance on behalf of Resident B and the staff have not corrected leaving Resident B up for an extended period of time. During an interview on 3/24/2025 at 12:45 p.m., Resident F indicated staff have not been laying his roommate, Resident B, down between meals. He stated if, and it was very rare that they do, the staff lay Resident B down between lunch and supper, then the staff do not get Resident B back up for dinner at all. He stated the staff had laid Resident B down between lunch and supper less than a handful of times since he raised his concern on 2/26/2025. 2b. The clinical record for Resident B was reviewed on 3/20/2025 at 11:30 a.m. The medical diagnoses included dementia and anxiety. A Quarterly Minimum Data Set assessment, dated 12/20/2024, indicated Resident B was cognitively impaired, did not have behaviors of rejecting care, was incontinent of bowel and bladder, and dependent on staff for toileting needs. An incontinence care plan, revised 2/2/2025, indicated Resident B had functional bladder incontinence. Resident B needed interventions of checking and changing incontinent products as needed. A grievance form, dated 2/26/2025, indicated a concern was filed regarding Resident B being left sitting in his chair for an extended period and regarding the last time he was assisted with toileting needs. The resolution entered on the grievance was to place Resident B back to bed after lunch and supper. During an observation on 3/19/2025 at 2:30 p.m., Resident B was noted to be sleeping in his Geri chair in the common room. During an observation on 3/21/2025 at 1:50 p.m., Resident B was noted to be sleeping in his Geri chair in the common room. A policy entitled, Resident and Family Grievances, was provided by the Director of Nursing Services on 3/24/2025 at 9:56 a.m. The policy indicated if a staff receives a grievance, then they are to forward the grievance form to the Grievance Official as soon as practicable, and the Grievance Official will take steps in resolving grievances. 3.1-7(a)(2)

Based on interview and record review, the facility failed to accurately input medication data into the Minimum Data Set (MDS) assessment for 1 of 1 resident reviewed for MDS accuracy. (Resident 70) Findings include: The clinical record for Resident 70 was reviewed on 3/20/25 at 11:41 a.m. The diagnoses included, but were not limited to, diabetes mellitus and dementia. The Admission MDS assessment, dated 2/14/25, indicated Resident 70 was on an anti-coagulant (blood thinner) and an antibiotic. Resident 70's Electronic Health Record (EHR) indicated no current order for an antibiotic or an anti-coagulant. The EHR indicated Resident 70 was on Plavix, which is considered an anti-platelet drug, not an anti-coagulant. During an interview with the MDS Coordinator on 3/20/25 at 12:08 p.m., she indicated she should have marked the anti-platelet tab and not the anti-coagulant tab while entering information into the Resident Assessment Instrument for inputting data. The MDS Coordinator indicated it was her error. The MDS Coordinator also indicated she thought Resident 70 was still on an antibiotic during their seven day look back period, but she was not, and it was entered in error. During an interview with the MDS Coordinator on 3/20/25 at 12:08 p.m., she indicated the Resident Assessment Instrument was used for inputting resident data for the MDS assessment because it had all the tools and information to put into the system.

Based on interview, observation, and record review, the facility failed to establish care plans for refusals of care (Resident H), psychological needs (Resident J), and transfer/ambulation status (Resident 190) for 3 of 8 residents reviewed for care planning. Findings include: 1. The clinical record for Resident H was reviewed on 3/21/2025 at 11:30 a.m. The medical diagnoses included diabetes and chronic obstructive pulmonary disease. An Admission Minimum Data Set assessment, dated 2/10/2025, indicated Resident H was cognitively intact, did not reject care, and was frequently incontinent of bowel and bladder. Review of shower documentation for Resident H indicated she refused nine showers in the last 60 days. No care plan was on file for Resident H's refusals of care. 2. The clinical record for Resident J was reviewed on 3/21/2025 at 12:15 p.m. The medical diagnoses included respiratory failure and diabetes. A Quarterly Minimum Data Set assessment, dated 2/7/2025, indicated Resident J was cognitively intact and did not exhibit behaviors. During an interview on 3/19/2025 at 12:12 p.m., Resident J indicated his roommate exhibited behavior in his room that made him uncomfortable. No care plan indicated Resident J's psychological needs regarding roommate's behavior. 3. The clinical record for Resident 190 was reviewed on 3/24/2025 at 2:30 p.m. The medical diagnoses included pain and anxiety. A nursing assessment, dated 3/13/2025, established Resident 190's functional status at admission. Resident 190 utilized supervision or touch assistance for walking 10 and 50 feet with a walker. During an interview on 3/19/2025 at 10:39 a.m., Registered Nurse (RN) 13 indicated they did not know Resident 190's transfer or ambulation status. During an interview on 3/19/2025 at 10:42 a.m., Certified Nurse Aide (CNA) 11 indicated she believed Resident 190 was able to be up on his own. No care plans were in place to discern Resident 190's transfer or ambulation status. A policy entitled Comprehensive Care Plans was provided by the Corporate Nurse on 3/21/2025 at 9:50 a.m. The policy indicated it was the goal of the facility to develop and implement a comprehensive person-centered care plans for each resident for all nursing, medical, mental, and psychosocial needs. 3.1-35(a) 3.1-35(b)(1) 3.1-35(b)(2)

Based on observation, interview, and record review, the facility failed to ensure a wound dressing remained in place as ordered (Resident G) and weekly skin assessments were conducted per the facility policy (Resident 59) for 2 of 3 residents reviewed for non-pressure skin concerns. Findings include: 1. The clinical record for Resident G was reviewed on 3/19/25 at 2:58 p.m. The diagnoses included, but were not limited to, dementia, anxiety disorder, insomnia, vertigo, and neoplasm of uncertain behavior of skin. An Annual Minimum Data Set (MDS) assessment, dated 1/16/25, indicated Resident G was severely cognitively impaired and had open lesions. A care plan, revised 1/25/25, indicated Resident G had skin impairment related to skin cancer to the right temple. The interventions included, but were not limited to, follow facility protocols for treatment of injury. A physician order, dated 2/18/25, indicated the cleanse the right forehead with wound cleanser, pat dry, apply Vaseline, then cover with foam every other day and as needed for soilage. An interview conducted with a family member of Resident G, on 3/19/25 at 11:25 a.m., indicated she was the power of attorney (POA) for Resident G and the facility was not good with communication. Resident G goes to the cancer center due to skin cancer to the right forehead. The cancer center had expressed concerns recently about the lack of healing and concerns of improper treatment of the wound. The following observations were conducted of Resident G with no treatment in place to the right forehead: 3/19/25 at 10:05 a.m., 3/19/25 at 12:08 p.m., 3/19/25 at 2:50 p.m., and 3/20/25 at 12:08 p.m. 2. The clinical record for Resident 59 was reviewed on 3/21/25 at 12:33 p.m. The diagnoses included, but were not limited to, asthma, Alzheimer's disease, chronic pain, and unspecified psychosis. An Annual MDS assessment, dated 1/8/25, indicated Resident 59 was severely cognitively impaired, supervision with transferring, supervision with walking, and had no skin impairments. A care plan for pressure ulcers, revised 1/12/25, indicated Resident 59 was at risk for pressure ulcers. The interventions included, but were not limited to, follow facility policies/protocols for the prevention/treatment of skin breakdown. The assessments conducted for Resident 59, located in the electronic health record, were reviewed and indicated the last weekly skin assessment was conducted on 2/24/25. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure a resident had weekly skin assessments for 1 of 4 residents reviewed for pressure injuries. (Resident 39) Findings include: The clinical record for Resident 39 was reviewed on 3/19/25 at 2:23 p.m. The diagnoses included, but were not limited to, polyneuropathy, pain, and anxiety. Resident 39 had a care plan, initiated 1/20/25, for potential for pressure ulcer development with an intervention to follow facility policies/protocols for the prevention/treatment of skin breakdown. The Braden Scale (for predicting pressure ulcer risk evaluation document), dated 2/24/25, indicated Resident 39 had a Braden score of 12, indicating Resident 39 was at high risk for developing pressure ulcers. The Annual Minimum Data Set assessment, dated 2/26/25, indicated Resident 39 was cognitively intact, was dependent on a mechanical lift for transfer, was chairfast, always incontinent of bowel and bladder, and was at risk for pressure injuries. Resident 39's weekly skin assessments indicated they had a skin assessment, completed 2/22/25, with skin intact documented. During review of the Electronic Health Record (EHR), Resident 39 did not have another skin assessment, until 3/12/25, which indicated Resident 39 had a new skin issue to the right gluteus, that was a pressure injury, stage 3 (a full-thickness skin loss, where subcutaneous fat is visible, but bone, tendon, or muscle is not exposed), and was acquired in house. A physician's order, dated 3/13/25, indicated to cleanse the right buttock with wound wash, pat dry, apply collagen to wound bed, and cover with a dry bordered dressing every day shift. During a wound care observation of Resident 39 on 3/21/25 at 10:44 a.m., with Registered Nurse (RN) 6, Resident 39 called out that it hurt and was grimacing when RN 6 removed the previous buttock dressing and began to do wound care. During an interview with Resident 39 on 3/24/25 at 11:00 a.m., they indicated they noticed their bottom hurting for some time and she indicated she was scratching it and had informed the aides that it was bothering her, but they told her it was just red from her scratching. Resident 39 indicated it hurts to sit. During an interview with the Director of Nursing Services (DNS) on 3/20/25 at 2:22 p.m., she indicated floor nurses and unit managers were responsible for completing weekly skin assessments. The DNS indicated they recently did a skin sweep of the facility, and the floor nurse staff did not keep up with them (assessments) and the unit managers were supposed to review them. A Skin Assessment policy provided by the DNS, on 3/20/25 at 1:15 p.m., indicated .1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter . A Pressure Injury Prevention and Management policy provided by the DNS, on 3/20/25 at 1:15 p.m., indicated .2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment .3 . (c) Licensed nurses will conduct a full body skin assessment on all residents weekly 3.1-40(a)(1)

Based on observation, interview, and record review, the facility failed to develop and implement a Range of Motion (ROM) program and splint program for a resident with limited ROM for 1 of 1 resident reviewed for ROM (Resident 75). Findings include During an interview with Resident 75 on 3/19/25 at 11:29 a.m., he indicated the facility does not provide him with ROM exercises. The resident indicated he was stiff and needed assistance moving all his extremities. The resident indicated he would like to be provided with ROM exercises. Review of the clinical record of Resident 75, on 3/19/25 at 2:00 p.m., indicated the diagnoses included, but were not limited to, hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting the right dominant side, muscle weakness, difficulty walking, depression and anxiety. The Occupational Therapy evaluation and plan for Resident 75, dated 8/2/24, indicated the goal was for the resident's family and caregivers to be provided with education and training on adaptive hemi-techniques, approach, encouragement, and safest strategies to use with assisting the resident with Activities of Daily Living (ADL), bed mobility, positioning, splinting of the right hand, checking for skin irritation and redness. Passive Range of Motion (PROM), pelvic floor strengthening exercises, and joint protection principles for the right upper and lower extremities. The Occupational Therapy discharge summary for Resident 75, dated 8/23/24, indicated the resident would be provided with a functional maintenance program of ROM and splint/brace program. The plan of care for Resident 75, dated 12/10/24, indicated the resident had an ADL self-care performance deficit related to limited mobility and stroke with right hemiplegia/hemiparesis. The interventions did not include any type of range of motion exercises or right-hand splint application. The most recent Minimum Data Set (MDS) assessment for Resident 75, dated 3/5/25, indicated the resident was moderately impaired for daily decision making. The resident had the ability to be understood and understand others. The resident had impairment of functional range of motion on one side of the upper and lower extremity. During an observation and interview with Resident 75 on 3/21/25 at 1:56 p.m., he indicated he could barely move his right arm, the resident raised his right arm slightly and it was flaccid (hanging loosely), and the resident raised his right leg slightly. The resident indicated it was hard to move his right arm and right leg. The resident indicated he was becoming more stiff. The facility did not provide range of motion exercises. The resident indicated that the CNA's do not provide ROM with care. The resident indicated he would like to be provided with ROM exercises so he could get better. The resident did not have a splint in place on the right hand. During an observation on 3/24/25 at 1:15 p.m., Resident 75 was propelling himself down the hallway in his wheelchair. The resident's right arm was flaccid, and he was not utilizing the right arm to propel himself. The resident was able to move his right leg some to assist in moving himself in the wheelchair. No splint was in place on the right hand. During an interview with Certified Nurse Aide (CNA) 10 on 3/24/25 at 1:16 p.m., they indicated the CNA's do not provide ROM exercises; the restorative aides were responsible for that. CNA 10 indicated they did not know where the facility documented ROM programs for the residents. During an interview with CNA 11 on 3/24/25 at 1:20 p.m., they indicated the CNA's do not provide ROM programs for the residents. The restorative aides were responsible for the ROM programs. During an interview with Restorative Aide 12 on 3/24/25 at 1:25 p.m., they indicated she had been the restorative aide for about a year. There was a binder they documented on and on the computer. Resident 75 was not on a restorative program for ROM exercise. During an interview with the Director of Therapy on 3/24/25 at 1:27 p.m., they indicated Resident 75's family came in the facility every day and provided ROM exercises for Resident 75. During an observation and interview with Resident 75 on 3/24/25 at 1:30 p.m., he indicated his family did not provide ROM exercises for him. The resident's family had their own health issues and was not able to provide ROM exercises for him. The resident indicated he did have a splint for his right hand. The CNAs put the splint on sometimes, but not every day. The resident indicated the splint does not bother him and he had never refused to wear it. The resident did not have a splint in place on the right hand. During an interview with the Director of Therapy on 3/24/25 at 1:33 p.m., they indicated the family, and the CNAs should be providing Resident 75 with ROM exercises and assist with applying the right-hand splint. During an interview with the Director of Nursing Services (DNS) on 3/24/25 at 1:55 p.m., she indicated the facility had restorative aides and they should be providing Resident 75 with the ROM program. During an observation on 3/25/25 at 10:05 a.m., Resident 75 was wheeling himself in a wheelchair within the common area of the facility with his left hand. Resident 75 had a splint in place on the right hand. The prevention of decline in ROM policy was provided by the DNS on 3/24/25 at 10:50 a.m. The policy indicated the facility would provide interventions, exercises, and therapy to maintain or improve ROM. This included, but were not limited to, specialized rehabilitation, restorative, maintenance and braces/splints. 3.1-42(a)(2)

Based on interview and record review, the facility failed to fully conduct a fall follow-up and implement interventions after a fall for 1 of 2 residents reviewed for falls. (Resident 59) Findings include: The clinical record for Resident 59 was reviewed on 3/21/25 at 12:33 p.m. The diagnoses included, but were not limited to, asthma, Alzheimer's disease, chronic pain, and unspecified psychosis. An Annual Minimum Data Set (MDS) assessment, dated 1/8/25, indicated Resident 59 was severely cognitively impaired, supervision with transferring, supervision with walking, and had a fall with injury since the last MDS assessment. A care plan for falls, revised 1/12/25, indicated Resident 59 was at risk for falls related to confusion and psychoactive drug use. The interventions included, but were not limited to, activities that minimized the potential for falls (initiated on 11/18/24) and staff to help when doing rounds (initiated on 2/28/25). A post fall evaluation note, dated 1/24/25 at 10:46 a.m., indicated Resident 59 fell on [DATE] at 12:30 a.m. Resident 59 was startled by a sounding alarm and fell to her knees. The alarm was silenced, and Resident 59 was sent to the emergency room (ER) for evaluation for pain. The note indicated Resident 59's care plan was updated. A post fall evaluation note, dated 1/26/25 at 6:29 a.m., indicated Resident 59 fell on [DATE] at 4:29 a.m. Resident 59 had an unwitnessed fall while attempting to get out of bed. Her bed was in a high position when the fall occurred. Resident 59 had a laceration to her left upper eye with bleeding, hematoma to the left lower eye, and a tear to the lower lip with bleeding. Resident 59 was sent out to the emergency room . A progress note, dated 1/26/25 at 8:48 a.m., indicated Resident 59 returned to the facility from the local hospital emergency room . She received sutures to the left eye. An interdisciplinary team (IDT) fall assessment, dated 1/27/25, indicated Resident 59 was found on the floor beside her bed on 1/26/25 at 5:00 a.m. Resident 59 was attempting to self-transfer and had her bed placed in a high position. The immediate interventions put into place was assessing Resident 59 for injury and assisted resident up and back to bed. Under the question of what additional interventions were put into place, the response was blank. Resident 59's fall care plan did not include an intervention listed for the fall events occurring on 1/21/25 and 1/26/25. A policy entitled Fall Prevention Program, dated 2024, was provided by the Director of Nursing Services on 3/24/25 at 2:00 p.m. The policy indicated when a resident experienced a fall the facility would assess the resident, complete a post-fall assessment, complete an incident report, notify the physician and family, review the resident's care plan and update as indicated, document all assessments and actions, and obtain witness statements in the case of injury. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure residents with weight loss were encouraged to consume supplements as recommended by the Registered Dietitian (RD) for 2 of 4 residents reviewed for nutrition. (Resident D and Resident 46) Findings include: 1. The clinical record for Resident D was reviewed on 3/20/25 at 2:58 p.m. The diagnoses included, but were not limited to, schizophrenia, alcohol-induced psychotic disorder, diabetes mellitus, malnutrition, and major depressive disorder. An Annual Minimum Data Set (MDS) assessment, dated 3/3/25, indicated Resident D had moderate cognitive impairment and was dependent on staff with eating. A physician order, dated 3/18/25, indicated Resident D was on a puree diet with nectar/mildly thick consistency for liquids. A care plan for nutrition, revised 3/16/25, indicated Resident D was on a puree diet, had a history of significant weight loss, and food was to be served in mugs and thinned to nectar consistency. The interventions included, but were not limited to, providing and serve diet as ordered, providing and serve supplements as ordered, and the RD to make diet change recommendations as needed. An observation was conducted of breakfast meal service in the Alzheimer's Care Unit (ACU) on 3/20/25 at 8:55 a.m. A staff member was next to Resident D and assisting him with eating his breakfast. There were four mugs that contained food and a magic cup supplement, in the original packaging, on his meal tray. The staff member removed the lid on each of the four mugs to assist with eating, but the magic cup remained unopened and did not attempt to be given to Resident D. An observation was conducted of lunch meal service in the ACU on 3/20/25 at 12:50 p.m. A staff member was assisting Resident D with eating and there were three mugs that had the lids removed on his tray along with a magic cup supplement in the original packaging. After Resident D was done consuming lunch, the staff member removed his meal tray and placed it on the tray rack. The magic cup remained unopened, and the staff member did not attempt or encourage Resident D to consume the magic cup supplement. 2. The clinical record for Resident 46 was reviewed on 3/21/25 at 11:49 a.m. The diagnoses included, but were not limited to, autistic disorder, anxiety disorder, malnutrition, and muscle weakness. A Quarterly MDS assessment, dated 2/4/25, indicated Resident 46 had severe cognitive impairment and was supervision with one staff member for eating. A physician order, dated 2/10/23, indicated Resident 46 was to be given snacks in-between meals and document the amount consumed. A nutrition care plan, revised 1/30/25, indicated Resident 46 had a history of significant weight loss and received and therapeutic diet. The interventions included, but were not limited to, providing and serve diet as ordered and providing and serving supplements as ordered: magic cup at lunch and fortified cereal at breakfast. An observation was conducted of lunch meal service on 3/20/25 from 12:25 p.m. to 1:10 p.m. During the observation, Resident 46 was consuming food from two bowls with a specialized spoon. Her meal tray was located on the kitchen island and contained another bowl of an unknown food item along with a magic cup supplement. When Resident 46 was finished consuming her food within the two bowels, Certified Nurse Aide (CNA) 3 proceeded to take the meal tray from the kitchen island and onto the tray rack. The magic cup was not opened or even placed near Resident 46 for them to consume. A policy entitled Nutritional and Dietary Supplements, dated 2022, was provided by the Director of Nursing Services on 3/24/25 at 9:52 a.m. The policy indicated that the facility would provide nutritional and dietary supplements to each resident, consistent with the resident's assessed needs and may be provided by dietitian recommendation as allowed by physician standing order. The care plan would be reflected with the new or modified nutritional interventions. 3.1-46(a)(2)

Based on interview, observation, and record review, the facility failed to prevent three events of resident-to-resident physical abuse perpetrated by Resident B for 3 of 5 resident reviewed for abuse. This deficient practice resulted in Resident D, Resident G, and Resident E being physically assaulted by Resident B and experiencing negative psychosocial outcomes. Findings include: The facility incident reports, dated from 7/8/2024 through 8/10/2024, indicated Resident B perpetrated resident-to-resident physical abuse on three events as follows: Event 1: 7/8/2024 indicated an event of resident-to-resident physical abuse perpetrated by Resident B occurred at 5:10 p.m. when Resident B was sitting in a wheelchair in the threshold of a staff member's door. The report indicated Resident D attempted to pass through the threshold, Resident B would not move, and Resident B tapped Resident D on the shoulder. Interventions for Resident B and Resident D were listed as: head-to-assessments, 15-minute checks, psychosocial follow up, reviewing of care plans, and updating care plans as needed. Event 2: 8/6/2024 indicated an event of resident-to-resident physical abuse occurred at 5:09 p.m., when Resident G attempted to get coffee in the dining room where Resident B was sitting in a wheelchair. Resident G asked Resident B to move multiple times then nudged Resident B's wheelchair. Resident B became agitated and made contact with Resident G's forearm with an open hand. Interventions were listed as: immediately separating Resident B and Resident G, Resident B was placed on line of site for remainder, Resident G was placed on 15-minute checks, and care plans for Resident B and Resident G were reviewed and updated as needed. Event 3: 8/10/2024 indicated an event of resident-to-resident physical abuse perpetrated by Resident B occurred at 8/5/2024 at 1:30 a.m. Resident E indicated Resident B made contact with the right side of Resident E's head. Interventions were listed as: psychosocial support for Resident B and Resident E, Resident B was placed on 15-minute checks, and care plans for Resident B and Resident E reviewed and updated as needed. The follow up on the incident, dated 8/15/2024, indicated Resident B was transferred to a neuropsychological hospital for evaluation. 1. The clinical record for Resident B was reviewed on 8/20/2024 at 11:45 a.m. Medical diagnoses included bipolar disorder, intellectual disabilities, encephalopathy, and anxiety disorder. A Quarterly Minimum Data Set (MDS) assessment, dated 8/1/2024, indicated Resident B was severely cognitively impaired, exhibited physical and verbal abusive behaviors symptoms directed toward others, and rejected care during the assessment period. A behavior care plan, last revised 5/15/2024, indicated Resident B had a history of exhibiting aggressive behaviors such as hitting, grabbing, pinching and kicking. Intervention included: assist Resident B to not enter other's personal space, redirect away and engage in personal activities as well as providing a quiet environment. An admission consent, dated 1/22/2024, indicated Resident B's next of kin refused in-house psychiatric services. The progress notes, dated from 2/1/2024 through 7/7/2024 indicated Resident B demonstrated seven events of physically abusive behaviors directed towards others. A psychotherapy note, dated 7/3/2024, indicated Resident B had difficulty trusting male providers. Resident B was also exhibited difficulty concentrating, irritability, grief, and loss of independence. A nursing progress note, dated 7/8/2024, indicated Resident B was .in staff office door when another resident was attempting to back out of office. The other resident ask resident to back up so that he could leave the room. This resident tapped the other resident on the shoulder. The behavior care plan, last revised on 5/15/2024, indicated an intervention of 15-minute checks initiated on 7/8/2024. Review of the July treatment administration record for Resident B after indicated 15-minute checks were completed per the physician order from 7/8/2024 through 7/15/2024. A primary care provider note, dated 7/9/2024, indicated Resident B had bipolar disorder with listed interventions to monitor mood, consult psych [consult psychological services], currently undergoing and continue group therapy with psychotherapist and next of kin. A social service progress note, dated 7/10/2024, indicated Resident B had no psychosocial distress. This note did not include any interventions or recommendations. The interdisciplinary progress notes, dated from 7/9/2024 through 8/6/2024, did not include documentation to indicate staff attempted to obtain a psychiatric consultation for Resident B, or psychiatric care was refused. A psychotherapy note, dated 7/16/2024, indicated a visit was made with Resident B and Resident B's next of kin. During the visit Resident B's next of kin noticed Resident B was more irritable and anxious. Interventions used during the therapy session were listed as exploration of emotions, psych-education, review of treatment, structured problem solving, supportive reflection, and symptom management. Clinical recommendations were Resume Treatment as Planned and Terminate Treatment, but did not include documentation to indicate the clinician recommended interventions to prevent further resident-to-resident physical abuse perpetrated by Resident B. A psychotherapy note, dated 7/18/2024, indicated Resident B was feeling more anxious and fearful. Resident B did not feel comfortable around all the staff and residents in the facility. A psychotherapy note, dated 7/26/2024, indicated Resident B had a dislike for another resident and was afraid of being harmed by another resident. Interventions utilized during the session included: exploration of emotions, interactive feedback, psycho-education, review of treatment, structured problem solving, supportive reflection, symptom management, and motivational interviewing/motivation therapy interventions. Clinical recommendations were Resume Treatment as Planned and Terminate Treatment, but did not include documentation to indicate the clinician recommended interventions to prevent further resident-to-resident physical abuse perpetrated by Resident B A primary care provider note, dated 8/5/2024, indicated Resident B had bipolar disorder with listed interventions to monitor mood, consult psych, currently undergoing and continue group therapy with psychotherapist and next of kin. A behavior charting note, dated 8/6/2024, indicated Resident G attempted to get coffee in the dining room. Resident B was in a wheelchair in front of the coffee. Resident G asked Resident B to move. When Resident B did not move, Resident G nudged Resident B's wheelchair. Resident B became agitated and made contact with Resident G's right forearm with an open hand. Immediate intervention of redirection of Resident B and line-of-site supervision were effective. A physician order, dated 8/6/2024, indicated a physician's order for Resident B to have line of sight for the remainder of the shift (continuous observation). A social service progress note, dated 8/8/2024, indicated Resident B had no psychological distress Review of the August 2024 treatment medication records indicated Resident B was on 15-minute checks from 8/6/2024 through 8/14/2024. During an interview with the Executive Director, on 8/21/2024 at 12:20 p.m., indicated part of the process for potential admission was to assure the facility can meet the needs of every admission. With Resident B's medical diagnosis, the facility anticipated that Resident B would have behaviors and elevated behavioral needs. During an interview with Registered Nurse (RN) 2 on 7/20/2024 at 12:15 p.m., indicated RN 2 was familiar with Resident B. RN 2 worked directly and indirectly with Resident B since admission. Resident B was known to have behaviors while at the facility. RN 2 indicated Resident B had physical behaviors with other residents and staff. Resident B's interventions were usually effective, but not always. RN 2 indicated interventions included diversional activities, utilizing Resident B's CD's, and calling Resident B's next of kin. When they were not effective, the staff were to try and eliminate the risk of Resident B harming other residents if possible. During an interview with Licensed Practical Nurse (LPN) 1, on 7/20/2024 at 12:45 p.m., indicated LPN 1 was aware that Resident B had a lot of behaviors since Resident B was admitted . LPN 1 had worked indirectly with Resident B since LPN 1 worked on the same unit as Resident B but did not work Resident B's hall. The staff try to keep [Resident B] away from others if they can. The only interventions LPN 1 recalled were utilizing Resident B's CD's, and redirection. During an interview with Activities Assistant 4, on 7/20/2024 on 1:25 p.m. indicated Resident B had behaviors. A week after Resident B was admitted , Activity Assistant 4 indicated Resident B had kicked me in the center of the chest unprovoked. Since the incident with Resident B, Activities Assistant 4 avoided Resident B to the degree of rescheduling or moving activities if Resident B was present. If Resident B had behaviors, Activity Assistant 4 indicated staff would make sure residents are safe then she would retrieve clinical staff since she was not comfortable with Resident B around. During an interview with the Director of Nursing Services, on 7/20/2024 at 2:15 p.m., the primary care physician team was responsible for managing Resident B's behaviors and medications due to the next of kin refusing psychiatric services. All staff were responsible for preventing resident-to-resident abuse. During an interview with the Executive Director, on 8/21/2024 at 2:00 p.m., the interventions implemented after the Event 1, reported on 7/8/2024, were 15-minute checks for the duration of the physician's order, review and update of the care plans, and social services to follow up for psychosocial support for both residents involved. During an interview with the Executive Director, on 8/21/2024 at 2:00 p.m., the interventions implemented, after the Event 2, reported on 8/6/2024, were listed as Resident B was placed line of sight for the remainder of the shift then 15-minute checks, psychological support as needed, and review and update of care plans as needed. A primary care provider note, dated 8/8/2024, indicated Resident B had bipolar disorder with listed interventions to include monitor mood, consult psych, currently undergoing group therapy with psychotherapist and next of kin. The note stated Resident B was agitated and had a gradual reduction dose failure. A psychotherapy note, dated 8/9/2024, indicated the behavioral psychotherapist spoke with Resident B's next of kin. Resident B's next of kin was agreeable to Resident B being seen by the in-house psychiatrist. During an interview with the Director of Nursing Services, on 7/20/2024 at 2:15 p.m., indicated the facility was in the process of getting Resident B seen by in house psychological services when Resident B was transferred for a neuropsychological evaluation. The progress note for Resident B, reviewed on 8/20/2024 at 11:45 a.m., did not indicate Event 3. Review of August 2024 treatment administration record after the Event 3, 15-minute checks were initiated on 8/6/2024. A social service progress note, dated 8/12/2024, indicated Resident B had no psychosocial distress. This note did not include any interventions or recommendations. A nursing progress note, dated 8/12/2024 at 2:15 a.m., indicated that Resident B's next of kin refused to have Resident B sent to a neuropsychiatric hospital for evaluation and treatment. The note did not contain additional interventions for Resident B's physical aggressive behaviors. The comprehensive care plan provided by the Director of Nursing Services (DNS), on 8/21/2024 at 11:15 a.m., did not include documentation to indicate a new intervention to prevent further resident-to-resident physical abuse perpetrated by Resident B after Event 2 or Event 3. During an interview with the Executive Director, on 8/21/2024 at 2:00 p.m., the interventions for the Event 3, reported 8/10/2024, were 15-minute checks as they worked with Resident B's next of kin about sending Resident B to a neuropsychiatric hospital for evaluation and treatment, 15-minute checks, review and update of the care plans, and social services to follow up for psychosocial assessments for both residents involved. The Executive Director indicated that the new of kin for Resident B refused neuropsychiatric evaluation after this event. An additional physical behavior event with Resident B striking a staff member, on 8/13/2024, was the deciding factor to prompt Resident B to be sent out for a neuropsychiatric evaluation and treatment. 2. The clinical record for Resident D was reviewed on 8/20/2024 at 11:27 a.m. The medical diagnoses included post-traumatic stress disorder, major depressive disorder, and anxiety disorder. A Quarterly MDS assessment, dated 6/5/2024, indicated Resident D was cognitively intact and did not exhibit behaviors in the last seven days. During an interview and observation with Resident D, on 8/20/2024 at 1:45 p.m., indicated on 7/8/2024 Resident D was making a phone call in the DNS's office. Resident D was attempting to leave the office when Resident B came in. Resident D stated, .[Resident B] got mad and slammed his wheelchair into mine, took the DVDs that he carries and threw the box at me then hit me on the head and shoulder with his fist . Further Resident D stated, .It stunned me to get hit with CDs . and that the punch to Resident D's shoulder .hurt and made a red mark . During an interview with the Executive Director, on 8/21/2024 at 2:00 p.m., the interventions implemented after Event 1 were 15-minute checks for the duration of the physician's order, review and update of the care plans, and social services to follow up for psychosocial assessments. The 15-minute checks were completed per the physician order, psychosocial assessments were completed for Resident D, and care plan was reviewed. 3. The clinical record for Resident G was reviewed on 8/21/2024 at 10:58 a.m. The medical diagnoses included mood disorder and schizophrenia. A Quarterly MDS assessment, dated 8/5/2024, indicated Resident G was cognitively intact and did not exhibit behaviors in the last seven days. During an interview and observation, on 8/21/2024 at 1:45 p.m., Resident G indicated, on 8/6/2024, Resident G had an altercation with Resident B. Resident G was trying to get coffee, but Resident B was sitting in front of the coffee and refused to move. Resident G stated .I asked him to move three times, and he wouldn't, so I moved his wheelchair just enough to reach the coffee. [Resident B] waited until I was reaching over to get the coffee then punched me in the stomach and the arm . Resident G reiterated it was a punch with a closed fist. Resident G did not have bruising or redness per recall but was a little sore. Resident G walked away and told the staff to call the police. Resident G indicated after the incident the Director of Nursing Services and Executive Director told Resident G to avoid Resident B. Resident G felt that was impossible since Resident B wanders all over the facility and into our rooms. Resident G stated, . I did not feel safe with [Resident B] around after that ., .I had been spending more time outside where [Resident B] cannot come to try and avoid [Resident B] . and [Resident B] has been gone about a week and I feel much safer. I was afraid [Resident B] would hit me anytime I was around him . 4. The clinical record for Resident E was reviewed on 8/20/2024 at 2:05 p.m. The medical diagnoses included major depressive disorder, dementia, and mood disturbances. A Quarterly MDS Assessment, dated 8/6/2024, indicated Resident E was cognitively intact and did not exhibit behaviors in the last seven days. During an interview and observation, on 8/21/2024 at 11:10 a.m., Resident E indicated that earlier this month Resident B came up behind Resident E and hit Resident E in the side of the head. Resident E stated, .he hit me so hard that my glasses went flying. They are carbon coated and have a large scratch in them, look at them . Resident E then took off eyeglasses to show a large scratch on the right lens. Resident E indicated that this was fourth time that Resident B had hit him. Resident E stated, .[Resident B] has hit me four times that I can remember. I've told staff about it, but they never do anything about it . When asked what interventions were placed after the 8/10/2024 event, Resident E stated, .they [the staff] told me to just avoid [Resident B], but I can't. [Resident B] goes anywhere [Resident B] wants. [Resident B] comes in my room, [Resident B] goes into the nurses' station. The staff let [Resident B] do whatever because they [the staff] are scared of [Resident B]. [Resident B] hits the staff and us. [Resident B] hit my roommate just a few weeks ago . Resident E indicated that he was scared that Resident B would hit Resident E again because Resident B attacked Resident E from behind. Resident E stated since the incident Resident E checked every room before going in to make sure Resident B was not in there and avoided activities if Resident B was around. Resident E indicated Resident B has been gone for about a week and Resident E felt that I can breathe without being afraid I'm going to get hit upside the head for no reason. A policy entitled, Abuse, Neglect and Exploitation, was provided by the Director of Nursing Services on 8/20/2024 at 12:50 p.m. The policy defined abuse as, .the willful infliction of injury .with resulting physical harm, pain or mental anguish, which many include .certain resident to resident altercations .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish . The policy of the facility indicated the intention was to, .provide protection for health, welfare and rights of reach resident by developing and implementing written policies and procedures that prohibit and prevent abuse . The policy further stated, .The facility will implement policies and procedures to prevent and prohibit all types of abuse . including, .identification, ongoing assessment, care planning for appropriate interventions, and monitor of residents with needs and behaviors which might lead to conflict . This citation relates to Complaints IN00439368 and IN00440821. 3.1-27(a)(1)

Based on interview and record review, the facility failed to follow up with a resident's change in condition (Resident B) in regard to loose stools for excessive duration that resulted in hospitalization , [CONDITION(S)], and shock for 1 of 3 residents reviewed for change in condition. Findings include: The clinical record for Resident B was reviewed on 10/21/22 at 12:46 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Significant Change Minimum Data Set (MDS) assessment, dated 5/16/22, indicated Resident B was cognitively impaired, required extensive assistance with 2 staff for bed mobility and transfers, extensive assistance with 1 staff for eating, and was always incontinent of bowel. An activities of daily living care plan, revised 5/17/22, listed an intervention for Resident B of Eating self care assist of extensive one. A care plan related to bowel elimination, dated 3/4/22, indicated Resident B was at risk in alteration in elimination of bowel related to constipation and functional incontinence. The interventions included, but were not limited to, encourage fluids and monitor bowel status frequency. A care plan related to [CONDITION(S)], dated 3/15/22, indicated the risk for sodium and potassium excess with interventions to obtain labs per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident B was scheduled for [CONDITION(S)] on Monday, Wednesday and Fridays. Hospital records, dated 5/6/22, indicated the discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no mentioning of Resident B having diarrhea during that hospitalization . A progress note, dated 5/10/22 at 2:36 p.m., indicated Resident B had loose stools and vomited after consuming lunch. The Nurse Practitioner was made aware of Resident B's condition change. A provider note, dated 5/10/22, indicated the nurse practitioner had seen Resident B. Resident B's diarrhea was documented as controlled and to continue with as needed medications for such. A lab result, dated 5/12/22, noted Resident B's creatinine level of 2.6 mg/dL (milligrams per deciliter- normal range of 0.6 to 1.0 mg/dL) (a measure of how well your kidneys are performing their job of filtering waste from your blood) and potassium level of 2.9 (normal range of 3.6 to 5.1 mEq/L [Milliequivalents Per Liter]). A lab result, dated 5/12/22, noted Resident B's white blood cell count of 10.5 (within normal range). These lab results were obtained the day after Resident B was scheduled for [CONDITION(S)]. A progress note, dated 5/13/22 at 1:03 a.m., indicated the on-call physician was notified of Resident B's potassium level of 2.9. A one-time order for potassium was obtained. A progress note, dated 5/15/22 at 12:21 p.m., indicated Resident B had vomited in the morning and appeared drowsy. Medication for nausea was administered and Tylenol due to Resident B having an elevated temperature of 101.8. The note indicated the on-call staff was notified of Resident B's change in condition. A progress note, dated 5/15/22 at 2:02 p.m., indicated Resident B vomited again and was given another dose of medication for nausea. A progress note, dated 5/15/22 at 2:09 p.m., indicated Resident B was noted with a distended abdomen. A progress note, dated 5/16/22 at 5:37 p.m., indicated Resident B only received a partial [CONDITION(S)] treatment due to becoming ill. They were given medications for vomiting. A progress note, dated 5/16/22 at 9:47 p.m., indicated Resident B had vomited twice and was given medication for nausea. There was no indication the on-call staff was notified. A physician order, dated 5/16/22, was noted for [MEDICATION(S)] (anti-nausea medication) 4 milligrams every 6 hours as needed for nausea and vomiting. A physician order, dated 5/16/22, was noted for loperamide (anti-diarrhea medication) 2 milligrams after each loose stool. A care plan for infection, dated 5/17/22, indicated the following, actual or at risk related to: possible C-diff [(also known as [CONDITION(S)] or C. difficile) is a germ (bacterium) that causes diarrhea and [CONDITION(S)] (an inflammation of the colon)] loose stools .Interventions .Labs as ordered A physician order, dated 5/17/22, indicated to place Resident B on contact precautions until C Diff results were obtained and negative. There were no labs obtained to check for c-diff for Resident B on, or around, 5/17/22. A weight note, dated 5/20/22, indicated Resident B exhibited an 8.3 pound (4.3%) weight loss over the previous week and was not taking in much nutrition since their return from the hospital. A progress note, dated 5/20/22, indicated Resident B was only able to complete a partial [CONDITION(S)] treatment due to becoming nauseous and vomiting. A provider note, dated 5/26/22, indicated Resident B's diarrhea was controlled and to continue giving as needed medication for such. The electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The EMAR for May of 2022, noted [MEDICATION(S)] administered on the following date(s)/time(s): 5/15/22 at 8:01 a.m.- ineffective results, 5/15/22 at 1:51 p.m.- effective results, 5/16/22 at 10:07 p.m.- effective results, & 5/22/22 at 3:26 p.m.- effective results. Documentation for May of 2022 in regard to Resident B's bowel continence was reviewed. The following date(s) were documented as Resident B having loose/diarrhea bowel movements: 5/6/22- evening shift, 5/7/22- evening and night shift, 5/8/22- evening shift, 5/10/22- day and evening shift, 5/12/22- day and evening shift, 5/14/22- day and evening shift, 5/15/22- day and evening shift, 5/16/22- twice on evening shift and night shift, 5/18/22- day shift, 5/20/22- evening and night shift, 5/23/22- day shift, 5/24/22- night shift, 5/25/22- day and evening shift, 5/26/22- day shift, 5/27/22- day and evening shift, 5/28/22- day and twice on night shift, 5/29/22- day shift, & 5/30/22- evening shift. A progress note, dated 6/2/22 at 1:58 p.m., indicated Resident B vomited at lunch and had diarrhea. Resident was given a medication for the diarrhea and nausea. There was no indication the on-call staff was notified of this change in condition. A progress note, dated 6/3/22 at 5:50 p.m., indicated Resident B vomited and had runny stools. Resident B was administered medication for nausea and diarrhea. The Nurse Practitioner was notified. There were no indication any new orders were obtained at that time. A progress note, dated 6/6/22 at 3:25 a.m., indicated Resident B had many loose stools and has a c-diff odor. A lab result, dated 6/6/22, indicated Resident B had c-diff detected in her stool. A lab result, collected on 6/6/22 and reported on 6/8/22 by the [CONDITION(S)] center, indicated Resident B had a low potassium level of 2.2 and an extremely high white blood cell count of 26.54 (normal range of 4.80 to 10.80). The document was initialed and dated for 6/9/22 by the nurse practitioner but no new orders were noted. An interview conducted with Nurse Consultant, on 10/25/22 at 2:00 p.m., indicated the staff discussed Resident B having loose stools back in May of 2022. At that time, we were told she was only having one stool a day and it was mushy in consistency. So, at that time we didn't move forward with testing her for c-diff. A number of lab reports from Resident B's [CONDITION(S)] center was given by Nurse Consultant on 10/25/22 at 4:00 p.m. These lab results were faxed from the laboratory to the facility on [DATE] at 3:42 p.m. and were not all accessible in Resident B's clinical record. The EMAR for June of 2022 noted loperamide administered on the following date(s)/time(s): 6/2/22 at 1:37 p.m.- effective results, 6/3/22 at 3:18 p.m.- effective results, 6/7/22 at 10:48 a.m.- effective results, & 6/11/22 at 1:32 p.m.- unknown results. The EMAR for June of 2022 noted [MEDICATION(S)] administered on the following date(s)/time(s): 6/2/22 at 1:37 p.m.- effective results, 6/3/22 at 3:18 p.m.- effective results, 6/10/22 at 12:51 p.m.- effective results, & 6/11/22 at 1:32 p.m.- unknown results. Documentation for June of 2022 in regard to Resident B's bowel continence was reviewed. The following date(s) were documented as Resident B having loose/diarrhea bowel movements: 6/1/22- day shift, 6/2/22- day and evening shift, 6/3/22- evening and twice on night shift, 6/4/22- day shift, 6/5/22- day shift, 6/6/22- day shift and twice on night shift, 6/7/22- day and evening shift, 6/8/22- day, evening, and night shift, 6/9/22- day, evening, and night shift, 6/10/22- day and evening shift, & 6/11/22- day shift. A provider note, dated 6/9/22, indicated Resident B complained of abdominal pain, nausea, and diarrhea. She refused [CONDITION(S)] on 6/8/22 with indication to monitor labs and fluid status. There were no orders listed for follow up. A progress note, dated 6/11/22 at 1:32 p.m., indicated Resident B vomited at 1:00 p.m. along with loose stools. Medication for nausea and diarrhea were administered along with a suggestion for the Nurse Practitioner to schedule Resident B on the nausea medication. A progress note, dated 6/11/22 at 5:06 p.m., indicated Resident B was sent out to the local hospital emergency room due to vomiting up feces and causing suspicion of perforated bowel. A hospital admission note, dated 6/12/22, indicated the following, .Per pt [patient] reported she had been vomiting for a week .Lab work showed a WBC [white blood cell] ct [count] of 17.7, k+ [potassium] of 2.2, and creatinine of 6.9 .Physical Exam .Mouth: Mucous membranes are dry .Principal Problem: Shock .Active Problems: [CONDITION(S)] [low levels of potassium] .[CONDITION(S)] on hemodialysis .[CONDITION(S)] .Bilious vomiting with nausea .4. [CONDITION(S)] on HD [hemodialysis] .the patient dialyzed Monday [6/6/22] for partial run and then did not go Wednesday because she was feeling ill .Weight .163 lbs [pounds] .Weight hx [history] .It appears she lost 37 lb or 19% body weight in one year .Recent labs .K [potassium] .2.0 [Critical result noted] .Hospital Course .Of note, her son at bedside reports being told that she had tested positive for C diff [sic] last week, he also notes that she was unable to tolerate her last HD [hemodialysis] run due to [CONDITION(S)] .Prior to transfer she was found to have [CONDITION(S)] with a potassium of 2.2, along with Cr [creatinine] of 8.0 (unclear when he last had HD, per records it appears he dialized [sic] 6/10, however son states it was Mon [Monday] 6/6) [sic] .She was given 2.5 AL [liters] boluses of fluid as well w/ [with] concern for hypovolemic shock in setting of Cdiff and N/V/D [nausea, vomiting, diarrhea] .Attending Attestation .Appears extremely dry and dehydrated .Nephrology Initial Consultation Note .She has missed most of her [CONDITION(S)] sessions over the past 2 weeks due to severe diarrhea. She was found to be [CONDITION(S)] and hypokalemic .On arrival here she was hypotensive in shock with confusion and transferred to the ICU [intensive care unit]. She was intubated and multiple pressors have been started .Fluid resuscitation started A hospital discharge summary, dated 6/12/22, indicated the following, .Hospital Course .In summary, this unfortunate female was admitted to the intensive care unit in a state of extremist with shock. She had previously been treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . She presented to us in shock and required immediate intubation and mechanical ventilation, placement of arterial and central venous access and administration of vigorous vasopressor support. She was treatment with [MEDICATION(S)] and [MEDICATION(S)]. The patient continued to be markedly hypotensive despite volume resuscitation and 3 vasopressors administrations [sic] .Despite intensive fluid management, vasopressor support, and ventilatory management, heart condition continued to deteriorate and she remained profoundly hypotensive and bradycardic .The patient was terminally extubated and passed away peacefully thereafter .DISCHARGE DIAGNOSIS/CAUSE OF DEATH: Shock, likely septic versus possibly cardiogenic A Discharge/Death diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . End-stage [CONDITION(S)], on hemodialysis .3. Congestive heart failure .4. Chronic obstructive pulmonary disease .5. Recent history of [CONDITION(S)] [CONDITION(S)] .6. Shock, cardiogenic versus hemodynamic .7. Acute [CONDITION(S)] A policy titled Notification of Changes, undated, was provided by the Executive Director on 10/24/22 at 9:25 a.m. The policy indicated the following, .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification .Compliance Guidelines .2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include .a. Life-threatening conditions .b. Clinical complications .3. Circumstances that require a need to alter treatment .This may include: a. New treatment .b. Discontinuation of current treatment due to .i. Adverse consequences .ii. Acute condition .iii. Exacerbation of a chronic condition This Federal tag relates to Complaint IN 199. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure a resident was safely assisted with locomotion while up in wheelchair for a resident observed leaning forward numerous times resulting in resident (Resident 30) falling forward and requiring sutures and failed to ensure fall interventions were implemented for Resident 54 for 2 of 3 residents reviewed for accidents. Findings include: 1. The clinical record for Resident 30 was reviewed on 10/20/22 at 3:04 p.m. The diagnoses included, but were not limited to, anxiety disorder, muscle weakness, pain, [CONDITION(S)], and history of [CONDITION(S)]. An Admission Minimum Data Set (MDS) assessment, dated 8/9/22, noted Resident 30 with needing extensive assistance with one staff for transfers, locomotion on and off of unit, and marked no for the use of a wheelchair but yes for a walker. An at risk for falls care plan, revised 10/21/22, indicated the following interventions: - Assess the wheelchair is of appropriate size; assess need for footrests, initiated on 8/3/22. - Education to staff and therapy staff wheelchair pedals (sic), initiated on 9/30/22. - Foot pedals to wheelchair when staff propelling wheelchair. Foot pedals not necessary when resident is propelling herself with supervision, initiated on 9/30/22 and revised on 10/21/22. A Physical Therapy Evaluation, dated 8/3/22, indicated the following, .Musculoskeletal System Assessment .RLE [right lower extremity] Strength .Impaired .LLE [left lower extremity] Strength .Impaired .Test/Sit Balance .Functional Reach - Forward Direction = 4 inches (predictive of falls) A Physical Therapy Progress Report, dated 8/30/22 to 9/12/22, indicated under the Functional Skills Assessment that Resident 30 was supervision with or touching assistance when using the wheelchair with 50 feet and partial/moderate assistance when using the wheelchair with 150 feet or greater. A post fall evaluation, dated 9/29/22, indicated the following, .9/29/2022 11:02 propel in w/c [wheel chair] by therapy .Reason for fall .res [resident] put feet down on floor and fell out of w/c .Injury Details .laceration to nose and head .ER Visit/hospitalization /Details .res [resident] received sutures .Fall Details Note .Resident was propelling self with therapy assistance, resident started to lean forward when therapy was trying to help resident with positioning she leaned forward and put feet on the floor causing her to fall forward hitting her head on the floor .Conclusion Note .Resident needs to ensure that foot pedals are on wheelchair when locomotion occurs in hallways An IDT (Interdisciplinary Team) Fall document, dated 10/2/22, indicated the following, .Resident was propelling to therapy with therapist as they were assisting resident then fell forward out of wheelchair hitting her head on the floor and causing laceration .What is the Root Cause of the fall .Resident was leaning forward while propelling herself per norm [normal] along with being assisted by therapist then resident fell forward to hit head. Therapist was attempting to intervene and help resident with positioning when she fell forward .What immediate interventions were put into place in response to the fall .New intervention of w/c [wheelchair] foot pedals put in place when resident is locomoting with assistance An interview conducted with Licensed Practical Nurse (LPN) 4, on 10/21/22 at 2:40 p.m., indicated she was working the day that Resident 30 fell forward from her wheelchair. She recalled Therapy Staff 3 assisting Resident 30 in her wheelchair. Resident 30 has these tendencies to where if she doesn't want to do something she will either tell you she doesn't want to do it or she will, in this case, lean forward in her wheelchair. LPN 4 recalled Therapy Staff 3 having to stop at least twice in the hallway to assist Resident 30 to sit upright in her wheelchair and move her back due to her leaning forward. LPN 4 was at the nurses' station charting and then heard a thud and had seen Resident 30 lying face down on the floor with her legs underneath her wheelchair. Resident 30 ended up going out to the hospital to have sutures placed. Resident 30 was able to propel herself in the wheelchair, but she didn't really utilize her feet. She would utilize her hands to propel the wheel chair and she was capable of going long distances. An interview conducted with Therapy Staff 3, on 10/24/22 at 2:27 p.m., indicated he was assisting Resident 30 with locomotion down the hallway. They were headed for group therapy at that time. Resident 30 was leaning forward a little bit. He would verbally redirect or touch her shoulder to instruct her to move her wheelchair if needed. He would ask Resident 30 to sit back up when she leaned forward, and she was able to sit back up but not completely straight. Therapy Staff 3 was not used to working with Resident 30 and was not familiar with her baseline. Resident 30 would bend her knees and brought her feet under her wheelchair to pull herself forward. Therapy Staff 3 was assisting Resident 30 a little and letting her guide the motion. When Resident 30 was propelling herself forward she would plant her feet on the floor to move herself forward. Resident 30 was leaning forward throughout the transport. It didn't appear that Resident 30 had foot pedals in place so she could propel the wheelchair. An interview conducted with Physical Therapist on 10/21/22 at 12:56 p.m., indicated Resident 30 was being propelled by therapy staff to go to group therapy from what he understood. Resident 30 had poor eyesight and that was part of the reason to make her supervision within 50 feet and partial/moderate assistance when 150 feet or greater with her wheelchair mobility. She got COVID-19 and had the incident of falling out of her wheelchair and that's why we have foot pedals on her wheelchair now. If a resident can propel themselves, we try not to place foot pedals on their chairs due to safety. An in-service attendance sheet, dated 9/30/22, indicated the following, .ALL RESIDENTS MUST BE TRANSPORTED WITH FOOTPEDALS REGARDLESS OF ABILITY TO SELF PROPEL WHEN STAFF IS TRANSPORTING FOR SAFETY AND TO PREVENT INJURIES An interview conducted with Nurse Consultant on 10/25/22 at 2:40 p.m. indicated when the staff physically transport resident, they are to have foot pedals in place as part of the in-service. 2.) During an observation on 10/18/22 at 2:32 p.m., Resident 54 was laying in bed, the resident's bed in was in a high position. During an observation on 10/20/22 at 3:40 p.m., Resident 54 was laying in bed, the resident's bed was in the high position. During an observation on 10/21/22 at 1:35 p.m., Resident 54 was sitting in bed, the resident's bed was in the high position. Review of the record of Resident 54 on 10/21/22 at 1:55 p.m., indicated the resident's diagnoses included, but were not limited to, displaced interchanteric fracture of left femur, [CONDITION(S)], [CONDITION(S)], dementia, anxiety, depression, adult failure to thrive and muscle weakness. The plan of care for Resident 54, dated 6/2/22, indicated the resident was at risk for falls due to new environment, medication and poor safety awareness. The intervention included, but were not limited to, low bed when in bed (10/10/22). The fall evaluation for Resident 54, dated 10/9/22 at 4:00 a.m., the resident had a history of falls. The resident was heard yelling for help. The resident found on the floor next to bed on her bottom. The resident was confused and unable to recall the reason for trying to get out of bed. The immediate intervention was to lower the bed to the floor. The fall evaluation for Resident 54, dated 10/15/22 at 5:00 p.m., indicated the resident fell attempting to get out of bed. The resident acquired bruising on the lower back and buttocks. The environmental cause was the bed was too high, leading to a worse fall. The fall risk assessment for Resident 54, dated 10/15/22, indicated the resident was at risk for falls. During an observation on 10/24/22 at 11:10 a.m., Resident 59 was laying in bed, the resident' bed was in high position. During an observation on 10/24/22 at 11:35 a.m., Resident 59 was laying in bed, the resident' bed was in high position. During an observation and interview on 10/24/22 at 2:25 p.m., Resident 59 was in bed with a hospital gown, her bed was in high position. LPN 1 indicated she was unsure why the resident;s bed was in the high position and put the resident's bed significantly lower position. A policy titled Accidents and Supervision, undated, was provided by the Executive Director on 10/24/22 at 9:25 a.m. The policy indicated the following, .Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes .1. Identifying hazard(s) and risk(s) .2. Evaluating and analyzing hazard(s) and risk(s) .3. Implementing interventions to reduce hazard(s) and risk(s) .5. Supervision- Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision .b. Based on the individual resident's assessed needs and identified hazards in the resident environment 3.1-45(a)(1) 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a resident received their diet as ordered that resulted in choking, administration of the [MEDICATION(S)] maneuver, administration of cardiopulmonary resuscitation (CPR), and ultimately in the death of Resident B for 1 of 3 residents reviewed for dietary needs. This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when a resident with a history of putting large amounts of food into his mouth at a time, put an entire piece of garlic bread in his mouth, that was not consistent with his diet orders, that resulted in choking, administration of the [MEDICATION(S)] maneuver, administration of CPR, and Resident B passing away on [DATE]. The Executive Director (ED), Director of Nursing (DON), Vice President of Clinical Operations, Resource Registered Nurse (RRN), and Area Vice President were notified of the Immediate Jeopardy on [DATE] at 11:31 a.m. Findings include: The clinical record for Resident B was reviewed on [DATE] at 4:30 p.m. The diagnoses included, but was not limited to, muscle wasting and atrophy, acute [CONDITION(S)] with [CONDITION(S)], [CONDITION(S)] flutter, depression, [CONDITION(S)], congestive heart failure, and dysphagia (difficulty or discomfort in swallowing). An admission Minimum Data Set (MDS) assessment, dated [DATE], indicated moderate cognitive impairment and supervision of one person for eating. A care plan for self-care impairment, dated [DATE], indicated eating assistance of one supervision. A nutrition care plan, dated [DATE], indicated the intervention to provide diet as ordered. A physician order, dated from [DATE] to [DATE], was noted for a mechanical soft/easy to chew diet for Resident B. Speech Therapy notes, dated [DATE], indicated the following, .Clinical Bedside Assessment of Swallowing .Clinical S/S [signs and symptoms] Dysphagia: Oral Phase Impairments characterized by: incomplete bolus [a small, rounded mass of a substance, especially of chewed food at the moment of swallowing] formation A progress note, dated [DATE] at 12:57 p.m., indicated the following, .resident began to have increased labored breathing - short- trouble swallowing and cough noted to be related - to shoveling of food during meal time - was able to extract food/particles - STAT [immediately] CXR [chest x-ray] to rule out aspiration - resident currently in dining room - with nurse and staff watch [sic] A progress note, dated [DATE] at 1:16 p.m., indicated Resident B's diet was downgraded to mechanical soft as a nursing measure. A progress note, dated [DATE] at 1:24 p.m., indicated the following, .Resident was in the dining room eating lunch and started coughing. Writer went to resident's table and resident was able to clear his throat. Writer asked resident if he needed help with anything. Resident stated he was ok. A progress note, dated [DATE] at 11:59 a.m., indicated the following, .Therapy reported that currently the biggest barrier for resident is confusion. Therapy reported that resident is in the severe range in ACLS [[NAME] Cognitive Level Screen Assessment], SLUMS [Saint Louis University Mental Status] and Clock assessments [It involves drawing a clock on a piece of paper with numbers, clock hands, and a specific time. The inability to do so is a strong indication of mental decline] A progress note, dated [DATE] at 12:15 p.m., indicated the following, .Resident put entire slice of garlic bread in mouth at once. Writer told resident not to take so much food at once and attempted to remove part of it but resident had already swallowed it A progress note, dated [DATE] at 12:25 p.m., indicated the following, .Writer was sitting at desk when CNA [certified nursing assistant] shouted to come because resident was turning blue. Resident was unable to speak or cough. [MEDICATION(S)] maneuver was attempted multiple times without success at which point therapist began to attempt [MEDICATION(S)], also without success at which point resident was moved from chair to floor and CPR initiated. A progress note, dated [DATE] at 2:05 p.m., indicated the following, .Code was called at 12:44 pm and 911 called. Resident was in the dining room with a nurse attempting the [MEDICATION(S)] maneuver. Therapy then took over and dislodged some food. Resident color off and he gasp for air once. Resident lowered to the ground and CPR with AED initiated at 12:44. No shock advised. A police officer arrived at 12:48 and took over compressions. EMS arrived at 12:49 and took over. EMS called time of death at 1:13 pm An interview conducted with CNA 2, on [DATE] at 5:54 p.m., indicated she worked on [DATE] when the incident occurred with Resident B. He had a history of shoveling food in his mouth on a frequent basis. She recalled hearing the nurse at the time, 10 minutes prior to the incident, commenting [Name of Resident b] stop shoveling food in your mouth. She proceeded to pass meal trays. About 10 minutes later she observed Resident B gasping and his lips appeared blue. She yelled toward the nurse at the time, and he jumped right up from the nurses' station and immediately started the [MEDICATION(S)] maneuver. A couple of staff members attempted the [MEDICATION(S)] maneuver without success. The staff then proceeded to place Resident B on the ground and initiate CPR. She doesn't recall there being many residents in the dining room during meal service when the incident occurred. Resident B was sitting at a table by himself before he was observed gasping and his lips turning blue. She believed that Resident B choked on pizza but when the staff lifted the lid on his tray the pizza remained on the plate. She stated so, it must have been the bread. A meal ticket with Resident B's name and picture, stated lunch, was provided by the Regional Dietary Staff on [DATE] at 4:55 p.m. Regional Dietary Staff indicated this was the meal ticket from [DATE] at lunch time. The meal ticket stated, Mechanical Soft, Regular Diet. A daily menu, dated [DATE], indicated the lunch being served consisted of pizza, Texas toast, salad, and pear gelatin. Under the category of mechanical soft/easy to chew, the options were to give spaghetti in place of pizza and wheat bread in place of Texas toast. A list of statements, typed, was provided by the Executive Director (ED), on [DATE] at 6:50 p.m. A statement from Registered Nurse (RN) 4, dated [DATE], indicated the following, .He passed the resident his lunch tray in the dining room at approximately 1215 [12:15 p.m.]. He turned around to get a tray for another resident and he observed the resident putting the whole piece of garlic bread in his mouth .He spoke to the resident and educated him on eating that fast and putting that much in his mouth. The resident had already swallowed the garlic bread. He then went to the nurses station to complete charting and then approximately ,d+[DATE] minutes later a CNA named [Name of CNA 2] approached him and stated to come help [Name of Resident B], he is turning blue .The resident couldn't speak, he couldn't cough .He stated his lunch tray was a slice of pizza, garlic bread, salad and jello with fruit in it. He did not know that the resident had an order for mechanical soft. He does not remember if the tray had a diet slip/tray ticket on it An interview conducted with the Director of Nursing (DON), on [DATE] at 7:00 p.m., indicated the facility started putting menus on the meal carts so the staff can see what each specific diet should specifically contain. There will be oversight for each meal service and also to monitor the kitchen to ensure proper meal items are being served. A policy titled Therapeutic Diet Orders, undated, was provided by the DON on [DATE] at 10:00 a.m. The policy indicated the following, .The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences .3. Therapeutic diets are provided only when ordered by the attending physician or a registered or licensed dietitian who has been delegated to write diet orders, to the extent allowed by state law .5. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed The Past Noncompliance Immediate Jeopardy began on [DATE]. The Immediate Jeopardy was removed and corrected on [DATE], before entrance into the facility, when the facility completed audits of all residents' diet orders, ensure monitoring was conducted during meal service, and staff were educated on dietary needs and services of the residents. The correction date was prior to the start of the survey and was therefore Past Noncompliance. This Federal tag relates to Complaint IN 280. 3.,d+[DATE](a) 3.,d+[DATE](i)(4)

Based on interview and record review, the facility failed to ensure supervision when a resident, requiring supervision with one staff person for eating, was observed placing an entire piece of garlic bread in his mouth, which later resulted in blue lips and gasping for air, followed by abdominal thrusts, cardiopulmonary resuscitation (CPR), and ultimately the death of Resident B for 1 of 3 residents reviewed for dining assistance. This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when a resident was observed placing an entire piece of garlic bread into his mouth. After ,d+[DATE] minutes had passed, he was then observed with blue lips and gasping for air. This had resulted in choking, administration of the [MEDICATION(S)] maneuver, administration of CPR, and Resident B passing away on [DATE]. The Executive Director (ED), Director of Nursing (DON), Vice President of Clinical Operations, Resource Registered Nurse (RRN), and Area Vice President were notified of the Immediate Jeopardy on [DATE] at 11:31 a.m. Findings include: The clinical record for Resident B was reviewed on [DATE] at 4:30 p.m. The diagnoses included, but was not limited to, muscle wasting and atrophy, acute [CONDITION(S)] with [CONDITION(S)], [CONDITION(S)] flutter, depression, [CONDITION(S)], congestive heart failure, and dysphagia (difficulty or discomfort in swallowing). An admission Minimum Data Set (MDS) assessment, dated [DATE], indicated moderate cognitive impairment and supervision of one person for eating. A care plan for self-care impairment, dated [DATE], indicated eating assistance of one supervision [sic]. A progress note, dated [DATE] at 12:15 p.m., indicated the following, .Resident put entire slice of garlic bread in mouth at once. Writer told resident not to take so much food at once and attempted to remove part of it but resident had already swallowed it A progress note, dated [DATE] at 12:25 p.m., indicated the following, .Writer was sitting at desk when CNA [certified nursing assistant] shouted to come because resident was turning blue. Resident was unable to speak or cough. [MEDICATION(S)] maneuver was attempted multiple times without success at which point therapist began to attempt [MEDICATION(S)], also without success at which point resident was moved from chair to floor and CPR initiated. A progress note, dated [DATE] at 2:05 p.m., indicated the following, .Code was called at 12:44 pm and 911 called. Resident was in the dining room with a nurse attempting the [MEDICATION(S)] maneuver. Therapy then took over and dislodged some food. Resident color off and he gasp for air once. Resident lowered to the ground and CPR with AED initiated at 12:44. No shock advised. A police officer arrived at 12:48 and took over compressions. EMS arrived at 12:49 and took over. EMS called time of death at 1:13 pm An interview conducted with CNA 2, on [DATE] at 5:54 p.m., indicated she worked on [DATE] when the incident occurred with Resident B. He had a history of shoveling food in his mouth on a frequent basis. She recalled hearing the nurse at the time, 10 minutes prior to the incident, commenting [Name of Resident b] stop shoveling food in your mouth. She proceeded to pass meal trays. About 10 minutes later she observed Resident B gasping and his lips appeared blue. She yelled toward the nurse at the time, and he jumped right up from the nurses' station and immediately started the [MEDICATION(S)] maneuver. A couple of staff members attempted the [MEDICATION(S)] maneuver without success. The staff then proceeded to place Resident B on the ground and initiate CPR. She doesn't recall there being many residents in the dining room during meal service when the incident occurred. Resident B was sitting at a table by himself before he was observed gasping and his lips turning blue. She believed that Resident B choked on pizza but when the staff lifted the lid on his tray the pizza remained on the plate. She stated so, it must have been the bread. A list of statements, typed, was provided by the Executive Director (ED), on [DATE] at 6:50 p.m. A statement from Registered Nurse (RN) 4, dated [DATE], indicated the following, .He passed the resident his lunch tray in the dining room at approximately 1215 [12:15 p.m.]. He turned around to get a tray for another resident and he observed the resident putting the whole piece of garlic bread in his mouth .He spoke to the resident and educated him on eating that fast and putting that much in his mouth. The resident had already swallowed the garlic bread. He then went to the nurses station to complete charting and then approximately ,d+[DATE] minutes later a CNA named [Name of CNA 2] approached him and stated to come help [Name of Resident B], he is turning blue .The resident couldn't speak, he couldn't cough .He stated his lunch tray was a slice of pizza, garlic bread, salad and jello with fruit in it. He did not know that the resident had an order for mechanical soft. He does not remember if the tray had a diet slip/tray ticket on it An interview conducted with the Director of Nursing (DON), on [DATE] at 7:00 p.m., indicated the facility started putting menus on the meal carts so the staff can see what each specific diet should specifically contain. There will be oversight for each meal service and also to monitor the kitchen to ensure proper meal items are being served. A policy titled Activities of Daily Living (ADLs), dated November of 2017, indicated the following, .The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable .Care and services will be provided for the following activities of daily living .4. Eating to include meals and snacks The Past Noncompliance Immediate Jeopardy began on [DATE]. The Immediate Jeopardy was removed and corrected on [DATE], before entrance into the facility, when the facility completed staff education on following the plan of care for assistance with eating based on residents' needs and conduct supervision during meal service to monitor for any changes in residents' condition. The correction date was prior to the start of the survey and was therefore Past Noncompliance. This Federal tag relates to Complaint IN 280. 3.,d+[DATE](a)(1) 3.,d+[DATE](a)(2)

Based on interview and record review the facility failed to prevent verbal abuse resulting in a resident experiencing mental anguish for 1 of 3 residents reviewed for abuse (Resident 82). Finding include: During an interview on 8/01/18 at 2:41 p.m., with Resident 82 indicated she had been abused by CNA 2 approximately one month ago. The CNA yelled at her because she was incontinent of urine. CNA 2 yelled that if she would use her wheelchair and go to the bathroom she wouldn't be wet. The resident indicated she could not always tell when she needed to use the restroom. The resident indicated it hurt her feelings and it made her cry. The resident reported it to her family and the family reported it to the facility. The facility staff talked with her about the situation and investigated it and the facility fired CNA 2. Review of the record of Resident 82 on 8/6/18 at 2:30 p.m., indicated the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment for Resident 82, dated 6/26/18, indicated the resident was reasonable and consistent with daily decision making. The resident required extensive assistance of two people to transfer. The resident required extensive assistance of one person for toileting needs and was frequently incontinent of her bowels and bladder. The progress note for Resident 82, dated 6/10/18 at 6:23 p.m., indicated the resident's family reported that when they walked into Resident 82's room the resident began crying. The resident indicated she was upset because a CNA (2) had been mean to her two days ago. The resident reported to the family member that CNA 2 said you need to your G-- D--- butt out of bed and go to the bathroom. The resident reported the incident made her afraid to ask him for any help and she had not put on her light for assistance all day due to this issue. The resident had a soiled brief when this nurse assisted her. The incident was immediately reported to the on call nurse and she stated she would call upper management. CNA 2 was informed he was suspended pending an investigation. The facility incident report for Resident 82, dated 6/11/18 (no time) indicated it was reported that CNA 2 spoke down to the resident and used profanity while caring for her. CNA 2 had been rude to the resident. CNA 2 was suspended pending an investigation. The investigation was completed on 6/15/18 and the allegation was substantiated. Resident 82's roommate confirmed that CNA 2 was being sarcastic when speaking. CNA 2 was terminated. During an interview on 8/07/18 1:58 p.m., the Director Of Nursing (DON) indicated the nurse on duty on 6/10/18 reported to the nurse manager the allegation of verbal abuse of Resident 82 and then the DON reported it to the Administrator immediately. CNA 2 was suspended immediately and was terminated after the investigation. Resident 82's roommate reported the same story and collaborated what Resident 82 had reported. The abuse policy provided by the Administrator on 8/7/18 at 2:30 p.m., indicated the definition of abuse included, but were not limited to, a willful infliction of metal anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance. 3.1-27(a)(b)

Based on interview and record review, the facility failed to ensure timely and accurate assessments of 1 of 3 residents reviewed for assessments, who was physician-documented with a change in condition, were conducted, prior to the resident experiencing a cardio-pulmonary arrest in the facility. (Resident B) Findings include: The clinical record of Resident B was reviewed on [DATE] at 9:56 a.m. His [DIAGNOSES REDACTED]. The attending physician handwrote an order for [REDACTED]. In review of the nursing progress notes and the clinical record, there was no documentation the resident had been assessed after the physician's orders [REDACTED]. Additionally, the STAT labwork had not been obtained in the nearly six hours after it had been ordered. On [DATE] at 2:20 p.m., RN 1 shared, I had been called over to draw his labs and I was not really familiar with him. The lab had been called and they couldn't get here until that evening to do the stat labs. As a matter of fact, I was getting ready to literally go in his room to draw his labs when all this happened. I think it was somewhere between 2:00 and 3:00 p.m. In another interview with RN 1 on [DATE] at 3:25 p.m., she stipulated she had just spoken with the attending physician who could not recall why he had written stat lab orders that day for Resident B. In interview with the Director of Nursing (DON) on [DATE] at 2:20 p.m., she indicated the nurse on duty that day and the previous afternoon/evening, RN 2, was no longer employed at the facility. I can't find anything in the nursing notes that say there were any problems for that date until the note about the CPR. Nothing from the day before either. Review of the clinical record demonstrated a nursing progress note, dated [DATE] at 8:00 a.m., indicating Resident B was alert and oriented, had no pain and displayed no pain or respiratory distress. This assessment was the last documented nursing assessment until the [DATE] assessment documented at 3:16 p.m. In an interview with a family member of Resident B on [DATE] at 11:59 a.m., she indicated on the morning of [DATE], Resident B had called her at approximately 9:30 a.m. and 10:30 a.m. to express he was having chest pain and nausea and felt so bad he thought he was going to die. She explained due to her inability to go to the facility, she had a family member call the facility with these concerns. She shared this family member, called the nursing home around 11:00 a.m., and told them somebody needed to check on (name of Resident B) because he was calling me and saying he was having chest pains and thought he was going to die .spoke to someone .who said dad was fine. She continued that she arrived to the facility around 2:00 p.m., and one of the aides, I don't know her name, said (Resident B) had vomited 3 times already .So I went to a male nurse who was at one of the med carts and told him (Resident B) was nauseated, had vomited and was having chest pain. His response was just that (Resident B) wasn't due for any pain meds until 11:00 that night. When I went back to the room, (Resident B) said I shouldn't have even bothered because that was the same nurse he had talked to earlier and pretty much refused to check him out. The family member recalled, After (name of Resident B) died and we got his belongings, we found some of his clothing with blood on them. No one was able to explain to us why the blood was on his clothes. In interview with CNA 4 on [DATE] at 1:55 p.m., she recalled working with Resident B on [DATE], as he resided on the hall that she routinely worked on. The day that he coded, I had been clocked out to lunch and when I came back, the fire department or ambulance service was in his room with the door closed. His daughter had come in to visit not long before I went to lunch. I don't recall him saying anything about being sick to his stomach or vomiting or hurting before any of that happened .But, I'm pretty sure that if he had been having any problems before that, I would remember talking to the nurse about it. That's not the kind of thing you forget. This Federal tag relates to Complaint IN 835. 3XXX,[DATE](a)

Based on observation, interview and record review, the facility failed to provide pain medication to a resident prior to a dressing change, resulting in extreme pain for 1 of 1 residents reviewed for hospice. (Resident #B) Findings include: Resident #B's record was reviewed on 5/24/16 at 12:18 p.m. Her [DIAGNOSES REDACTED]. Resident #B's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated she sometimes was understood and she sometimes understood others. She was severely impaired in her cognitive daily decision making skills She required extensive assistance of 1 person for bed mobility, dressing, eating, and personal hygiene. She required extensive assistance of 2 persons for transfer and toileting. She did not walk. She had no impairment in her range of motion. She was not on a scheduled pain medication. She had received no as needed (PRN) pain medication She had 3 stage II ulcers. She was a Hospice resident. an order for [REDACTED]. A plan of care for Resident #B initiated 4/12/16, indicated she was on hospice related to end of life care. Her goal indicated she would be comfortable and have her needs met. An intervention was to evaluate the effectiveness of medications/interventions to address comfort. A significant change Clinical Health Status assessment dated [DATE], indicated her pain was 5 on a 0-10 pain scale. Her negative vocalization indicated an occasional moan or groan. Low level speech with a negative or disapproving quality. Her facial expression indicated sad, frightened, frown. Her body language indicated rigid. Fist clenched, knees pulled up. Pulling or pushing away. Striking out. A Wound Evaluation Flow Sheet for Resident #B signed 5/20/16, indicated she had a 2.0 centimeter (cm) long by 1.1 cm wide by 0.1 cm deep pressure ulcer on her left second toe identified in the facility on 4/11/16. Her pain was 1.5 on a pain scale of 0 to 10. A Wound Evaluation Flow Sheet for Resident #B signed on 5/20/16, indicated she had a 0.8 cm long by 0.9 cm wide by 0.2 cm deep pressure ulcer on her left great toe identified in the facility on 4/13/16. Her pain was 6 on a pain scale of 0 to 10. Resident #B's medication record indicated she had not received any Tylenol PRN medication in May 2016. A physician's orders [REDACTED]. On 5/23/16 at 10:50 a.m., the Assistant Director of Nursing (ADON) was observed providing wound care to Resident #B's left great toe and left second toe. The ADON removed her soiled dressings from her left great toe and left second toe. Blood was visible on her toes and her toes laid against each other. The ADON sprayed her toes with wound cleanser and cleaned her toes with sterile gauze. Resident #B kept her eyes closed as she winced, moaned, and yelled out in pain. The ADON rubbed the inner left great toe and inner left second toe with skin-prep wipes. Resident #B continued to keep her eyes closed as she winced, moaned, and yelled out in pain. The wound on her inner left great toe had a whitish/yellowish wound bed and the wound on her inner left second toe had a red wound bed with bloody drainage. There was a foul odor from the wounds. [MEDICATION NAME] foam adhesive dressings were applied to the inner left great toe and inner left 2nd toe. On 5/23/16 at 11:56 a.m., Unit Coordinator #6 indicated the Hospice Nurse ordered [MEDICATION NAME] to be given to Resident #B 1 hour prior to her dressing change and PRN. An interview with the ADON on 5/23/16 at 1:00 p.m., indicated he provided Resident #B with her dressing change the majority of the time and Unit Coordinator #6 provided Resident #B with her dressing change sometimes. He indicated he had never noticed Resident #B show any signs or symptoms of pain prior to this day. He indicated he had notified the Hospice Nurse Resident #B showed signs of pain during her dressing change. An interview with Unit Coordinator #6 on 5/23/16 at 1:04 p.m., indicated she had provided Resident #B with her dressing change sometimes. She stated I have seen her grimace or say oh, but I had never seen her holler out like she did today. She indicated when Resident #B had showed signs of pain in the past she had asked Resident #B is she needed something for pain and Resident #B had always told her no. The Pain Management Guideline provided by the Administrator on 5/25/16 at 11:33 a.m., indicated the following: Guideline Statement: To provide guidance for consistent assessment, management and documentation of pain in order to provide maximum comfort and enhanced quality of life, in concert with the patient's/resident's plan of care and goals for pain management. Guidelines: Functions of appropriate pain management include, but are not limited to: Ensuring involvement of patient/resident in pain management. Recognizing and reporting pain as a 5th vital sign. Assessing pain and evaluating response to pain management interventions using a pain management scale based on patient/resident self-report or objective assessment for the cognitively impaired. Intervening to treat pain before the pain becomes severe. Anticipating pain during activities that may be uncomfortable (i.e. dressing changes, transfers, bathing) and pre-treating with pain medication 3.1-37(a)

Based on observation, interview and record review, the facility failed to prevent a dependent resident from falling forward out of her wheelchair while being propelled by staff, resulting in a head laceration and failed to ensure a resident with a history of falls was assisted with ambulation with the use of a gait belt, for 2 of 2 residents reviewed for accidents. (Resident #B and #137) Findings include: 1. Resident #B's record was reviewed on 5/24/16 at 12:18 p.m. Her [DIAGNOSES REDACTED]. Resident #B's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated she sometimes was understood and she sometimes understood others. She was severely impaired in her cognitive daily decision making skills She required extensive assistance of 1 person for bed mobility, dressing, eating, and personal hygiene. She required extensive assistance of 2 persons for transfer and toileting. She did not walk. She was a hospice resident. A Verification of Investigation summary and outcome for Resident #B indicated on 3/13/16 at 4:32 p.m., CNA #17 had been propelling Resident #B in her wheelchair in the dining room and Resident #B fell out of her wheelchair onto her face. CNA #17 had notified the nurse. When the nurse entered the room, Resident #B had been observed lying on the floor on her stomach with her face turned to the right side, and there was blood on the floor. She had a laceration to the center of her hairline and bruising to the back of her right hand with an abrasion. She had been sent to a local emergency room due to the severity of her injury. The intervention put in place to prevent a reoccurrence was Resident #B would have two foot pedals on wheelchair at all times during locomotion. The interview summary from CNA #17 indicated indicated I was moving resident to get another resident into the dining room. I moved her wheelchair and she fell out. The post fall analysis and plan indicated Resident #B had impaired safety awareness/judgement and a history of falls. A Progress Note for Resident #B dated 3/14/16 at 3:57 p.m., indicated she had sutures intact to the center of her forehead with no active bleeding and bruising over the top of her right hand onto her fingers from her previous fall. On 5/20/16 at 10:16 a.m., Resident #B was observed seated in her geriatric chair with her feet slightly elevated on the chair foot rest. She had a dark scab approximately the size of a nickel in the middle of her forehead near her hairline. Her son was in her room visiting and he indicated the scab on her forehead was where she fell out of her wheelchair approximately 2 months prior. He was informed by the facility, a staff member had been propelling his mother's wheelchair in the dining room and she fell forward out of the chair. She had only had 1 foot rest on her wheelchair. On 5/23/16 at 10:00 a.m., Resident #B's daughter was in visiting her mother. Resident #B's daughter indicated when her mother used to utilize a standard wheelchair most often there were no footrest on her wheelchair and they were often left lying on her mother's bed, or there was only 1 footrest on her wheelchair. When there was 1 footrest on her mother's wheelchair, staff would place 1 of her feet on the footrest and cross the other foot on top of the foot that was on the wheelchair footrest. On 5/23/16 at 1:40 p.m., the DON indicated when she had spoke to CNA #17 about Resident #B's fall from her wheelchair on 3/13/16, CNA #17 indicated she had been propelling Resident #B in the dining room to allow another resident to enter the dining room and Resident #B let her feet touch the floor and she fell out. Resident #B normally only had 1 footrest on her wheelchair because she was encouraged to use her good foot to propel her wheelchair. Resident #B would lift her foot when propelled by staff. The intervention for Resident #B to prevent a reoccurrence was 2 footrest were placed on her wheelchair. 2. Resident #137's record was reviewed on 5/24/16 at 2:43 p.m. His [DIAGNOSES REDACTED]. Resident #137's quarterly MDS assessment dated [DATE], indicated he was understood and had the ability to understand others. He was severely impaired in his cognitive daily decision making skills. He required limited assistance of 1 person to transfer and walk in his room. He utilized a walker and wheelchair for locomotion. He had 2 or more falls without injury. A Verification Of Investigation for Resident #137 indicated on 1/5/16, a CNA had walked past his room and saw him sitting on the floor, leaning against his bed. Resident #137 had stated I just wanted to get up. Resident #137 had a habit of laying across his bed with his feet in his wheelchair. Staff reminded him frequently it was not a safe position but he disregarded what staff said. An intervention to prevent reoccurrence would be to remind him not to recline across his bed with his feet in his wheelchair. Staff would check to make sure his wheelchair brakes were locked. A Verification of Investigation for Resident #137 indicated on 1/26/16, he had slid out of his wheelchair onto the floor and laid on his right side. Resident #137 had stated he was trying to go to bed and slid out of bed. He had a history of [REDACTED]. An intervention to prevent reoccurrence would be to put him to bed as soon as he was done eating. A Verification of Investigation for Resident #137 indicated on 3/31/16, he had been found sitting on his floor next to his bed. Resident #137 stated he had scooted on his butt onto the floor. He had a wet brief and was confused at times. An intervention to prevent reoccurrence would be a mat beside his bed. A plan of care for Resident #137 initiated 5/27/15, indicated his focus was Ambulation (restorative): Resident is at risk for decline in ambulation r/t (related to) Cerebrovascular Disease. His focus was to ambulate to/from the dining room for meals and to/from the bathroom for toileting 2 times a day for up to 6 days a week. An intervention was to utilize a gait belt and a 4 wheeled walker for ambulation. An interview with Resident #137's sister on 5/18/16 at 11:48 a.m., indicated Resident #137 had fell 3 or 4 times. She indicated he had fallen approximately a week and a half prior to this date. He had been coming out of the bathroom and fell . He had a little place on his forehead, elbow, knee, but nothing major. On 5/20/16 at 11:43 a.m., Resident #137 was observed lying on his back in bed. He denied any recent falls no not really. Resident #137's sister was in his room visiting. She indicated Resident #137 sometimes got up on his own but he really needed assistance. She put his shoes on, assisted him to sit up on the side of the bed, and placed his wheelchair next to his bed and locked the wheels. She held his arm as he stood, pivoted, and sat down in his wheelchair. Resident #137 stated piece of cake. He was slightly unsteady, leaning to his left after he had his back was facing the wheelchair but was able to correct his stance before sitting down. His sister propelled him to the dining room in his wheelchair. An interview with Unit Coordinator #6 on 5/20/16 at 1:53 p.m., indicated Resident #137 transferred himself and was unsteady at times. He utilized a wheelchair when he was tired or unsteady and out of his room. He typically didn't ambulate the unit but would ambulate in his bedroom with his rolling walker. On 5/24/16 at 9:43 a.m., Resident #137 was observed seated in a dining chair at the dining table. CNA #18 indicated Resident #137 was on an ambulation restorative program where he walked to his bathroom and from his bedroom to the dining room. He was pretty good at participating in the program. He had a walker in his bedroom that he used. She went to Resident #137's bedroom and returned with his rollator. She locked the wheels on his rollator and he stood independently holding onto the rollator's arms and her holding onto his arm. He ambulated out of the dining room and down the hallway toward his bedroom with short steps and his feet turned outward. His gait was slow and unsteady. CNA #18 pulled his wheelchair behind him with her right hand and held onto his left arm with her left hand. The wheelchair was close to his legs as he ambulated. He stopped in the hallway outside his bedroom and sat down in his wheelchair due to a medication cart blocked his bedroom door. After the medication cart was moved, CNA #18 locked the left wheel of his wheelchair. He placed his hands on the rollator's arms and attempted to stand but the right side of his wheelchair was moving. After he made several attempts to stand, CNA #18 grabbed the back of his sweat pants with her right hand while holding his left arm with her left hand and assisted him to his feet. She indicated she had forgot to lock the right side of his wheelchair. He ambulated to his bed with CNA #18 pulling his wheelchair behind him with her right hand and holding his left arm with her left hand. He stood from the wheelchair with the wheels unlocked. He was unsteady when he pivoted and sat down on his bed. CNA #18 began to leave his room with his wheelchair next to his bed and the wheels unlocked. When she was queried if his wheelchair brakes should be left in the locked position she stated sometimes it is and sometimes it's not. Requested his wheelchair brakes be locked in case he decided to get out of bed and into his wheelchair. CNA #18 stated yeah, I guess he might. When CNA #18 was queried if Resident #137 should wear a gait belt around his waist during assisted ambulation she stated yes, I forgot to get one this morning. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure a resident was safely assisted back to her room via wheelchair resulting in a large V-shaped, tendon exposed laceration to the right hand with an emergency room visit for multiple sutures. This affected 1 of 1 resident reviewed for accidents. (Resident #3) Findings include: The clinical record for Resident #3 was reviewed on 3/18/14 at 11:30 a.m. The [DIAGNOSES REDACTED]. The 2/27/14 Quarterly MDS (Minimum Data Set) assessment indicated Resident #3 required extensive assistance of 1 person for locomotion on the unit. It indicated she had a BIMS (Brief Interview For Mental Status) score of 9. The BIMS scores range from 0 to 15 with 15 indicative of no cognitive impairment. The 3/6/14 Incident Report submitted to ISDH (Indiana State Department of Health) indicated, "Brief Description of Incident: Resident was assisted back to her room in her wheelchair by a CNA (Certified Nursing Assistant). When entering resident's room, resident dropped her hand down onto the side of the wheelchair and her hand caught between the wheel of the wheelchair and the foot board on her roommates bed. Type of Injury/Injuries: A large avulsed skin tear approximately 12 to 13 cm, to the back of the right hand with copious amounts of bleeding noted. Immediate Action Taken: Gauze and pressure applied, sent to (name of hospital) Emergency Department. Interview staff. Preventative measures taken: Pad foot board of roommate's bed, all rooms entry ways measured to ensure adequate space available to safely maneuver residents through. Therapy to screen for wheelchair positioning and transfers. In-service staff on ensuring resident placement of hands/arms are in lap or across chest while being assisted with propelling wheelchair." An observation of Resident #3 sitting in her wheelchair, eating lunch in the dining room was made on 3/18/14 at 12:42 p.m. with emphasis on the width of her wheelchair. Her right hand was wrapped and in a splint. Her right thumb was bruised and purplish brown. An observation of Resident #3's entry way to her room was made on 3/18/14 at 12:45 p.m. The door opened to the left approximately 8 inches from the wall. A night stand was located in front of the open door. Resident #3's roommate's footboard of her bed was on the right. Adequate space to maneuver was observed, given the observed width of Resident #3's wheelchair. A telephone interview was conducted with CNA #1 on 3/18/14 at 1:01 p.m. regarding the incident with Resident #3. She indicated, "She asked me to push her to her room, and I said yes. As I was pushing (name of Resident #3) into her room, the door was not open all the way. Before I pushed her, I asked her to put her hands on the armrest and I saw her do it, but when I was talking to another resident, she moved it." She indicated Resident #3's right hand was no longer on the armrest, but "down by the wheel." She stated, "Since the door wasn't all the way open, I tried to get the left footrest to push the door open, so I had to turn the wheelchair to the right a little, and that's when her hand got caught between the wheel of her wheelchair and the bed." Regarding the use of Resident #3's left foot rest in an attempt to push the door open rather than open the door herself, she indicated it was because she was distracted by the other resident. Regarding the physical location of the door while pushing Resident #3 into her room, she stated, "The door was not close to the wall. I could have opened the door all the way, so there would have been enough room to push her through, but I was distracted by the other resident that I was talking to. Normally, that's what I would have done. There's always been room to get her through." Regarding whether the furniture had been rearranged since the incident, and whether she'd been in-serviced, she stated, "They put the padding on the bed, but didn't rearrange the furniture...The DON (Director of Nursing) talked to me afterwards, and she said I would need a drug screen, and I took that 2 Thursdays ago. I haven't had the in-service yet. She said the in-service would be with everyone and an individual one for me. I haven't had either. She didn't write anything down or make me sign anything." Regarding whether she would have done anything differently regarding the incident with Resident #3, she stated, "Differently, I would have paid more attention by looking at (name of Resident #3) while pushing her. I was looking back at (name of resident by which CNA #1 alleges to have been distracted) while pushing her in, and would have pushed the door open with my hand." An interview was conducted with the DON on 3/18/14 at 1:30 p.m. regarding the incident and whether CNA #1 had been in-serviced. She stated, "After I investigated, we found 10 inches of clearance on both sides of the wheelchair. We haven't in-serviced all CNA's, but will this coming Thursday. I in-serviced (name of CNA #1) by telling her over the phone to ensure proper hand placement while pushing a resident." She indicated she documented verification of the in-service in the investigation. An observation of Resident #3's entryway into her room was made with the DON on 3/18/14 at 1:35 p.m. The DON indicated adequate space was observed to safely maneuver Resident #3 into her room in her wheelchair. The DON placed the door 1/3 to 1/2 way shut. She indicated that was where CNA #1 indicated to her the door was positioned when the incident occurred. Regarding whether she thought Resident #3 would have been able to safely enter if the door had been opened more, the DON nodded her head. The 3/5/14 Verification Of Investigation was provided by the DON on 3/18/14 at 2:00 p.m. It indicated, "Provide a detailed description of event/allegation: (name of Resident #3) was being wheeled into her room, in wc (wheelchair), after supper by staff. Hand caught between wheel of w/c (symbol for "and") end of bed, causing large s/t (skin tear) to back of rt (right) hand...Resident Interview Summary: 'I, I, I, hurt it,' making sounds after that could not be understood...Causal/Contributing factors and observations: Poor safety awareness, grabs at wheels on wheelchair while being assisted with mobility in wheelchair. Thin fragile skin...Specify recommendations/interventions taken to prevent reoccurrence: Resident reminded to keep hands and arms in lap while being assisted with mobility in wheelchair, especially when entering or exiting narrow spaces...Witness Name: (name of CNA #1) Date: 3/5/14 Time: 07:15 Interview Summary: (Name of Resident #3) was by the Fireside Dining Room and asked me to push her back to her room after supper. I told (name of Resident #3) to let go of the wheel and to put her hand up on the arm of the wheelchair. Another resident asked me to help her to her room and I told her I would be right there. I started to push (name of Resident #3) into her room and the door was partially shut. I angled the wheelchair slightly so that I could open the door farther. (Name of Resident #3) said 'ouch, ouch'. I looked down as I asked her what was the matter and she said 'my hand.' (Name of Resident #3's) hand was between the foot of roommates bed and the wheel of the wheelchair. I saw her hand was bleeding and had a bad cut on it. I called for the nurse to come in right away and then started to wipe the blood from the bottom of her hand with a wipe, and then nurse came in. (Name of CNA #1) was reminded that when transporting a resident in the wheelchair to always ensure proper placement of hands away from wheels and into lap area for safety. Name of interviewer: (Name of DON) Date: 3/6/14 Time: 15:50." The Causal/Contributing Factors section did not indicate the door being partially shut as a factor, nor did the Interview Summary indicate CNA #1 was spoken to regarding ensuring a resident's door was open to ensure adequate space to maneuver. The 3/5/14 Emergency Department Note indicated, "Patient has a large V-shaped laceration with the apex of the skin flap denuded and very thin. The patient's extensor tendons are exposed, there are no obvious discontinuities. Patient's laceration is approximately 12-13 cm in length. Discussion of ED (emergency department) Course: I discussed the case with (Name of doctor), the hand surgeon at (name of hospital). He recommended approximating the wound is (sic) loosely as possible, placing a splint, and having the patient follow up in clinic for reevaluation. See the procedure note for wound closure, the wound was closed with as little tension as possible, however this was a difficult task given a portion of the wound it was missing, her thin skin, and the large size of the skin flap. Procedures Performed: 1. hand laceration repair --- 2% lidocaine used to anesthetize the area. Following this the wound was cleaned with saline. Multiple horizontal mattress sutures were placed with 3-0 nylon to get the large wound to come together. I had to remove the apex of the flap as it was nonviable and very thin. Following the mattress sutures, several interrupted simple 3-0 nylon sutures were placed to approximate the wound better. Unfortunately, I was unable to close the apex of the wound. I was able to approximate the rest of the wound, but this was under some pressure. He had to take fairly large bites for the mattress sutures. Following closure, a dressing was placed and a splint was placed to minimize movement of that hand...Additional Instructions: Keep the splint and dressing clean, dry, and in place until evaluated by hand surgery. Return for worsening symptoms, weakness, color changes of the fingers, or any other concerns. Follow up with hand surgery in 2-3 days, call to make an appointment." This deficiency was cited on January 30, 2014. The facility failed to implement a systemic plan of correction to prevent recurrence. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure a resident was safely assisted back to her room via wheelchair resulting in a large V-shaped, tendon exposed laceration to the right hand with an emergency room visit for multiple sutures. This affected 1 of 1 resident reviewed for accidents. (Resident #3) Findings include: The clinical record for Resident #3 was reviewed on 3/18/14 at 11:30 a.m. The [DIAGNOSES REDACTED]. The 2/27/14 Quarterly MDS (Minimum Data Set) assessment indicated Resident #3 required extensive assistance of 1 person for locomotion on the unit. It indicated she had a BIMS (Brief Interview For Mental Status) score of 9. The BIMS scores range from 0 to 15 with 15 indicative of no cognitive impairment. The 3/6/14 Incident Report submitted to ISDH (Indiana State Department of Health) indicated, Brief Description of Incident: Resident was assisted back to her room in her wheelchair by a CNA (Certified Nursing Assistant). When entering resident's room, resident dropped her hand down onto the side of the wheelchair and her hand caught between the wheel of the wheelchair and the foot board on her roommates bed. Type of Injury/Injuries: A large avulsed skin tear approximately 12 to 13 cm, to the back of the right hand with copious amounts of bleeding noted. Immediate Action Taken: Gauze and pressure applied, sent to (name of hospital) Emergency Department. Interview staff. Preventative measures taken: Pad foot board of roommate's bed, all rooms entry ways measured to ensure adequate space available to safely maneuver residents through. Therapy to screen for wheelchair positioning and transfers. In-service staff on ensuring resident placement of hands/arms are in lap or across chest while being assisted with propelling wheelchair. An observation of Resident #3 sitting in her wheelchair, eating lunch in the dining room was made on 3/18/14 at 12:42 p.m. with emphasis on the width of her wheelchair. Her right hand was wrapped and in a splint. Her right thumb was bruised and purplish brown. An observation of Resident #3's entry way to her room was made on 3/18/14 at 12:45 p.m. The door opened to the left approximately 8 inches from the wall. A night stand was located in front of the open door. Resident #3's roommate's footboard of her bed was on the right. Adequate space to maneuver was observed, given the observed width of Resident #3's wheelchair. A telephone interview was conducted with CNA #1 on 3/18/14 at 1:01 p.m. regarding the incident with Resident #3. She indicated, She asked me to push her to her room, and I said yes. As I was pushing (name of Resident #3) into her room, the door was not open all the way. Before I pushed her, I asked her to put her hands on the armrest and I saw her do it, but when I was talking to another resident, she moved it. She indicated Resident #3's right hand was no longer on the armrest, but down by the wheel. She stated, Since the door wasn't all the way open, I tried to get the left footrest to push the door open, so I had to turn the wheelchair to the right a little, and that's when her hand got caught between the wheel of her wheelchair and the bed. Regarding the use of Resident #3's left foot rest in an attempt to push the door open rather than open the door herself, she indicated it was because she was distracted by the other resident. Regarding the physical location of the door while pushing Resident #3 into her room, she stated, The door was not close to the wall. I could have opened the door all the way, so there would have been enough room to push her through, but I was distracted by the other resident that I was talking to. Normally, that's what I would have done. There's always been room to get her through. Regarding whether the furniture had been rearranged since the incident, and whether she'd been in-serviced, she stated, They put the padding on the bed, but didn't rearrange the furniture.The DON (Director of Nursing) talked to me afterwards, and she said I would need a drug screen, and I took that 2 Thursdays ago. I haven't had the in-service yet. She said the in-service would be with everyone and an individual one for me. I haven't had either. She didn't write anything down or make me sign anything. Regarding whether she would have done anything differently regarding the incident with Resident #3, she stated, Differently, I would have paid more attention by looking at (name of Resident #3) while pushing her. I was looking back at (name of resident by which CNA #1 alleges to have been distracted) while pushing her in, and would have pushed the door open with my hand. An interview was conducted with the DON on 3/18/14 at 1:30 p.m. regarding the incident and whether CNA #1 had been in-serviced. She stated, After I investigated, we found 10 inches of clearance on both sides of the wheelchair. We haven't in-serviced all CNA's, but will this coming Thursday. I in-serviced (name of CNA #1) by telling her over the phone to ensure proper hand placement while pushing a resident. She indicated she documented verification of the in-service in the investigation. An observation of Resident #3's entryway into her room was made with the DON on 3/18/14 at 1:35 p.m. The DON indicated adequate space was observed to safely maneuver Resident #3 into her room in her wheelchair. The DON placed the door 1/3 to 1/2 way shut. She indicated that was where CNA #1 indicated to her the door was positioned when the incident occurred. Regarding whether she thought Resident #3 would have been able to safely enter if the door had been opened more, the DON nodded her head. The 3/5/14 Verification Of Investigation was provided by the DON on 3/18/14 at 2:00 p.m. It indicated, Provide a detailed description of event/allegation: (name of Resident #3) was being wheeled into her room, in wc (wheelchair), after supper by staff. Hand caught between wheel of w/c (symbol for and) end of bed, causing large s/t (skin tear) to back of rt (right) hand.Resident Interview Summary: 'I, I, I, hurt it,' making sounds after that could not be understood.Causal/Contributing factors and observations: Poor safety awareness, grabs at wheels on wheelchair while being assisted with mobility in wheelchair. Thin fragile skin.Specify recommendations/interventions taken to prevent reoccurrence: Resident reminded to keep hands and arms in lap while being assisted with mobility in wheelchair, especially when entering or exiting narrow spaces.Witness Name: (name of CNA #1) Date: 3/5/14 Time: 07:15 Interview Summary: (Name of Resident #3) was by the Fireside Dining Room and asked me to push her back to her room after supper. I told (name of Resident #3) to let go of the wheel and to put her hand up on the arm of the wheelchair. Another resident asked me to help her to her room and I told her I would be right there. I started to push (name of Resident #3) into her room and the door was partially shut. I angled the wheelchair slightly so that I could open the door farther. (Name of Resident #3) said 'ouch, ouch'. I looked down as I asked her what was the matter and she said 'my hand.' (Name of Resident #3's) hand was between the foot of roommates bed and the wheel of the wheelchair. I saw her hand was bleeding and had a bad cut on it. I called for the nurse to come in right away and then started to wipe the blood from the bottom of her hand with a wipe, and then nurse came in. (Name of CNA #1) was reminded that when transporting a resident in the wheelchair to always ensure proper placement of hands away from wheels and into lap area for safety. Name of interviewer: (Name of DON) Date: 3/6/14 Time: 15:50. The Causal/Contributing Factors section did not indicate the door being partially shut as a factor, nor did the Interview Summary indicate CNA #1 was spoken to regarding ensuring a resident's door was open to ensure adequate space to maneuver. The 3/5/14 Emergency Department Note indicated, Patient has a large V-shaped laceration with the apex of the skin flap denuded and very thin. The patient's extensor tendons are exposed, there are no obvious discontinuities. Patient's laceration is approximately 12-13 cm in length. Discussion of ED (emergency department) Course: I discussed the case with (Name of doctor), the hand surgeon at (name of hospital). He recommended approximating the wound is (sic) loosely as possible, placing a splint, and having the patient follow up in clinic for reevaluation. See the procedure note for wound closure, the wound was closed with as little tension as possible, however this was a difficult task given a portion of the wound it was missing, her thin skin, and the large size of the skin flap. Procedures Performed: 1. hand laceration repair --- 2% lidocaine used to anesthetize the area. Following this the wound was cleaned with saline. Multiple horizontal mattress sutures were placed with 3-0 nylon to get the large wound to come together. I had to remove the apex of the flap as it was nonviable and very thin. Following the mattress sutures, several interrupted simple 3-0 nylon sutures were placed to approximate the wound better. Unfortunately, I was unable to close the apex of the wound. I was able to approximate the rest of the wound, but this was under some pressure. He had to take fairly large bites for the mattress sutures. Following closure, a dressing was placed and a splint was placed to minimize movement of that hand.Additional Instructions: Keep the splint and dressing clean, dry, and in place until evaluated by hand surgery. Return for worsening symptoms, weakness, color changes of the fingers, or any other concerns. Follow up with hand surgery in 2-3 days, call to make an appointment. This deficiency was cited on January 30, 2014. The facility failed to implement a systemic plan of correction to prevent recurrence. 3.1-45(a)(2)