Every finding on record at Brickyard Healthcare - Brentwood Care Center

Based on observation, interview, and record review, the facility failed to ensure medications were properly dated, labeled, and not expired for 1 of 4 medication carts, and 2 of 2 medication storage rooms reviewed for medication storage. (400 Hall Medication Cart, North Hall Medication Storage Room Refrigerator, South Hall Medication Room with Refrigerator) Findings include: On 2/20/25 at 10:00 A.M., the following undated medications were observed in the 400 Hall Medication Cart: 1 Humalog Insulin pen for [Patient Name] with no open date On 2/24/25 at 9:10 A.M., the following expired medications were observed in the North Hall Medication Storage Room Refrigerator: 1 bottle of Mary's Medical Mouth Wash for [Resident Name] with an expiration date of 1/15/25 On 2/24/25 at 10:16 A.M., the following expired medications were found in the South Hall Medication Storage Room and Refrigerator: 1 bottle of 0.9% Sodium Chloride Solution for [Patient Name] with an expiration date of 10/19/24 1 bottle of 0.9% Sodium Chloride Solution for [Patient Name] with an expiration date of 1/24/25 1 vial of Tuberculin Solution with no open date During an interview on 2/24/25 at 10:15 A.M., Licensed Practical Nurse (LPN) 6 indicated a medication should have a label and date if have Physician Order. The medications should have an open date when they are opened and if expired should be destroyed. During an interview on 2/24/25 at 10:20 A.M., Registered Nurse (RN) 7 indicated tuberculin solution should be dated once it is opened. On 2/25/25 at 9:48 A.M., the Administrator provided a current, non-dated policy Labeling of Medications and Biological. The policy indicated all medications . used in the facility will be labeled in accordance with current state and federal considerations .must include resident name .and expiration date . On 2/25/25 at 9:48 A.M., the Administrator provided a current, non-dated policy Medication Storage. The policy indicated .unused medications are routinely inspected for discontinued and outdated medications .these medications are destroyed according to Destruction of Unused Drugs Policy 3.1-25(j) 3.1-25(o)

Based on observation, interview, and record review, the facility failed to ensure respiratory services were provided according to professional standards for 1 of 2 residents reviewed for hospice. (Resident 1) A resident received a different amount of oxygen than what the physician ordered. Finding includes: On 2/20/25 at 2:08 P.M., Resident 1 was observed lying in bed receiving 4 Liters (L) of oxygen via nasal cannula. At that time, Resident 1 indicated he was supposed to be receiving 2L of oxygen. On 2/21/25 at 2:53 P.M., Resident 1 was observed lying in bed receiving 4L of oxygen via nasal cannula. On 2/24/25 at 10:51 A.M., Resident 1 was observed lying in bed receiving 4L of oxygen via nasal cannula. On 2/21/24 at 2:38 P.M., Resident 1's clinical record was reviewed. Diagnoses included, but were not limited to, acute and chronic respiratory failure with hypoxia. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 11/22/24, indicated Resident 1 was cognitively intact, required substantial to maximal assistance (staff does more than half) for bed mobility and was dependent on staff for toileting and bathing, and was receiving oxygen therapy. Current physician orders included, but were not limited to: Continuous oxygen at 3L via nasal cannula related to acute and chronic respiratory failure with hypoxia, dated 5/27/24. The most current care plan conference was completed on 2/20/25 at 11:50 A.M. Care plan conference notes indicated Resident 1's care plan was reviewed and for staff to continue to follow the current plan of care. A current oxygen therapy care plan, initiated 4/11/23, included an intervention to administer oxygen as needed per physician order. A current alteration in respiratory status care plan, initiated 12/22/20 and revised on 9/15/21, included an intervention to administer oxygen as ordered per physician order. During an interview on 2/25/25 at 8:21 A.M., the Director of Nursing (DON) indicated that Resident 1 should be on 3L of oxygen. The order had not been increased to 4L to her knowledge. On 2/25/25 at 9:46 A.M., the Administrator provided a current Oxygen Administration policy, dated 2024, that indicated Oxygen is administered under orders of a physician . 3.1-47(a)(6)

Based on observation, record review, and interview, the facility failed to ensure infection prevention standards were implemented during care provided for two random observations of residents requiring Enhanced Barrier Precautions (EBP). (Resident 1 and Resident 12) Findings include: 1. During a direct care observation on 2/24/25 at 10:51 A.M., Hospice Nurse 11 assisted in repositioning Resident 1 in bed by pulling the resident up. Hospice Nurse 11 was not wearing a gown. Resident 1's room door had a sign indicating enhanced barrier precautions should be followed and staff who perform high contact activities with Resident 1 should wear a gown and gloves. On 2/21/25 at 2:38 P.M., Resident 1's clinical record was reviewed. Diagnoses included, but were not limited to, chronic kidney disease. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 11/22/24, indicated Resident 1 was cognitively intact, required substantial assistance (staff do more than half of the work) for rolling left to right, and had an indwelling catheter. Current physician orders included, but were not limited to: Resident may be in Enhanced Barrier Precautions secondary to indwelling catheter every day and night shift, start date 5/10/24 Catheter type Foley, size 16 French related to urinary retention, start date 5/14/24 The current care plan included, but was not limited to: I am at risk for infection related to indwelling Foley catheter secondary to in house MDRO (multi-drug-resistant organisms). Date Initiated: 4/1/24 Maintain enhanced barrier precautions. Date Initiated: 4/1/24 During an interview on 2/25/25 at 9:01 A.M., the infection preventionist indicated all staff should wear gloves and a gown when direct care is provided to residents who require enhanced barrier precautions. 46758 2. On 2/21/25 at 9:16 A.M., during a random observation Qualified Medicine Aide (QMA) 12 was observed entering Resident 5's room without donning Personal Protection Equipment (PPE) due to being on Enhanced Barrier Protocol (EBP). Direct resident care was observed when the residents incontinent brief was removed and changed. On 2/21/25 at 1:59 P.M., Resident 5's clinical record was reviewed. Diagnosis included, but was not limited to, neuromuscular dysfunction of bladder. The Current Minimum Data Set (MDS) Assessment indicated Resident 5 was cognitively intact. The resident had a suprapubic catheter and was dependent on dressing and toileting. Current physician orders included, but were not limited to: Resident may be in Enhanced Barrier Precautions (EBP) secondary to indwelling Catheter every day and night shift for IFC/EHB (Infection control/Enhanced Barrier) precautions dated 4/1/24. May implement Enhanced Barrier Precautions (EBP) to reduce potential transmission of multi-drug-resistant organisms (MDRO) during high-contact resident care activities for residents with chronic wounds or indwelling medical device(s) regardless of their MDRO status dated 4/1/24. The current EBP care dated 1/9/25 indicated Resident 5 uses EBP for indwelling urinary catheter with goal of remaining free of infection. Current interventions included, but were limited to following enhanced barrier precautions, informing resident and visitors of necessary precautions, and PPE used for High-Contact resident care activities such as changing briefs or assisting toileting. dated 10/4/24. On 2/25/25 at 9:45 A.M., the Administrator provided a policy titled Enhanced Barrier Precautions, dated 2025, that indicated It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. PPE (personal protective equipment) for enhanced barrier precautions is necessary when performing high-contact care activities High-contact resident care activities include: Dressing; Bathing; Transferring; Providing hygiene; Changing linen; Changing briefs or assisting with toileting; Device care or use; Wound care. 3.1-18(b)(1) 3.1-18(b)(2) 3.1-18(j)

Based on observation, interview, and record review, the facility failed to ensure services were provided according to professional standards to prevent urinary tract infections (UTI) for 1 of 2 residents reviewed with indwelling urinary catheter use. (Resident 90) Referrals to the urologist were not made, voiding trials were not completed as ordered, care plans were not updated to reflect new orders, the provider did not assess the resident in a timely manner, and infection control practices were not followed. Finding includes: On 2/20/25 at 10:40 A.M., Resident 90 was observed sitting in his wheelchair in the hallway. An indwelling catheter bag was observed hooked to the bottom of his wheelchair. The catheter bag and tubing were observed dragging on the floor. Sediment was observed in the catheter tubing. On 2/21/25 at 11:10 A.M., Resident 90's clinical record was reviewed. Diagnoses included, but were not limited to, obstructive and reflux uropathy and retention of urine. The resident was admitted to the facility on [DATE] from the hospital with an indwelling catheter. The most current Admission Minimum Data Set (MDS) Assessment, dated 12/2/24, indicated Resident 90 was not cognitively intact, required substantial to maximal assistance (staff does more than half) for toileting, had an indwelling catheter, and had no urinary tract infections (UTIs) upon admission. Current physician orders included, but were not limited to: Maintain catheter size 18 French (fr) with 10 milliliter (ml) bulb related to retention of urine, dated 1/22/25 Macrobid oral capsule 100 mg (milligram) - Give one capsule by mouth two times a day for UTI for seven days, dated 2/25/25 Completed physician orders included, but were not limited to: Obtain urine for urinalysis (UA) with culture and sensitivity (C&S) one time only for urinary frequency, completed 12/11/24 cefuroxime axetil (an antibiotic) oral tablet 500 mg - Give one tablet by mouth two times a day for UTI for five days, completed 12/11/24 to 12/16/24 cefuroxime axetil oral tablet 500 mg - Give one tablet by mouth two times a day for UTI for five days, completed 12/16/24 to 12/21/24 Referral for Urology for catheter and enlarged testicle. Nursing to schedule. - one time only for appointment scheduling related to retention of urine, noninflammatory disorders of the testis, and obstructive and reflux uropathy, completed 1/10/25. Obtain urine for UA with C&S - one time only for urinary symptoms, completed 1/21/25 Bactrim DS (an antibiotic) tablet 800-160 mg - Give one tablet by mouth every 12 hours for bacterial infection - UTI for five days, completed 1/22/25 to 1/27/25 The most recent care plan conference, dated 11/22/24, indicated acute and chronic medical conditions, including bowel and bladder, were discussed. Resident 90's plan of care was initiated. The most recent indwelling catheter care plan, initiated 11/22/24, included, but were not limited to, the following interventions: CATHETER: has Catheter size 14 fr with 10 ml bulb. Position catheter bag and tubing below the level of the bladder and away from entrance room door, initiated on 11/22/24 and last revised on 12/23/24 The clinical record lacked a care plan addressing antibiotic use, urinary tract infection, or an enlarged testicle. A nursing progress note, dated 11/21/24 at 7:39 P.M., indicated Resident 90 was admitted to the facility with a 10 fr indwelling catheter in place. A Nurse Practitioner (NP) provider note, dated 11/22/24, indicated Resident 90 had an indwelling catheter in place. Orders included May need to trial without. Could not find in hospital paperwork if it was tried. Urology referral. A nursing order note, dated 11/24/24 at 2:35 P.M., indicated Resident 90 pulled out his catheter. The indwelling catheter with an inflated bulb was lying on the floor next to the bed. A new indwelling catheter size 14 fr was re-inserted. The NP was notified. An NP provider note, dated 11/25/24, indicated Resident 90 was seen due to confusion and multiple falls. The following order was given: Voiding trial. Discontinue Foley catheter. If no UOP (urine output) within 6 hours reanchor foley and refer to urology. A nursing progress note, dated 12/11/24 at 5:01 A.M., indicated Resident 90 complained of pain and urgency to urinate. The NP was notified and gave an order for a UA with C&S. A nursing progress note, dated 12/11/24 at 3:29 P.M., indicated an order was received for cefuroxine (an antibiotic) for UTI pending the urine culture report. A nursing progress note, dated 12/16/24 at 4:52 P.M., indicated Resident 90 was still complaining of pain and urgency to urinate. C&S results indicated the urine contained E. coli bacteria and orders were given to continue/extend antibiotic therapy for five days. A nursing progress note, dated 12/24/24 at 7:51 A.M., indicated Resident 90 was observed to have an enlarged left testicle. The NP was notified. A nursing progress note, dated 12/25/24 at 12:35 P.M., indicated Resident 90 continued to have an enlarged left testicle. NP to assess on next visit to the facility. Progress notes, provider notes, physician orders, and care plans, dated 12/25/24 to 1/7/25, lacked documentation to indicate Resident 90 was seen by the NP for evaluation of an enlarged left testicle. An NP provider note, dated 1/8/25, indicated Staff reporting enlarged testicle. Denies pain at this time. Failed previous voiding trial. Continues with Foley. Was supposed to be referred after failing voiding trial to urology but apparently got missed. Urology referral R/T (related to) catheter and enlarged testicle. Progress notes, provider notes, physician orders, and care plans, dated 11/22/24 to 1/8/25, lacked documentation to indicate a voiding trial was performed or the resident was referred to a urologist as ordered following NP visits on 11/22/24 and 11/25/24. A nursing progress note, dated 1/14/25 at 3:40 P.M., indicated an appointment was scheduled with a urologist for 1/21/25. A nursing progress note, dated 1/21/25 at 1:55 P.M., indicated Resident c/o (complained of) urinary discomfort on this shift several times. This nurse went in and assessed resident. Resident was noted to be wet with urine and cath (catheter) only having 50 ml (milliliters) in the bag. This nurse also noticed resident's abdomen was distended, painful to the touch, this nurse also noticed resident has swollen lymph node in right groin area. This nurse took old cath out d/t (due to) possible clog in cath line. As soon as this nurse pulled old cath out resident started urinating everywhere for a few seconds then the urinating stopped. This nurse placed bigger cath 18 gauge due to resident's penis having a split in it and urine leaking out around the 14 gauge cath. As soon as new cath was placed dark brown, mucous filled thick urine began to flow into cath bag. Resident had 875ml of urine come out of his new cath. Notified NP and received new order to get UA with C&S. A nursing progress note, dated 1/21/25 at 2:40 P.M., indicated Resident 90 returned to the facility from an appointment with the urologist with new orders to discontinue Flomax (a medication that relaxes the muscles in the prostate and bladder making it easier to urinate) and continue monthly catheter exchanges at the facility. A nursing progress note, dated 1/22/25 at 11:13 A.M., indicated a new order was received for Bactrim (an antibiotic) for five days pending the urine culture report. A nursing progress report, dated 2/24/25 at 8:00 A.M., indicated Resident 90's indwelling catheter was changed due to a partial occlusion. Sediment and dark urine was noted in the tubing. The NP was notified and a new order for a UA with C&S was received. A nursing progress note, dated 2/24/25 at 8:44 P.M., indicated a new order for Macrobid (an antibiotic) for seven days for UTI was received. During an interview on 2/24/25 at 10:55 A.M., the Director of Nursing (DON) indicated that a voiding trial was not completed on Resident 90 and he was not referred to the urologist until 1/8/25. She indicated that the NP must have written the orders for the voiding trial and referral on the provider note, but did not give them to the facility directly. She was unsure why the NP had indicated a voiding trial had been failed. The NP was usually in the facility three days a week seeing residents. The NP who saw Resident 90 from November to January no longer worked for the facility. During an interview on 2/25/25 at 8:26 A.M., the DON indicated care plans were revised during morning meetings. Reports of new or changed orders were run daily, and care plans were updated from there. During an interview on 2/25/25 at 10:07 A.M., the Regional Consultant indicated that the indwelling catheter bag and tubing should not touch the floor, and staff should place catheter equipment according to professional standards of practice. During an interview on 2/25/25 at 12:08 P.M., the Administrator indicated she had talked to the NP on the phone. She indicated Resident 90 did not have a voiding trial and the NP confused Resident 90 with another resident who had a voiding trial and documented on the wrong person. She indicated the NP did not come into the facility to see residents between 12/24/24 and 1/8/25 due to the holidays and weather-related events. At that time, she indicated Resident 90's care plan should indicate the resident had an 18 fr indwelling catheter and not a 14 fr indwelling catheter. On 2/25/25 at 9:46 A.M., the Administrator provided a current Nurse Staff RN (Registered Nurse) Job Description, dated 9/10/14, that indicated essential job duties included Work in collaboration with physician and/or other health care professionals by sharing information relevant to changing plan of care. On 2/25/25 at 9:46 A.M., the Administrator provided a current Documentation in Medical Record policy, dated 2024, that indicated Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. On 2/25/25 at 10:07 A.M., the Regional Consultant provided a current Indwelling Catheter Use and Removal policy, dated 2024, that indicated Residents that admit with an indwelling catheter .will be assessed for removal of the catheter as soon as possible . If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures . 3.1-18(a)(2)

Based on observation, record review, and interview, the facility failed to provide proper storage of medications and personal property in 3 of 5 medication carts reviewed. Loose pills, unlabeled medications, and resident's personal property were found in medication drawers and the narcotic box of medication carts. (200 Hall, 500 Hall, Alzheimer Unit) Findings include: 1. On 1/18/24 at 8:38 A.M., the upper drawer of the tan cart on the 200 hall was observed to have the following unlabeled medications: 1 box of antihistamine lacked a name and label. 1 box of antihistamine with [patient name] lacked a label. 1 bottle of acetaminophen with [patient name] lacked a label. 2. On 1/18/24 at 8:59 A.M., the medication cart on the 500 Hall was observed to have the following medications loose in 2 drawers of the cart: 1 bottle of Flonase with [patient name] 1 bottle of Calcitonin with [patient name] 1 large pill with KCL M20 1/2 large oblong pill 1/2 white circle pill 2 1/2 medium white circle pill with no numbers 1 oblong yellow pill with no numbers 1 small round peach pill with number S 1P 1 small round yellow pill with R 158 1/2 small round blue pill with no numbers 2 1/2 small round white pills with no numbers 1 small oblong pink pill 1 white capsule 3. On 1/18/24 at 9:27 A.M., the medication cart of the Alzheimer Unit was observed to have the following items in the upper drawer and narcotic box: 1 hearing aid, not labeled 1 gold watch, not labeled 4 gold rings, not labeled 1 bag containing important papers, not labeled During an interview on 1/18/24 at 8:44 A.M., RN (Registered Nurse) 2 indicated the medications should be properly labeled with the resident's name, dose, frequency, route, and physician name. During an interview on 1/18/24 at 9:00 A.M., QMA (Qualified Medication Aide) indicated there should be no loose pills. At that time, she indicated a cart auditor cleaned the carts frequently and the loose pills should have been removed then. She also indicated she cleaned the cart as she was able. During an interview on 1/18/24 at 9:27 A.M., RN 6 indicated the evening nurse could have found the hearing aid when a resident passed over the weekend and placed it in the upper drawer for safe keeping. RN 6 also noted that the medication cart was the most accessible lock box. The unit manager had a lock box in her office, but she was not at the facility on the weekends in case the resident or family needed to access it. During an interview on 1/23/24 at 8:56 A.M., LPN (Licensed Practical Nurse) 4 indicated there should be nothing but narcotics in the locked box. The residents' bedside tables were equipped with locks so they could place items in there for safe keeping. On 1/23/23 at 9:16 A.M., the Administrator provided a current Labeling of Medications and Biologicals policy that indicated all medications .used in the facility will be labeled in accordance with current state and federal considerations .must include resident name . Labels for over the counter medications must be labeled with the following: the original manufacturer's or pharmacy-applied label indicating the medication name; the strength, quantity, lot and control number; the expiration date when applicable; appropriate accessory and precautionary statements; and directions for use. 3.1-25(j)

Based on observation, interview, and record review, the facility failed to ensure food was served at a palatable temperature for 1 of 1 tray tested for food temperature. Finding includes: On 1/16/24 at 11:30 A.M., Resident 79 indicated the food was not hot enough. On 1/16/24 at 11:38 A.M., Resident 1 indicated the food was cold. She lived in the last room served on her hall. On 1/18/24 at 12:03 P.M., 2 Certified Nursing Aides (CNA) were observed delivering meal trays on the 500 hallway. All but 4 trays were in a large, insulated cart. The other 4 trays were on a small pushcart, not insulated. At that time, CNA 11 indicated the larger insulated cart was too small to hold all the trays for the hall. On 1/18/24 at 12:15 P.M., a test tray was obtained from the 500 hallway. Food temperatures for that meal were as follows: Goulash - 120 degrees F (Fahrenheit) Cauliflower - 105 degrees F Milk - 43 degrees F A food serving temperature policy was requested and not provided. 3.1-21(a)(2)

Based on observation, interview, and record review, the facility failed to store foods in accordance with professional standards and maintain the dishwasher with the proper equipment for 1 of 1 kitchens reviewed. Findings include: 1. On [DATE] at 10:20 A.M., a tour of the kitchen began. Two staff were present, a cook and the dishwasher. On [DATE] at 10:35 A.M., food packages were observed in the walk-in refrigerator labeled with a date in black marker. None of the marked dates differentiated between open date and use-by date. Outdated/expired food included: 1 angel food cake, cut, opened, in plastic wrap dated [DATE] 1 angel food cake, in plastic wrap, not cut, no date 1 gallon pickles, opened, manufacturer's use-by date was [DATE] 1 5-lb (pound) container cottage cheese, opened, manufacturer's expiration date was [DATE] 1 5-lb container sour cream, opened, manufacturer's expiration date was [DATE] 2 large trays of ground beef thawing on the bottom shelf, not dated, in plastic bags open to air 1 16-ounce container of chicken base, opened not dated. 1 bag salad mix, opened, not dated, brown and slimy 1 bag salad mix, opened, dated [DATE], brown On [DATE] at 10:17 A.M., the following outdated/expired food was observed in the walk-in refrigerator: 1 bag salad mix, opened, dated [DATE], brown On [DATE] at 08:46 A.M., spice containers were observed to have dates written on them with a black marker. The dates failed to indicate whether that was an open date or use by date. The spices had no manufacturer expiration dates. The following spices were observed: onion powder, no date poultry seasoning, delivered [DATE]. At that time, the kitchen supervisor gave the container to staff to throw away. At that time, the kitchen manager indicated they used pre-printed labels and also wrote on the packages in the walk-in refrigerator and freezer with a marker because the stickers came off. A sticker included a place to note the prepared and use-by dates. These labels were not observed in the walk-in refrigerator during the initial tour of the kitchen. 2. On [DATE] at 9:55 A.M., the kitchen supervisor was observed testing the chemical sanitization of the dishwasher. She obtained a test strip from a bottle and put it in the rinse water. The manufacturer label on the test strips indicated they expired [DATE]. On [DATE] at 08:33 A.M., the kitchen supervisor indicated different test strips were used to check the sanitization buckets used for cleaning the food preparation surfaces than they use for the dishwasher. She removed a test strip from a bottle and demonstrated testing the sanitization buckets. The manufacturer's expiration date on the test strips indicated they expired on [DATE]. On [DATE] at 9:16 A.M., the Administrator provided a current Food Safety policy, dated 2023, which indicated that food facility staff shall inspect all food, food products, and beverages for .timely and proper storage .labeling, dating, and monitoring refrigerated food .so it is used by its use-by date or frozen/discarded. 3XXX,d+[DATE](i)(2) 3XXX,d+[DATE](i)(3)

Based on interview and record review, the facility failed to ensure the MDS (Minimum Data Set) assessment was completed accurately for 1 of 1 resident reviewed for dialysis. (Resident 50) Finding includes: On 1/17/24 at 2:18 P.M., Resident 50's clinical record was reviewed. Diagnoses included, but were not limited to, muscle wasting and atrophy, legal blindness, type 2 diabetes mellitus, end stage renal disease, and long term (current) use of insulin. The most recent quarterly MDS (Minimum Data Set) Assessment, dated 12/12/23, indicated Resident 50 had moderate cognitive impairment, received an insulin injection for 7 out of 7 days during the look back period (12/6/23 - 12/12/23), did not receive any hypoglycemic medication, had a weight loss of 5% or more in the past month or 10% or more in the past 6 months, and had a weight gain of 5% or more in the last month or 10% or more in the last 6 months. Current physician orders included, but were not limited to: Insulin Lispro (a fast-acting hypoglycemic medication) Subcutaneous Solution Pen-injector 100 unit/ml (units per milliliters) - Inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units if blood sugar > 400 mg/dl (milligrams per deciliter) give 10 units and notify MD/NP (medical doctor / nurse practitioner), subcutaneously before meals related to type 2 diabetes mellitus, dated 9/8/23 Monthly weights and vitals - every day shift every 1 month starting on the 1st for 5 day(s), dated 10/1/2023 Discontinued physician orders included, but were not limited to: Insulin Glargine Solostar (a long-acting hypoglycemic medication) 100 unit/ml - inject 30 units subcutaneously at bedtime related to type 2 diabetes mellitus, discontinued 12/16/23 The Medication Administration Record (MAR) for December 2023 indicated Resident 50 received Insulin Lispro on 12/6, 12/7, 12/8, 12/9, 12/11, and 12/12 and Insulin Glargine on 12/6, 12/7, 12/8, 12/9, 12/10, 12/11, and 12/12. Resident 50's weights for the past 6 months included, but were not limited to: 12/6/2023 - 171 lbs (pounds) 11/1/2023 - 177 lbs 6/12/2023 - 193 lbs The clinical record lacked documentation of a weight gain. A nutritional assessment, dated 12/1/23, indicated the resident had a weight loss greater than 7.5% in 90 days and was monitored for significant weight loss by the Registered Dietician. On 1/22/24 at 8:26 A.M., MDS Coordinator 5 indicated insulin should be coded as a hypoglycemic on the 12/12/23 MDS assessment. At that time, she indicated the resident did not have any weight gain and only weight loss should be indicated on the 12/12/23 MDS assessment. On 1/23/24 at 9:16 A.M., the Administrator provided a current Conducting an Accurate Resident Assessment policy, dated 2023, that indicated appropriate, qualified health professional(s) correctly document the resident's medical, functional, and psychosocial problems .using the appropriate Resident Assessment Instrument.

Based on record review and interview, the facility failed to ensure CNAs (Certified Nursing Aide) had a current and valid certificate to work in the facility for 1 CNA whose certificate had expired at the time of hire. (CNA 7) Finding includes: On [DATE] at 12:10 P.M., the employee records were reviewed. CNA 7 started employment at the facility on [DATE]. The facility's employee license binder lacked a record of CNA certification for CNA 7. On [DATE] at 12:54 P.M., an Indiana Professional Licensing Agency search indicated CNA 7's CNA certificate expired [DATE]. On [DATE] at 2:38 P.M., the Administrator provided a valid CNA certificate for CNA 7 with a renewal date of [DATE]. On [DATE] at 11:12 A.M., the Administrator indicated she was aware CNA 7 had been hired with an expired license, but assumed it had been taken care of and was unaware it hadn't been renewed until it was brought to her attention on [DATE]. On [DATE] at 9:16 A.M., the Administrator provided a current License Verification policy, dated 2023, that indicated any licensed/certified employee is responsible for submitting verification of licensure/certification renewal to Human Resources prior to expiration. 3XXX,d+[DATE](e)

Based on interview and record review, the facility failed to ensure proper interventions were in place for monitoring symptoms, side effects, and behaviors of medications used for dementia for 1 of 3 residents reviewed for dementia care. (Resident 80) Finding includes: On 1/17/24 at 2:38 P.M., Resident 80's clinical record was reviewed. Diagnosis included, but was not limited to, Alzheimer's Disease with late onset and unspecified dementia. The current quarterly MDS (Minimum Data Set) assessment, dated 12/24/23, indicated the resident was cognitively intact and needed limited assistance with mobility, transfers, and eating. The MDS assessment also indicated the resident received an antipsychotic medication during the 7 day lookback period. Current physician orders included but were not limited to: Rexulti (an antipsychotic medication) - 1 mg (milligram) in the evening for dementia with behaviors, dated 11/6/23. The clinical record lacked an order, care plan, and documentation for monitoring antipsychotic side effects and behaviors. The current MAR (Medication Administration Record) lacked monitoring for side effects and behaviors for antipsychotic drugs. During an interview on 1/22/24 at 10:02 A.M., LPN (Licensed Practical Nurse) 12 indicated residents who received antipsychotics were to have an order for monitoring side effects and behaviors. On 1/22/24 at 2:45 P.M., the Administrator provided a current Behavioral Health Services policy that indicated . the facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status .the staff will . accurately document the changes . in the resident's record . 3.1-48(a)(3)

Based on observation, record review, and interview, the facility failed to post the actual hours worked of licensed and unlicensed nursing staff directly responsible for resident care per shift daily for 7 of 7 days reviewed. Finding includes: During an observation, on 1/16/24 at 2:35 P.M., the staff numbers posted on the hallway at the main entrance of the facility reflected the census was 86 residents. The form did not provide actual hours worked by nursing staff. On 1/22/24 at 1:00 P.M., staff posting sheets were provided by the Administrator for the following dates: 1/16/24 1/17/24 1/18/14 1/19/24 1/20/24 1/21/24 1/22/24 Each staff posting sheet included the date, census, and total hours each discipline was in the building. Disciplines included RN (Registered Nurse), LPN (Licensed Practical Nurse), and CNA (Certified Nursing Aide). The actual hours worked by each shift were not included on the sheets. During an interview on 1/22/24 at 2:35 P.M., the Administrator indicated she didn't realize the hours weren't listed on the posted nursing staffing sheet. On 1/12/24 at 9:11 A.M., a Nurse Staffing Posting Information policy, dated 2023, was provided by the Administrator and indicated The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurses .Licensed Practical Nurses .Certified Nursing Aides.

Based on observation, interview, and record review, the facility failed to ensure residents who display or are diagnosed with dementia, received the appropriate treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents reviewed for dementia. Family consent was given for a resident with a diagnoses of dementia to be in a consensual sexual relationship. ( Resident B) Finding includes: On 10/2/23 at 10:10 a.m., Resident B was observed lying awake in bed. Resident B did not answer questions appropriately and was not interviewable. On 10/2/23 at 11:12 a.m., Resident B's clinical record was reviewed. Resident B had diagnoses that included, but were not limited to, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, mood disturbance, anxiety, cognitive communication deficit, unspecified psychosis not related to a substance or known physiological condition, major depressive disorder, recurrent, unspecified, need for assistance with personal care. A quarterly MDS (Minimum Data Set) assessment dated [DATE], indicated Resident B's cognition was severely impaired. Care plans were reviewed and included, but were not limited to: Family gives consent for resident to be in a consensual relationship with due to cognitive impairment dx dementia, date initiated 9/11/23. Interventions included: If I display inappropriate behavior, quietly attempt to re-direct, reminding me that the behavior is not appropriate, date initiated 9/4/23. Let my physician know if (sic) my behaviors, date initiated 9/11/23. Please give me privacy for solitary acts, date initiated 9/11/23. Please help me maintain safe hygiene, date initiated 9/11/23. Please refer me to mental health services as needed, date initiated 9/4/23. Staff will let me know that my behavior is affecting others, date initiated 9/11/23. Treat me with dignity and respect regardless of any behaviors, date initiated 9/11/23. Sometimes I demonstrate sexually inappropriate behaviors exhibited by : Inappropriate touching, hand holding and kissing of male residents, date initiated 2/23/23. Interventions included: As a diversion, offer me something else I like, date initiated 2/23/23. Help me to avoid situations or people that tend to trigger these behaviors, date initiated 2/23/23. Please give me privacy for solitary acts, date initiated 2/23/23. Remind me that I am still married but respect my decisions, date initiated 2/23/23. Treat me with dignity and respect regardless of any behaviors, date initiated, 2/23/23. I have a short attention span exhibited by : Not being able to focus on anything for long. Wandering in and out of activities, date initiated 11/4/21. I have a diagnosis of dementia with behavioral disturbances, date initiated 11/4/21. Resident has diagnosis of dementia, hx psychosis. Due to cognitive loss, diminished decision making capabilities and safety and security issues, placement in the secure Alzheimer's unit with programs designed for this population is needed as evidenced by moderate to severe cognitive loss, date initiated 2/8/21. Impaired communication due to : Not always being understood and not always understanding others. Requires hearing aides, date initiated 3/7/21. I sometimes resist care related to dementia as evidenced by refusing to take a shower. date initiated 5/13/21. I prefer to cuddle, hold and care for a doll. This comforts me as exhibits by me holding, and carrying a doll throughout the unit r/t dementia, date initiated 8/9/22. I sometimes have behaviors which include rejection of care, date initiated 3/7/21. I have a physical functioning deficit related to: Mobility impairment, self care impairment, date initiated 1/22/21. CAA (Care Area Assessment ) 02-Cognitive loss/dementia : I have impaired cognitive function, related to dementia, date initiated 4/7/23. Interventions included, but were not limited to: Use short phrases and questions which requires yes or no answerers. Use gestures as needed. Verbal reminders which assist patient in orientation, date initiated 4/7/23. A progress note dated 9/3/23 at 10:30 a.m., indicated Late entry : Note text: Spoke to POA (Power of Attorney) (name of POA) regarding resident expressing interest in an affectionate relationship. (name of POA) gave consent for his mother to be in an affectionate relationship. On 10/2/23 at 12:29 p.m., Social Services 2 indicated Resident B and a male resident began to like each other, one day the male resident kissed Resident B. The resident's POA's gave consent for the resident's to be in a relationship. On 10/3/23 at 12:10 p.m., the Administrator was interviewed by phone. The Administrator indicated Resident B was observed holding hands, kissing, and being affectionate with a male resident. The Administrator indicated they had gone to both residents and asked them if wanted to be in an affectionate relationship, both said yes. The facility called and obtained consent from the resident's POA's to be in a affectionate relationship. The Administrator indicated she read through the guidance related to this, to her knowledge the residents were always affectionate in a public place, she was not aware of any sexual relationship between them. On 10/3/23 at 1:00 p.m., CNA 1 indicated they was not told of any residents who had consent to be in a sexual or affectionate relationship, or given education on what to do. On 10/3/23 at 1:08 p.m., CNA 2 indicated they were not told of any residents who could be in a sexual or affectionate relationship, an in-service was done the day before, 10/2/23, about monitoring for signs if a relationship between residents was consensual or non consensual. On 10/3/23 at 1:58 p.m., the [NAME] President of Clinical Operations indicated she had spoken with the Administrator and DON, no additional in- services were provided to staff related to the consents for the residents to be in a consensual relationship. On 10/3/23 at 12:51 p.m., the [NAME] President of Clinical Operations provided the current policy on Resident Assessment of Cognitive Patterns with a copyright date of 2023. The policy included, but was not limited to: It is the policy of the facility to use section C of the MDS properly in order to determine the resident's attention, orientation, and ability to register and recall new information .2. Licensed nursing staff document general cognitive observations on admission and routine nursing assessments in accordance with procedures for nursing assessments. Sample observations include, but are not limited to: a. presence or absence of short-term or long-term memory problems. b. memory recall ability. c. ability to make daily decisions . On 10/3/23 at 12:51 p.m., the [NAME] President of Clinical Operations provided the current policy on Conducting an Accurate Resident Assessment with a copyright date of 2023. The policy include, but was not limited to: The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas .6. The physical, mental and psychosocial condition of the resident determines the appropriate level of involvement of physicians, nurses, rehabilitation therapist, activities professional, medical social workers, dietitians, and other professionals, such as developmental disabilities specialist, in assessing the resident, and in correcting resident assessments, Involvement of other disciplines is dependent upon individual resident status and needs . This Federal tag relates to Complaint IN00417761. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure infection control practices were maintained to mitigate the spread of COVID-19 for 6 of 8 observations. Staff were observed to enter rooms that required COVID- 19 transmission based precautions without the proper PPE (Personal Protective Equipment) procedures. (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]) Findings include: On 9/12/23 at 8:44 a.m., CNA 1 was observed to don a gown, gloves, N95 mask, face shield, and enter room [ROOM NUMBER]. CNA 1's gown was observed to not be tied at the neck and the N95 mask was placed over a surgical mask before entering the room. CNA 1 was observed exiting the room with a surgical mask on. room [ROOM NUMBER] had signage on the door indicating the room required COVID-19 transmission based precautions. On 9/12/23 at 8:58 a.m., CNA 1 was observed to don a gown, gloves, N95 mask, face shield, and enter room [ROOM NUMBER]. CNA 1's gown was observed to not be tied at the neck and the N95 mask was placed over a surgical mask before entering the room. CNA 1 was observed exiting the room with a surgical mask on and touching the mask with her hand. No hand hygiene was observed to be performed after touching the mask. room [ROOM NUMBER] had signage on the door indicating the room required COVID-19 transmission based precautions. On 9/12/23 at 9:00 a.m., the Admissions Director was observed to don a gown, gloves, N95 mask, face shield, and enter room [ROOM NUMBER]. The Admission Director was observed to place the N95 mask over a KN95 mask before entering the room. After exiting the room, the Admissions Director was observed to perform hand hygiene, take off the N95 mask and walk down the hallway carrying the mask in her hands. room [ROOM NUMBER] had signage on the door indicating the room required COVID-19 transmission based precautions. On 9/12/23 at 10:51 a.m., CNA 2 was observed to enter room [ROOM NUMBER], speak to the resident, exit the room, walk down the hallway to a supply room, obtain a portable oxygen tank, walk back down the hallway, and enter and exit room [ROOM NUMBER]. CNA 2 was wearing only a surgical mask during the observation. room [ROOM NUMBER] had signage on the door indicating the room required COVID-19 transmission based precautions. On 9/12/23 at 10:55 a.m., CNA 3 was observed to don a gown, N95 mask, gloves, face shield, and enter room [ROOM NUMBER]. CNA 3 was observed to place the N95 mask over a surgical mask before entering the room. CNA 3 was observed exiting the room with a surgical mask on. room [ROOM NUMBER] had signage on the door indicating the room required COVID-19 transmission based precautions. On 9/12/23 at 10:39 a.m., the Admissions Director indicated when entering a room that required COVID-19 transmission based precautions, a N95 mask, face shield, gloves, and gown should be donned, the KN95 mask should be taken off before the N95 mask is put on. On 9/13/23 at 10:28 a.m., CNA 4 was observed to don a gown, N95 mask, gloves, face shield, and enter room [ROOM NUMBER]. The gown was not tied at the neck or waist before entering the room. room [ROOM NUMBER] had signage on the door indicating the room required COVID-19 transmission based precautions. On 9/13/23 at 10:35 a.m., CNA 4 indicated when entering a room that required COVID-19 transmission based precautions, the gown should be tied at the neck and waist. The rooms that required COVID-19 transmission based precautions were observed to have signage that included, but was not limited to: Donning (putting on the gear) 1. Gather PPE (Personal Protection Equipment) to donn. 2. Perform hand hygiene using hand sanitizer. 3. Put on isolation gown and tie all ties on the gown. 4. Put on mask or N95 depending on isolation. 5. Put on face shied. 6. Put on gloves. 7. Knock and enter the room. Doffing (taking off the gear) 1. Remove gloves-glove in glove-bird beak. 2. Remove face shield. 3. Remove gown-untie all ties reaching up to the shoulders and carefully pull gown down away form body and roll the gown and dispose in trash receptacle. 4. Remove mask. 5. Redon a new surgical mask. On 9/12/23 at 8:15 a.m., upon entry to the facility, the Administrator indicated 47 residents were positive for COVID-19. On the last day of the survey 9/14/23, two more residents had tested positive for COVID-19. On 9/13/23 at 11:04 a.m., the Administrator provided the current policy on transmission- based (isolation) precautions with a copyright date of 2023. The policy included, but was not limited to: The facility will use standard approaches, as defined by the CDC, for transmission-based precautions: airborne, contact, and droplet precautions. The category of transmission-based precautions will determine the type of personal protective equipment (PPE) to be used .f. The facility will have PPE before readily available near the entrance of the resident's room to don appropriate PPE before or upon entry into the environment of a resident on transmission-based precautions . This Federal tag relates to Complaint IN00417253. 3.1-18(b)(1)

Based on interview and record review, the facility failed to prevent the misappropriation of resident's narcotic medication for 1 of 1 residents reviewed for misappropriation of property. (Resident H) Findings include: During record review on 3/22/23 at 11:05 a.m., a facility reported incident, with an incident date of 3/14/23, indicated that RN 1 noticed changes to Resident H's narcotic count sheet. On 3/22/23 at 1:40 p.m., the Administrator indicated that 4 of Resident H's pain pills were unaccounted for. A nurse had told her the count was right, but it looked like the dates had been changed on the sheet to show he had received the medication more than two times on some dates. Resident H had indicated he only received his medication 2 times a day. An investigation was done, 5 nurses who had access to the medication cart were drug tested , with negative results, no one admitted to changing the dates or witnessing someone changing dates. On 3/22/23 at 1:45 p.m., the DON indicated the math was done on how many pills should have been given to Resident H, the count should have been 20 and it was 16, the missing pills won't show until the end of the script. During record review on 3/22/23 at 2:05 p.m. Resident H's diagnoses included, but were not limited to, quadriplegia, chronic pain syndrome, neuralgia and neuritis. Resident H's March 2023 physician orders included, but were not limited to, Dilaudid (pain medication) Tablet 8 mg (milligram) (Hydromorphone HCI), give 1 tablet by mouth two times a day related to chronic pain syndrome. (start date 5/4/22). Resident H refused to be interviewed. A copy of the controlled substance accountability sheet was reviewed on 3/23/23 at 9:00 a.m. The beginning count was documented as 28, some dates appeared to be bolded and altered to show Resident H was given 4 doses on 3/8/23 and 3/10/23. A copy of the pharmacy packing slip dated 3/7/23 indicated 28 doses of Resident H's medication was delivered On 3/23/23 at 2:30 p.m., the ADON (Assisted Director of Nursing), indicated the floor nurse wanted her to look at the count sheet and she realized it was not right. She reported it to the DON and Administrator, the count and card matched, but the sheet was scribbled on. She went back to the date the medication was received and added up the count for Resident H taking it twice a day and it did not add up. She further indicated Resident H knows exactly what pills he is receiving, he can literally count them with his tongue how many pills he has in his mouth, he indicated he had only received the medication twice a day. On 3/23/23 at 9:20 a.m., the Administrator provided the policy on abuse, neglect, and exploitation with a revision date of October 2022. The policy included, but was not limited to, It is the policy of this facility to provide protections 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 .Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. The deficient practice was corrected on 3/14/23 after the facility implemented a systemic plan that included the following actions: Ad HOC QAPI meeting was held on 3/14/23 an action plan included inservice review of policy for controlled substances with staff, and the on going monitoring of the controlled substances. 3.1-28(a)

Based on observation, interview, and record review, the facility failed to ensure a resident with an IV (intravenous) -implanted port received IV fluids as ordered by a physician to maintain patency for 1 of 2 residents reviewed for IV care. A resident did not receive routine flushes through a venous access port. (Resident D) Finding includes: During an observation and interview on 10/31/22 at 12:05 P.M., Resident D was sitting on their bed in their room. Resident D indicated they had a venous access port and pointed toward their left shoulder. The resident indicated that the port is not routinely cared for and that they do not receive monthly flushes. During record review on 10/31/22 at 11:00 A.M., Resident D's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident D's most recent quarterly MDS (Minimum Data Set) dated, 9/8/22, indicated the resident was cognitively intact. Resident D's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident D's care plan included, but was not limited to; resident has potential for infection/complication due to port placement (initiated 10/21/21). Interventions included, but were not limited to; administer IV fluids/medications per physicians order. Resident D's medical record lacked any documentation that the resident's port was flushed monthly. During an interview on 10/31/22 at 12:10 P.M., LPN 9 indicated Resident D should receive a monthly flush to their port. During an interview on 10/31/22 at 1:00 P.M., the DON (Director of Nursing) indicated the order for Resident D's flush was entered into the electronic medical record incorrectly, which resulted in nursing staff not being prompted to flush the port or document that the port had been flushed monthly, as ordered. On 10/31/22 at 1:10 P.M., the DON provided a facility policy titled Accessing and De-accessing an Implanted Vascular Access Port, dated 2021. The policy included, .4. If not routinely used, implanted ports will be flushed and locked per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] This Federal tag relates to complaint allegation IN 442. 3.1-47(a)(2)

Based on observation, interview, and record review, the facility failed to ensure services were provided in accordance with the written plan of care for 1 of 3 residents reviewed for accidents and 3 of 6 residents reviewed for pressure injury. (Resident 22, Resident 51, Resident 36, Resident 21) Findings include: 1. On 3/3/22 at 12:25 P.M., Resident 51's clinical record was reviewed. The most recent quarterly MDS, dated [DATE], indicated Resident 51 was cognitively intact. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A current risk for pressure ulcer care plan, dated 11/14/21, included, but was not limited to, an intervention to complete Braden Scale per policy, and for a toileting plan, also dated 11/14/21. Resident 51 was admitted [DATE] with the following hospitalization : 1/29/22 - 2/1/22 Resident 51's clinical record lacked completed Braden Scale assessments after return from the hospital, and lacked a current toileting plan. During an interview on 3/4/22 at 1:03 P.M., CNA 3 indicated Resident 51 was not currently on any type of toileting plan or program. During an interview on 3/7/22 at 1:45 P.M., the DON (Director of Nursing) indicated Resident 51 was not on any type of toileting plan, and the toileting plan intervention on Resident 51's care plan was left there in error after it was discontinued. During an interview on 3/4/22 at 1:13 P.M., the Administrator indicated a Braden Scale assessment should be completed after admission, weekly for four weeks, then quarterly. The Administrator further indicated the same should be completed after a re-admission from the hospital. 2. On 3/7/22 at 1:09 P.M., Resident 22's clinical record was reviewed. The most recent quarterly MDS (Minimum Data Set) Assessment, dated 12/29/21, indicated Resident 22 was cognitively intact. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A current risk for pressure ulcer care plan, dated 8/25/21, included, but was not limited to, an intervention to complete Braden Scale per policy, also dated 8/25/21. Resident 22's clinical record included, but was not limited to, the following hospitalization s: 11/22/21 - 11/23/22 12/15/21 (less than 24 hour stay) 12/21/21 (less than 24 hour stay) 1/25/22 - 1/28/22 2/7/22 - 2/12/22 Resident 22's clinical record lacked completed Braden Scale assessments after returns from the hospital. 3. During record review on 3/1/22 at 9:15 A.M., Resident 36's most recent quarterly MDS, dated [DATE], indicated the resident required extensive assist with bed mobility and toileting, was always incontinent of bowel, and had 1 unhealed stage III pressure injury. Resident 36's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 36's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 36's care plan included, but was not limited to, altered skin integrity pressure related to wound to left ear (initiated 1/27/22) and pressure ulcer actual or at risk due to: wound to right thigh (initiated 11/23/21). Interventions included, but were not limited to; foam protectors to oxygen tubing and provide thorough skin care after incontinent episodes and apply barrier cream. During an observation on 3/7/22 at 1:41 P.M., Resident 36 was being assisted with incontinence care by CNA 16 and CNA 18. Resident 36 was assisted to bed, staff applied oxygen tubing to Resident 36. The tubing did not have foam protectors over the ears. Resident 36 was incontinent of bowel. CNA 16 provided incontinence care, changed the resident's brief, adjusted the resident in bed, performed hand hygiene, and exited the room. No barrier cream was applied. During an interview on 3/7/22 at 2:00 P.M., CNA 16 indicated Resident 36 should have foam protectors to the oxygen tubing and that barrier cream should be applied by the nursing staff. During an interview on 3/8/22 at 11:00 A.M., CE 21 (Clinical Educator) indicated that CNA's could apply barrier cream after incontinence care. 4. On 3/2/22 at 12:48 P.M., Resident 21 was observed lying in bed. Resident 21 was not observed to be wearing a wander guard on either ankle. On 3/7/22 at 12:50 P.M. RN 7 came into Resident 21's room to look for wander guard. RN 7 indicated Resident 21's wander guard must have been removed from his ankle, as she could not locate it on him or in his room. At that time, Unit Director 8 indicated Resident 21 had been wearing a wander guard on the ankle the previous day, and also could not currently locate it. On 3/2/22 at 1:00 P.M. Resident 21's clinical record was reviewed. The most recent admission MDS, dated [DATE], indicated Resident 21 had a moderate cognitive impairment. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 21's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A current risk for elopement care plan, dated 12/27/21, included, but was not limited to, an intervention to maintain wander guard placement as ordered, also dated 12/27/21. During an interview on 3/2/22 at 12:58 P.M., Unit Director 8 indicated the wander guard band did not alarm when taken off. Unit Director 8 also indicated that if worked on and stretched, the wander guard band could be removed. During an interview on 3/8/22 at 8:53 A.M., Unit Director 8 indicated Resident 21 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/8/22 at 1:00 P.M., a current non-dated Comprehensive Care Plan policy was provided and indicated The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress . Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made On 3/4/22 at 11:00 A.M., the Facility Administrator supplied a facility policy dated, 2021, and titled, Pressure Injury Prevention and Management. The policy included, but was not limited to; .Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present . 3.1-35(a)

Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed for 2 of 4 resident observed for care, and 1 of 2 random observations of staff; the facility failed to properly prevent and/or contain COVID-19 for 1 of 2 random observations of staff. Gloves were not changed from dirty to clean tasks, hands were not washed appropriately, a resident was placed in a soiled wheelchair, staff was not appropriately wearing a face mask, and a staff did not sanitize hands after bodily contact. (Resident 61, Resident 18, RN 7, CNA 15, HK 13) Findings include: 1. During a random observation on 3/3/22 at 9:19 A.M., HK (Housekeeper) 13 was observed standing in the doorway of room [ROOM NUMBER] with his hand and forearm under his uniform pants as well as under the underpants that was exposed. HK 13 then pulled his hand out, obtained a washrag from the cleaning cart in the hall, entered room [ROOM NUMBER], and began wiping the bedside table, the bathroom door, and the doorknob of the room. HK 13 did not wash or sanitize his hands, or put on gloves before wiping surfaces in the room. 2. On 3/4/22 at 10:45 A.M., RN 7 and CNA 9 were observed assisting Resident 61 to the toilet off of the main dining area on the locked unit. Both RN 7 and CNA 9 washed their hands and put on gloves upon entering the restroom. When Resident 61 was assisted out of the wheelchair, a smeared brown substance was observed on the sheet on the wheelchair cushion as well as on the cushion. A yellow spot was observed on the sheet as well. Resident 61 was assisted onto the toilet, while CNA 9 removed the visibly soiled brief, and handed it to RN 7 who disposed of it in the trash. While CNA 9 put on a clean brief, it was placed through the pant legs, and under Resident 61's tennis shoes, touching the bottoms of both shoes. After assisting the resident to stand, RN 7 wiped Resident 61 with toilet paper twice. The second wipe was observed with brown substance on the toilet paper. CNA 9 then pulled up the clean brief and pants and assisted Resident 61 back into the wheelchair with the same soiled sheet on the cushion. RN 7 then removed gloves and washed hands. CNA 9 then removed gloves and washed hands for a 9 second lather before rinsing. 3. During a random observation on 3/3/22 at 12:49 P.M., CNA 15 was observed walking past the 200/300 nurses station with a face mask pulled under the chin, putting something in her mouth. A resident was observed within arms length. During an interview on 3/8/22 at 8:21 A.M., CNA 12 indicated hands should be washed for 20 seconds before and after resident care. She indicated gloves should be changed between dirty and clean tasks, such as after changing a brief and before the new one is put on. She further indicated staff should disinfect resident equipment that is visibly soiled before placing resident on that equipment. 4. During record review on 3/3/22 at 12:27 P.M., Resident 18's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 18's most recent quarterly MDS assessment, dated 12/21/21, indicated the resident had a urinary catheter. Resident 18's care plan included but was not limited to, potential for altered urinary elimination due to use of indwelling catheter, history of recurrent UTI's. Interventions included, but were not limited to, provide indwelling catheter care every shift and as needed. Secure catheter and tubing appropriately (indicated 6/13/2019). During an observation on 3/7/22 at 12:00 P.M. Resident 18 was observed in the wheelchair in the activity room with the urinary catheter bag in a cover and dragging the floor. At that time, RN 4 assisted Resident 18 to the dining room in the wheelchair while the catheter bag cover dragged against the floor. During an observation on 3/7/22 at 12:51 P.M. Resident 18 was observed in the wheelchair in the 400 hallway propelling self in the wheelchair. The urinary catheter bag in a cover was dragging the floor. During an observation on 3/8/22 at 10:51 A.M., Resident 18 was propelling self in the wheelchair in front of the 500 hall nurse's station. The urinary catheter bag in a cover was dragging the floor. During an interview on 3/8/22 at 11:00 A.M., CE 21 (Clinical Educator) indicated staff should reposition catheter bags so they did not drag on the floor. On 3/7/22 at 10:00 A.M., a current non-dated Hand Hygiene policy was proved and indicated hand hygiene should be performed using proper technique consistent with accepted standards of practice and when washing with soap and water, hands should be rubbed for at least 20 seconds. On 3/8/22 at 1:00 P.M., a current non-dated Personal Protective Equipment policy was provided and indicated the facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to resident, visitors, and other staff 3.1-18(b) 3.1-18(l)

Based on interview, record review, and observation, the facility failed to successfully inform the residents of how to contact the state and/or local ombudsman. 11 of 11 resident council members indicated being unaware of how to contact or where to find information about contacting the state and/or local ombudsman. A local ombudsman contact information notice was not posted and a State ombudsman contact number was obstructed by a picture frame. Findings include: During a Resident Council meeting on 3/1/22 at 1:45 P.M., 11 of 11 Resident Council meeting members indicated not knowing how to contact their ombudsman or where to find information regarding the ombudsman contacts. During an interview on 3/3/22 9:24 A.M., the DON (Director of Nursing)indicated being unsure where the ombudsman information was posted. The Facility Administrator then indicated the information was posted toward the main entrance of the facility. During an observation on 3/3/22 at 9:25 A.M., the local ombudsman information was not hanging on the wall towards the main entrance of the facility. A long term care State ombudsman phone number was posted towards the bottom of a framed notice hanging at about 6 feet above the floor. The State ombudsman contact number was obstructed by the picture frame and was not readable for someone of shorter stature or that may be confined to a wheelchair. During an interview on 3/3/22 at 9:25 A.M., the Facility Administrator indicated the local ombudsman contact information was framed and hung on the wall but had fallen a week prior and had not been hung back up. On 3/8/22 at 1:00 P.M., the Facility Administrator supplied a facility policy, dated 2021, and titled, Facility Required Postings. The policy included, The facility will post required postings in an area that is accessible to all staff and residents . Facility postings include the following: a. A list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups to include but limited to: .iv\. Office of the State of Long-Term Care Ombudsman . 3.1-4(j)(3)(C)

Based on record review and interview, the facility failed to implement adequate supervision and specific interventions for 1 of 3 residents who was identified as a fall risk. Resident E had an unwitnessed fall that resulted in a laceration to the forehead that required sutures and a cervical (C5) fracture. (Resident E) Findings include: During a review of Resident E's clinical record on 3/29/21 at 2:11 p.m., it indicated Resident E's diagnoses included, but were not limited to, [CONDITION(S)], stage 2, hypertension, non-Alzheimer's dementia, [CONDITION(S)], primary [CONDITION(S)]. Resident E's Quarterly MDS (minimum data set), dated 2/16/21, indicated Resident E had severe cognitive impairment. Resident E required supervision with ambulation, assistance x 1 with ADLs and help in part of bathing. The MDS indicated Resident E had no prior falls or history of falls. Resident E's care plans indicated, but were not limited to, At risk for falls related to a new environment, use of medications. Interventions included, but were not limited to, call light and personal items available and in easy reach, footwear to prevent slipping, keep environment well-lit and free of clutter, observe for side effects to medications and report abnormal findings to physician, orientation to new room and roommate, therapy referral as indicated. Start date 1/21/21. Physical functioning deficit related to mobility impairment, self-care impairment. Interventions included, but were not limited to, call bell within reach, dressing assist x 1, encourage choices with care, inform resident of risks of refusal of care, inspect skin with care, locomotion assist x 1, monitor and report changes in physical functioning ability, monitor and report changes in range of motion ability, provide supervision with bed mobility, assist as needed, provide supervision with eating and set up or assist as needed, provide supervision with toilet use, provide supervision with transfers, rehab services as ordered. Last revised date 1/22/21. An Occupational Therapy (OT) order, dated 3/7/21 at 9:14 a.m., included, but was not limited to, OT to treat 5 x (times) a week for 30 days for therapeutic exercise, therapeutic activity, and ADL. A Physical Therapy (PT) order, dated 3/7/21 at 9:15 a.m., included, but was not limited to, PT evaluation completed. PT to treat 5 x (times) a week for therapeutic exercise, therapeutic activity, neuro-muscular re-education, and gait training as needed. Resident E's progress notes indicated, 1/27/21 0625 a.m.- Resident reported to this nurse that she was in bed rolled over sat up on the side of the bed sometime during the night and slide off the bed onto the floor on her buttocks. Resident stated I pulled myself to the door & called for help, they came & got me back in bed. Resident denies pain or discomfort, skin assessment showed no open areas or skin discolorations @ this time. When asked nurse during report she stated that was explained to her by the CNA that it was only a slide.142/88-62-16-97.6-95% R/A pupils equal & react to light. Faxed update to MD & family notified. 3/3/2021 01:05 a.m.- Resident was overheard crying in room by staff. When staff walked into the room, resident was observed sitting on the floor with an open laceration to the right side of her forehead. Resident assessed. Vitals temperature 98.1, BP 110/60, pulse 79, oxygen 97% on room air, respirations 16. Resident alert to self. Complained of pain to right eye on a scale of 5/10. Pressure applied to affected area on forehead but bleeding continued. 911 called immediately. Family notified. Physician made aware. 3/3/2021 at 5:10 a.m.- Communication with the Emergency Department of the hospital. Resident admitted to (local hospital) for fracture to cervical spine (C5). Stitches applied to laceration. Physician updated. 3/3/2021 at 8:51 a.m.- Spoke with the nurse from (local hospital), she stated resident had a fracture C5 and a neurological consult this morning. 3/4/2021 at 5:33 p.m.- Resident returned to facility via wheelchair. Resident in room eating dinner, in pleasant mood and denies any pain. Call light in reach and resident educated on using call light. Resident voiced understanding. Vital signs as followed: 158/88, 66, 18, 95% room air, 98.2 temporal, weight: 157.8 standing. 3/4/2021 at 9:04 p.m. Skin warm & dry, skin color WNL (within normal limits), mucous membranes moist, turgor normal. Resident has current skin issues. Skin Issue: Laceration. Skin Issue Location: right forehead Length: 3 centimeters. No wound odor. No tunneling. No undermining. readmitted to facility after hospital stay post fall. admitted with C5 fracture and has laceration on right side of forehead measuring 3 centimeters. 3/9/2021 at 10:28 a.m.- Nurse practitioner via video visited with resident. New orders for lab studies in the AM & to remove the stitches on the 13th obtained. 3/9/2021 at 1:21 p.m.- Late Entry: Obtained copy of emergency records for review. CT scan of head indicated no [CONDITION(S)], no mass affect, no midline shift, right frontal soft tissue swelling. Cervical x-ray indicated C5 anterior/inferior vertebral fracture without placement. Fracture seen on previous exam. CT of C spine 3/3/21 indicates minor residual deformity, along the anterior/inferior C5 level R/T prior fracture 8/29/20. Urinalysis indicated LE positive and bacteria present. [MEDICATION(S)] ordered. Culture result pending. 3/10/2021 at 08:01 a.m.- Resident continues on restorative program for dressing/grooming: staff to provide instructions to resident to put clothing on in correct order, set up supplies for grooming (brush hair, wash face, etc), daily to assist with maintaining function with ADL's (activities of daily living). Will continue program as resident benefits. 3/10/2021 at 08:02 a.m.- Resident continues on restorative program for walking, staff to walk resident up to 150 feet, provide cues/reminders to use slow, steady gait. Walk daily. No signs or symptoms of pain noted. Will continue program as resident tolerates. A fall risk assessment was completed on 1/21/21, indicated Resident E was at risk for falls. A fall risk assessment was completed on 3/4/21, indicated Resident E was at risk for falls. The clinical record lacked information regarding the interventions in place at the time of the fall and the root cause of the fall. The clinical record lacked post fall assessments or an IDT (interdisciplinary team) fall note with new interventions. The clinical record lacked new fall interventions after the 3/3/21 fall with injury. During an interview with the Regional Director 2 on 3/29/21 at 9:30 a.m., she indicated Resident E had an unwitnessed fall on 3/3/21 that resulted in a laceration to her forehead that required sutures and a cervical fracture. She indicated she did not know much more about the fall other than what had been documented in the clinical record. During an interview with the MDS Coordinator on 3/30/21 at 8:48 a.m., she indicated no IDT note was entered after Resident E's fall by the Director of Nursing. She indicated a morning meeting was held to discuss the fall, route cause, and interventions, but it was not noted in the clinical record. She was unsure what interventions were in place at the time of the fall, as it was not noted in the clinical record. On 4/1/21 at 10:12 a.m., the MDS Coordinator indicated the care plans were updated after every fall and with each IDT review. The MDS Coordinator indicated the care plan had not been individualized for the resident's fall interventions. The current facility policy, review date 4/25/18, included, but was not limited to, During the preadmission intake, determine if the potential resident has a history of falling or is unsteady in gait. Assure that the appropriate fall interventions are in place prior to the resident's admission. Newly admitted /readmitted resident are assessed for fall risk by means of the Clinical Health Status tool. Following the completion of the MDS, if a resident triggers at risk for falls, the resident has further assessment utilizing the CAA [Care Area Assessment] guidelines. The plan of care is updated, if indicated, to further minimize the risk of fall. Following a resident's fall, the licensed nurse assesses the resident for injuries and provides necessary treatment and initiates the Change in Condition Report-Post Fall/Trauma, by hand. The physician and resident's representative is notified. Appropriate interventions are implemented. This Federal tag relates to Complaints IN 025, IN 346, IN 986, IN 226, and IN 694 3.1-45(a)

Based on observation, record review, and interview, the facility failed to ensure residents received showers or full bed baths as scheduled for 4 of 5 residents reviewed for showers. (Resident E, Resident T, Resident S, Resident D) Findings include: 1. During a review of Resident E's clinical record on 3/29/21 at 2:11 p.m., it indicated Resident E's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident E's Quarterly MDS (minimum data set), dated 2/16/21, indicated Resident E had severe cognitive impairment. Resident E required assistance x 1 with ADLs and help in part of bathing. Physical functioning deficit related to mobility impairment, self care impairment. Interventions included, but were not limited to, call bell within reach, dressing assist x 1, encourage choices with care, inform resident of risks of refusal of care, inspect skin with care, locomotion assist x 1, monitor and report changes in physical functioning ability, monitor and report changes in range of motion ability, provide supervision with bed mobility, assist as needed, provide supervision with eating and set up or assist as needed, provide supervision with toilet use, provide supervision with transfers, rehab services as ordered. Last revised 1/22/21. During a review of Resident E's shower schedule, it indicated Resident E was scheduled to receive showers on Wednesday and Saturday evenings. A review of Resident E's showers for 2/28/21-3/29/21 indicated the following, 2/28 partial SUN 3/1 partial MON 3/2 partial TUES 3/3 res not avail WED- Shower day 3/4 res not avail THURS 3/5 partial FRI 3/6 partial SAT- Shower day 3/7 partial SUN 3/8 partial MON 3/9 partial TUES 3/10 partial WED- Shower day 3/11 partial THURS 3/12 shower FRI 3/13 partial SAT- Shower day 3/14 partial SUN 3/15 partial MON 3/16 partial TUES 3/17 partial WED- Shower day 3/18 partial THURS 3/19 partial FRI 3/20 shower SAT- Shower day 3/21 partial SUN 3/22 partial MON 3/23 partial TUES 3/24 partial WED- Shower day 3/25 partial THURS 3/26 partial FRI 3/27 shower SAT- Shower day 3/28 partial SUN 3/29 partial MON Resident E was out of the facility on 3/3/21- 3/4/21. Resident E only received 3 showers in a 30 day review. 2. During an observation on 4/1/21 at 8:49 a.m., Resident T was observed sitting on the edge of her bed. Resident T was in her electric wheelchair. Resident T's hair was greasy. During a review of Resident T's clinical record on 4/1/21 8:59 a.m., Resident T's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident T's Quarterly MDS (minimum data set), dated 1/19/21 indicated Resident T required extensive assistance x 1 and total dependence for bathing. During a review of Resident T's care plans, they indicated, ADL/physical functioning deficit related to decreased mobility, self care impairment due to weakness secondary to end stage renal disease, arthritis of knees, vision impairment. Interventions included, but were not limited to, require extensive assistance with bed mobility, toileting, transfers, inform resident of risks of refusal of care, may use string on door to assist with shutting door independently, observe for changes in physical functioning/ROM (range of motion), rehab services as ordered, sit to stand lift and assist x 2 for transfers. Prefers to have shower/bed bath 2 times a week on Tues/Sat in the evenings. Interventions included, but were not limited to, offer resident shower/bed bath as preferred. During a review of Resident T's shower schedule, it indicated Resident T was to receive showers on Tuesday and Saturday evenings. A review of Resident T's showers for 3/3-4/1/21 indicated the following, 3/3 partial WED 3/4 partial THURS 3/5 partial FRI 3/6 nothing SAT- Shower day 3/7 shower SUN 3/8 shower MON 3/9 partial TUES- Shower day 3/10 partial WED 3/11 partial THURS 3/12 res not avail FRI 3/13 nothing SAT- Shower day 3/14 nothing SUN 3/15 nothing MON 3/16 nothing TUES- Shower day 3/17 nothing WED 3/18 nothing THURS 3/19 nothing FRI 3/20 partial SAT- Shower day 3/21 partial SUN 3/22 partial MON 3/23 partial TUES- Shower day 3/24 nothing WED 3/25 nothing THURS 3/26 shower FRI 3/27 shower SAT- Shower day 3/28 partial SUN 3/29 partial MON 3/30 partial TUES- Shower day 3/31 partial WED 4/1 partial THURS No refusals were documented in the clinical record for evening showers on the scheduled shower days. Resident T only received 8 showers in a 30 day review. During a review of the progress notes on 3/17/21 and 3/22/21 indicated staff only offered showers in the AM. The resident refused at that time. The clinical record lacked documentation that they reapproached during the evening hours. 3/17/2021 at 9:10 a.m.- Resident refused to go to [CONDITION(S)] this date resident states that it is because she wanted a shower offered. Shower times 2 to resident before [CONDITION(S)] resident then states that her husband has to bring shower supplies resident continues to refuse after offered to use facility supplies transportation canceled per request of resident. 3/22/2021 12:48 a.m.- Resident offered shower @7 a.m. by RN; resident refused and stated, I am not going to [CONDITION(S)] today. Resident offered shower again by CNA, refused she was polishing her finger nails. 3. During an observation on 4/1/21 at 9:03 a.m., Resident S was observed sitting on the edge of her bed in the same gown she was observed in on 3/31/21. Resident S's hair was unkempt and sticking out from her head. During a review of Resident S's clinical record on 4/1/21 at 10:51 a.m., it indicated Resident S's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident S's Quarterly MDS, dated [DATE], indicated Resident S required extensive assist x 2 with bed mobility, limited assist x 1 with transfers, extensive assist x 1 with hygiene, toileting, and dressing, and total dependence with bathing. During a review of Resident S's care plans, they indicated the following, ADL/physical functioning deficit related to decreased mobility, self care impairment due to weakness, obesity, decreased activity tolerance related to [CONDITION(S)]. Interventions included, but were not limited to, bed mobility assist x 1, may use 2, encourage choices with care, prefers bed baths, toileting assist x 1, transfer assist x 1, may use 2. A review of Resident S's bathing schedule indicated Resident S was scheduled for showers on Wednesday and Saturday evenings. It noted Resident S preferred bed baths. A review of Resident S's showers 3/3-4/1/21 it indicated the following, 3/3 partial WED- shower/bed bath day 3/4 partial THURS 3/5 partial FRI 3/6 partial SAT- shower day/bed bath day 3/7 partial SUN 3/8 partial MON 3/9 partial TUES 3/10 partial WED- shower day/bed bath day 3/11 partial THURS 3/12 partial FRI 3/13 refused SAT- shower day/bed bath day 3/14 nothing SUN 3/15 refused MON 3/16 partial TUES 3/17 partial WED- shower'/bed bath day 3/18 partial THURS 3/19 partial FRI 3/20 partial SAT- shower/bed bath day 3/21 partial SUN 3/22 partial MON 3/23 partial TUES 3/24 partial WED- shower/bed bath day 3/25 shower THURS 3/26 shower FRI 3/27 partial SAT- shower/bed bath day 3/28 nothing SUN 3/29 partial MON 3/30 partial TUES 3/31 partial WED- shower/bed bath day 4/1 partial THURS Resident S did not receive 9 full bed baths. Two refusals were noted. 4. On 3/29/21 at 8:21 a.m., Resident D was observed lying in bed. His hair was greasy in appearance and facial hair was observed. On 3/30/21 at 3/30/21 at 8:48 a.m., Resident D indicated he was to receive a shower twice a week. States had a bath last Wednesday and had never refused a shower. Resident D indicated the staff would give him a bed bath but he preferred a shower. Resident D indicated the facility did not have enough staff oftentimes for them to give him a shower. On 3/30/21 at 10:56 a.m., Resident D was observed sitting in his room in a wheelchair. His hair was dirty and greasy and had not been combed and the resident had facial hair. Resident D indicated he had not been shaved in quite some time. The clinical record for Resident D was reviewed on 3/30/21 at 11:02 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission MDS (Minimum Data Set) assessment, dated 1/5/21, indicated Resident D had slight cognitive impairment. The MDS assessment indicated Resident D required extensive assist of 1 person for personal hygiene and total dependence of 2 persons for bathing. A physical functioning care plan, dated 12/30/20, included, but was not limited to, resident is a 1-2 person assist for personal care, start date 12/30/20. A CNA Assignment Sheet, updated 3/22/21, obtained from LPN 4 on 3/28/21 at 8:58 a.m., indicated Resident D was to receive a shower every Wednesday and Saturday on the day shift. Review of the resident's bathing dated 3/1/21 through 3/27/21, indicated the following: 3/1/21 (Mon): Partial bath. 3/2/21 (Tues): Partial bath. 3/3/21 (Wed): Full bed bath. (Shower day) 3/4/21 (Thurs): Nothing. 3/5/21 (Fri): Partial bath 3/6/21 (Sat): Shower (Shower day) 3/7/21 (Sun): Partial bath 3/8/21 (Mon): Partial bath x 2 3/9/21 (Tues): Nothing 3/10/21 (Wed): Partial and Full bed bath (Shower day) 3/11/21 (Thurs): Nothing 3/12/21 (Fri): Partial bath 3/13/21 (Sat): Nothing (Shower day) 3/14/21 (Sun): Nothing 3/15/21 (Mon): Partial bath 3/16/21 (Tues): Partial and Full bed bath 3/17/21 (Wed): Nothing (Shower day) 3/18/21 (Thurs): Partial bath 3/19/21 (Fri): Partial bath x 2 3/20/21 (Sat): Partial and Full bed bath (Shower day) 3/21/21 (Sun): Partial bath 3/22/21 (Mon): Nothing 3/23/21 (Tues): Nothing 3/24/21 (Wed): Full bed bath (Shower day) 3/25/21 (Thurs): Nothing 3/26/21 (Fri): Nothing 3/27/21 (Sat): Full bed bath Resident D had received one shower on 3/6/21. The resident should have received 8 showers. The clinical record lacked documentation of any refusal of showers by the resident. Review of the Resident Council Minutes, dated 3/16/21, provided by the Interim Administrator on 3/29/21 at 10:00 a.m., indicated Old Business: included, but was not limited to, Staffing issues: evening showers not happening regularly. New Business concerns included, but were not limited to, Not getting showers regularly. During an interview with CNA 2 on 3/29/21 at 8:33 p.m., she indicated she only had time to check and change residents and did not have time to give showers during her shift. She knew some residents were scheduled for showers, but she was not going to get to them. If she does not get to them and if she works the next day, she will tell the next shift so they get done, but if she is not working she does not know if they get done. During an interview with the Activity Director on 3/29/21 at 8:36 p.m., he indicated he is also a CNA and will sometimes have to come in and help give showers if staff is short-staffed and unable to get them done. During an interview on 4/1/21 at 11:14 a.m., the Activity Director indicated he facilitates the resident council meetings. Any concerns brought up in the meetings were brought to the department head that it pertained to. He indicated showers not getting done was a concern that was brought up and it was brought to the attention of the Director of Nursing, but no follow up was completed. A Bath, Shower procedure, review date 8/23/18, provided by the Transitional Executive Director on 4/5/21, included, but was not limited to, the purpose of the procedure was to cleanse and refresh the resident, to observe the skin, and to provide increased circulation. The procedure included the face should be washed and the hair shampooed. The procedure lacked documentation regarding shaving of the resident. The facility lacked documentation of a policy for ADLs. The current facility policy, dated 5/3/20, provided by the Interim Administrator on 4/5/21 at 12:14 p.m., included, but was not limited to, The resident has a right to be treated with respect and dignity, including: The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. This Federal tag relates to Complaints IN 025, IN 346, IN 986, IN 226, and IN 694. 3.1-38(a)(3)

Based on interview and record review, the facility failed to accurately assess and stage a pressure ulcer, implement recommended treatment orders, ensure nutritional interventions were implemented immediately, and assess the ulcer and document the characteristics at least weekly, resulting in hospitalization for osteo[DIAGNOSES REDACTED], for 1 of 3 residents reviewed with pressure ulcers (Resident B). Findings include: The closed clinical record of Resident B was reviewed on 10/26/20 at 2:35 P.M. [DIAGNOSES REDACTED]. A Care Plan, dated 4/17/20, indicated: Pressure ulcer actual due to: pressure ulcer to coccyx. Interventions included: anchor Foley for wound healing, Date Initiated: 06/15/2020, Do not massage over bony prominence Date Initiated: 04/17/2020, LAL(low air loss) mattress on bed with bed extender Date Initiated: 05/07/2020, Provide pressure reducing wheelchair cushion Date Initiated: 04/17/2020, Provide thorough skin care after incontinent episodes and apply barrier cream, Date Initiated: 04/17/2020, Skin assessment to be completed per Living Center Policy, Date Initiated: 04/17/2020, supplements for wound healing as ordered, Date Initiated: 05/19/2020, Treatments as ordered Date Initiated: 04/17/2020, Turning and repositioning schedule per assessment, Date Initiated: 04/17/2020. Weekly Wound assessment, Date Initiated: 04/17/2020. A Progress Note, dated 4/14/20 at 7:49 P.M., indicated, Open area noted during weekly skin assessment on coccyx 2.2 x 2.0 x 1.2 cm (centimeters). Hx (history) [MEDICAL CONDITION](stroke), received total ADL (activities of daily living) care from staff, HX open areas on coccyx, protective dressing applied daily to help prevent skin breakdown on bony prominence with scar tissue present .MD updated, dressing orders received A Wound Evaluation Flow Sheet included: Effective 4/14/2020, Week 1, Site: Sacrum, Type Pressure, Units of Measure: centimeters (cm), Length 2.2, Width 2.0, Depth 1.2, Stage II. When was the wound identified? 04/14/2020. Wound Type: Pressure Ulcer (In-house acquired), Exudate (drainage): Color/Type: Serosanguineous (blood tinged), Consistency: Thin, watery, Amount: Scant .Wound Bed: [DIAGNOSES REDACTED] (redness), Painful .Current Treatment: Cleanse with wound cleanser, apply [MEDICATION NAME] to wound bed, cover with border foam dressing, change daily and PRN (as needed) soilage .Wound nurse updated and resident to be added to weekly wound monitoring by Wound MD. This was signed on 6/3/20. Included on the form was the following descriptions of pressure wounds . Stage II: Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red pink wound bed, without slough (yellowish/tannish tissue) . Stage IV: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar (black tissue) may be present on some parts of the wound bed. Often include undermining and tunneling. Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough .and/or eschar .in the wound bed. A Wound Evaluation Week 2, dated 4/27/20, included: Length (in cm) 2.2, Width 2.0, Depth 0.1, Staging II, Exudate: Color/Type: Serous (clear), Consistency: Thick, tenacious, Amount: Small/minimal .Wound Bed: [DIAGNOSES REDACTED], Tender to touch .Current Treatment: Calcium Alginate and dressing daily .Wound to coccyx area assessed on 4/20/2020 .Treatment to continue with Calcium Alginate sheet and dressing daily The next Wound Evaluation (3) was documented 9 days later, on 5/6/20. The evaluation included: Length (in cm) 2.2, Width 2.0, Depth 0.1, Staging II, Exudate: Color/Type: Serous, Consistency: Thick, tenacious, Amount: Small/minimal .Wound Bed: [DIAGNOSES REDACTED] .Current Treatment: Calcium Alginate sheet and dressing daily .Wound to coccyx area assessed on 5/1/2020 .Treatment to continue with Calcium Alginate sheet and dressing daily A Wound Evaluation Week 4, dated 5/7/20, included: Length (in cm) 2.2, Width 2.0, Depth 0.1, Staging II, Exudate: Color/Type: Serous (clear), Consistency: Thick, tenacious, Amount: Moderate .Wound Bed: [DIAGNOSES REDACTED], Tender to touch .Current Treatment: Calcium Alginate sheet and dressing daily .Wound to coccyx area assessed on 4/20/2020 .Treatment to continue with Calcium Alginate sheet and dressing daily Although the wound drainage was increasing, the treatment ordered remained the same. The pressure ulcer continued to be documented as a Stage II, although the wound drainage was documented as thick, tenacious. A Wound Care Telemedicine Initial Evaluation, dated 5/11/20, included: Chief Complaint: Patient presents with a wound on his coccyx .He has an unstageable (due to necrosis) coccyx (sic) for at least 7 days duration. There is moderate serous exudate .Etiology: Pressure .This wound is in an [MEDICAL CONDITION] stage and is unable to progress to a healing phase because of the presence of a biofilm .If the patient does not have a dietician following, recommend dietary consultation A Wound Evaluation Week 5, dated 5/13/20, included: Length (in cm) 3.0, Width 2.0, Depth 0.4, Staging Unstageable, Exudate: Color/Type: Serous, Consistency: Thick, tenacious, Amount: Moderate .Wound Bed: [DIAGNOSES REDACTED], Tender to touch. Slough 100% .Current Treatment: Santyl ointment, Calcium Alginate and dressing daily .Wound to coccyx area assessed on 5/11/2020. Wound bed measures 3.0 x 2.0 x 0.4 cm and is unmeasurable due to necrotic slough covering full wound bed .A moderate amount of serous drainage to previous dressing. PCP (primary care physician) notified and referred treatment to wound MD. Wound MD observed wound bed via telemedicine. Treatment updated A Nutrition Assessment, dated 5/20/20, indicated, Skin Intact .Current diet regimen is approp. (sic). Continue current POC (plan of care. RD (registered dietician) avail. (sic) as needed. The assessment did not address the resident's pressure ulcer. A Specialty Physician Wound Evaluation, dated 5/20/20, indicated, He has a stage 4 pressure wound coccyx (sic) for at least 14 days duration. There is heavy serous exudate .Wound progress: No change .Recommendations: Zinc [MEDICATION NAME] .Vitamin C .Dressing Treatment Plan, Add Mesalt, Continue Santyl, Discontinue Alginate Calcium A quarterly Minimum Data Set (MDS) assessment, dated 5/21/20, indicated Resident B had a short term and long term memory problem, and required extensive assistance of two plus staff for bed mobility, transfer, and toilet use. The resident had 1 unhealed Stage 2 pressure ulcer. The assessment did not accurately document the Stage IV pressure ulcer. A Wound Evaluation Week 6, dated 5/22/20, included: Length (in cm) 4.0, Width 2.5, Depth 0.4, Staging Unstageable, Exudate: Color/Type: Serous, Consistency: Thick, tenacious, Amount: Moderate .Wound Bed: [DIAGNOSES REDACTED], Tender to touch, 100% slough .Current Treatment: Santyl ointment, Calcium Alginate sheet, and dressing daily .Wound to coccyx area assessed on 5/18/2020 .Wound noted to have an increase in surface area .new order for Pro Stat 30 cc BID (twice daily) to assist with wound heating Documentation did not include why the wound physician's recommendation for a different treatment was not followed. A Wound Clinic note, dated 5/29/20, included: Procedure: Debridement (removal of necrotic tissue) .Pressure ulcer of sacral region, stage 4, Sacrum ulcer .The pressure ulcer measures 4.5 cm x 4.5 cm x 1.8 cm .There is a large amount of Serosanguineous and malodorous exudate draining from the pressure ulcer. The pressure ulcer base .has slough, is covered with a necrotic eschar, is covered with [MEDICATION NAME], and covered with necrotic tissue The pressure ulcer bed has exposed subcutaneous and bone tissue The next documented Wound Evaluation was 12 days later, on 6/3/20. A Wound Evaluation Week 7, dated 6/3/20, included: Length (in cm) 4.5, Width 4.5, Depth 1.8, Staging IV, Exudate: Color/Type: Serous, Consistency: Thick, tenacious, Amount: Moderate .Wound Bed: [DIAGNOSES REDACTED], Tender to .Current Treatment: Santyl ointment, [MEDICATION NAME] AG, and dressing daily .Wound to coccyx area assessed by wound clinic on 5/29/2020 .Wound clinic MD performed debridement to area adjusted wound label to sacrum from coccyx A Wound Evaluation Week 8, dated 6/10/20, included: Length (in cm) 4.5, Width 4.5, Depth 1.8, Staging IV, Exudate: Color/Type: Serous, Consistency: Thick, tenacious, Amount: Moderate .Wound Bed: [DIAGNOSES REDACTED], [MEDICAL CONDITION] (swelling) Current Treatment: Santyl ointment, [MEDICATION NAME] AG, and dressing daily .Wound to coccyx area assessed by wound clinic on 6/1/2020 Progress Notes continued: 6/9/20 at 10:23 A.M. (charted late on 6/19/20 at 10:23 A.M.): Wound bed assessed by wound clinic on 6/9/2020. Wound bed measures 4.4 x 4.5 x 1.6 cm. Wound bed is 50% granulation tissue and 50% slough. Wound bed has a moderate amount of serous drainage to previous dressing. Wound bed noted to have an increase in slough releasing from wound bed. Treatment to continue with Santyl ointment, [MEDICATION NAME] AG, and dressing daily. Documentation of further wound assessments from 6/9/20 until 6/18/20 was not found in the clinical record. 6/18/20 at 6:23 P.M.: Resident sent out via (ambulance service) to (name of Wound Clinic) this afternoon .received a call from (name of Wound Clinic) that resident was being direct admitted to (name of hospital) for wound debridement and IV ATB (antibiotic) for osteo[DIAGNOSES REDACTED]. A Wound Clinic note, dated 6/18/20, indicated, Patient arrived to WCC (wound care clinic) with dry gauze and [MEDICATION NAME] Border in place. No Santyl and [MEDICATION NAME] AG in place .3:28 P.M. Per (name of physician), patient direct admitted to (hospital) for IV abx (sic therapy. A Wound Clinic physician's note, dated 6/18/20, indicated, Stg (stage) 4 ulcer with visible sacral bone present was slightly larger in size .Debrided, biopsied, cultured necrotic sacral bone and wound bed .Had patient admitted to the hospital for IV antibiotics for osteo[DIAGNOSES REDACTED] of sacrum On 10/28/20 at 11:25 A.M., the Wound Care Nurse was interviewed. She indicated Resident B was a heavy man, and real tall, with advanced dementia, and was hard to keep turned. She indicated Resident B developed an open area on a bony part of his coccyx, and it never seemed to get better. The facility had a wound physician come in and they added an air flow mattress, Prostat (a protein supplement), and Zinc. The resident eventually went to a wound clinic. The Wound Care Nurse indicated she would view the pressure ulcer when the wound physician came in, and updated the assessments weekly. On 10/29/20 at 9:00 A.M., the Administrator provided the current facility policy, Skin Integrity Guideline, dated 1/28/19. The policy included: The facility develops a routine schedule to review patients/residents with wounds or at risk on a weekly basis and will document findings .Wound status is monitored on a weekly basis .Nursing notifies dietary of any patient/resident admitted with pressure ulcers or newly identified acquired pressure ulcers. Nutritional Assessment determines need for nutritional interventions .Documentation completed by Dining Services Manager or Registered Dietician .occurs on initial notification of a new pressure ulcer .and continues monthly for non-healing Stage II or greater areas until healed .Licensed nurse to document weekly on identified wounds .Care plan is to be implemented, evaluated and revised based on the needs of the resident On 10/29/20 at 11:50 A.M., the Director of Nursing (DON) was interviewed. She indicated she had been the DON at the facility for approximately 1 month, and did not care for Resident B's pressure ulcer. When reviewing the resident's clinical record, she indicated the wound evaluations should be completed weekly. This Federal tag relates to Complaint IN 221 and IN 780. 3.1-40(a)(2)

Based on interview and record review, the facility failed to have a system in place to determine code status for 2 of 2 residents who were not provided Cardiopulmonary Resuscitation. The facility failed to perform Cardiopulmonary Resuscitation (CPR) on a resident who had requested to be a full code. (Resident #51) The facility failed to obtain a valid code status for Resident #36. (Resident #51, Resident #36) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when the staff failed to provide CPR for a resident without a valid Advanced Directive. The Administrator and DON were notified of the Immediate Jeopardy on [DATE] at 1:40 p.m. The Immediate Jeopardy was removed on [DATE] at 3:01 p.m., but the noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: 1. On [DATE] at 10:51 a.m., Resident #51's clinical record was reviewed. Resident #51's [DIAGNOSES REDACTED]. The Indiana Physician order [REDACTED].#51, which would have indicated whether Resident #51 wanted life sustaining measures in the event of a [MEDICAL CONDITION], was incomplete and not signed by a physician. The document did not have a date of resident's signature. A recapitulation of Resident #51's most recent hospitalization on [DATE] indicated Resident #51 was a full code in the event of a [MEDICAL CONDITION]. The physician's recapitulation orders, signed [DATE], lacked an identified code status. The Nursing Home/Assisted Living Facility visit, from Resident #51's physician, dated and signed on [DATE], indicated Resident #51 was a full code. The Nursing Progress Notes, entered as a late entry on [DATE] at 3:00 a.m., for [DATE] at 5:00 a.m., included, but was not limited to: Resident is in bed at present time. Respirations and all pulses have ceased. Skin color is ash color, cyanotic fingertips, and skin is cool to touch. Pupils are fixed and dilated. No s/s (signs or symptoms) or evidence of activity from resident. Resident's status confirmed by second nurse on duty. (No CPR was initiated or performed for the resident.) On-call MD (Medical Doctor) and family notified and CPR (Cardiopulmonary Resuscitation) order discontinued per MD .The entry was completed by LPN #5. On [DATE] at 3:30 p.m., LPN #5 was interviewed. LPN #5 indicated she had walked into the resident's room and found him without evidence of vital signs and walked out to the nurses station to check the resident's code status. LPN #5 indicated there was not an Advanced Directive in the resident's chart. At that time, LPN #5 indicated she was unaware of how to proceed and contacted the physician. LPN #5 indicated the physician instructed her to make Resident #51 a DNR (Do Not Resuscitate). LPN #5 indicated she had not performed CPR on Resident #51. LPN #5 was asked to describe what should happen when a resident is found without vital signs. LPN #5 indicated one nurse should contact the physician and another nurse should retrieve the crash cart. When queried regarding who would initiate CPR and who would call for the emergency services, LPN #5 indicated the nurse who contacted the physician would call the emergency services. The nurse who retrieved the crash cart, should initiate CPR. When queried regarding the late entry of charting surrounding Resident #51's death, LPN #5 indicated she had been exhausted and could no longer think. 2. On [DATE] at 12:10 p.m., Resident #36's clinical record was reviewed. Resident #36's [DIAGNOSES REDACTED]. Resident #36's Do Not Resuscitate/Do Not Intubate Request, was signed by the physician on [DATE]. (The resident died on [DATE].) The Electronic Health Record indicated Resident #36 was a full cardiac code, ordered on [DATE]. The Nursing Progress Notes, dated [DATE] at 12:55 a.m., included, but was not limited to: Resident is in bed at present time. Daughter notified and arrived at bedside. Resident is non-responsive. Color ashy and cool to touch on extremities. Cyanosis noted to all four extremities. Bilateral blood pressure absent, pulses absent, and respirations absent. Verified resident's condition by two on staff nurses. MD notified and new orders received. On [DATE] at 3:30 p.m., LPN #5 was interviewed. LPN #5 indicated Resident #36 was a hospice patient. LPN #5 further indicated she figured most hospice patients are not resuscitated. LPN #5 indicated the resident was expected to die because of hospice services. When queried regarding a resuscitation order, LPN #5 indicated she was unsure of Resident #36's code status. On [DATE] at 11:56 a.m., the Administrator provided the Cardiopulmonary Resuscitation (CPR) Guideline, created on [DATE] and reviewed on [DATE]. The policy included, but was not limited to: In the event a resident/patient experiences [MEDICAL CONDITION], cardiopulmonary resuscitation will be provided in the absence of a valid Advanced Directive or a Do Not Resuscitate (DNR) order directing others. If a patient/resident is found unresponsive, begin evaluation to determine presence or absence of pulse and/or respirations. In the absence of pulse and/or respirations do the following: 1. Remain calm. 2. Call out for help. Direct another staff member to announce the emergency per (Name of Facility) protocol and call Emergency Medical Services (EMS). Direct another staff member to bring the emergency supplies and AED (Automated External Defibrillator). 3. A charge nurse will assume command of the scene and will direct other personnel in the effort. CPR certified personnel, when present in facility, shall manage the physical efforts involved in resuscitation. 4. A staff member other than the one who is providing the resuscitative effort must promptly identify/validate current code status. While that step is undertaken, AED should be prepared and [MEDICATION NAME] placed. 5. If DNR status is validated, do not initiate CPR. If CPR/Code Status is undetermined, CPR will be initiated and will continue until the arrival of EMS . 7. Once resuscitative efforts are concluded or resident/patient is transported to emergency center: call attending/covering physician, call resident/patient family, document details of CPR in record On [DATE] at 12:05 p.m., the DON indicated if staff members found a resident unresponsive they were to initiate the CPR policy and procedure. 3XXX,[DATE](f)(5)

Based on record review and interview, the facility failed to implement their policy and procedure to ensure the investigation, for 1 of 3 residents reviewed for allegations of sexual assault, was thorough and to ensure key parts of the investigation were completed timely, in that staff members on duty at the time of the alleged incident were not interviewed thoroughly and timely. (Resident E) The facility also failed to implement their policy and procedure to ensure 1 of 3 resident allegations of sexual assault was identified as an allegation of abuse and reported immediately to the administrator of the facility, in that the nurse thought the resident was "talking out of her head," and did not report it immediately to the administrator. (Resident F) Findings include: 1. On 7/19/11 at 1:00 p.m., the Interim Administrator and Director of Nurses (DoN) indicated Resident E had alleged she was raped by a CNA (CNA #6) on the previous night shift. The Administrator indicated the resident had told a CNA (CNA #14), at around 11:30 a.m., who immediately informed the Director of Nurses and the facility had begun investigating. She indicated the resident was being sent to the hospital for examination and the police had been called. The CNA had been notified that he was not to report to work until further notice due to an investigation. On 7/19/11 at 4:00 p.m., the DoN and Administrator indicated a detective from the local police department had been in and asked them not to talk to the alleged perpetrator until he had the opportunity to interview him. The resident was still at the hospital at that time. On 7/20/11 at 8:30 a.m., the DoN indicated the resident had returned from the hospital during the evening and no new orders had been given and no information from the hospital was received. The resident had been placed on one to one observation, where a staff person monitored the room, from the hallway. Two staff were doing all care on the resident. On 7/21/11 at 5:22 a.m., the building was entered. CNAs #8 and #9 were observed working on the 400 hall. CNA #8 indicated he was brand new and had only been working for a week. He indicated he and CNA #9 had been working as a team. They would get report, pass ice water, start bed checks, do paperwork, then restart bed checks. He indicated, because he was new, they were working together to do bed checks, so he could be introduced by the other CNA and learn what each resident needed. CNA #8 indicated he had not worked on 7/18-7/19 night shift. CNA #9 was then interviewed, at 5:30 a.m. She indicated she had worked Monday (7/18-7/19) night shift, Tuesday, and Wednesday. She indicated she worked 400 hall and CNA #6 had worked 500 hall. She indicated some CNAs chose to work their hall alone and some preferred to work together as a team. She indicated that she had worked by herself on Monday night, 7/18-7/19/11. She indicated she would still go over to the hall if help was needed, or to answer lights. The CNA indicated she had not been questioned by anyone else about that night, i.e. no facility personnel, or others. A Hospice RN was present on the unit. She was interviewed at 5:40 a.m. on 7/21/11, and she indicated Resident E was on her caseload. She indicated she was requested to come in on 7/19/11 to witness an interview and physical assessment of Resident E. She indicated she and the Minimum Data Set (MDS) assessment coordinator had been in the room together. The resident reported to them she had been raped on the night shift and indicated it was CNA #6 who raped her. She indicated the physical assessment was completed. The resident was wet, so her brief was changed. She indicated they had put the brief and linens used to cleanse the resident in a bag and saved it for the police investigation. She indicated there were no red marks, no significant bruises, except for several small bruises, none of them new, on her arms and knees. There were no red marks. The resident had a flat affect throughout the interview and exam. She indicated the interview and assessment happened "around noon." She indicated, according to the MDS coordinator, the story was consistent. She further stated, "Unfortunately, I know this resident and she's not always truthful." CNA #10 was observed seated outside Resident E's room [ROOM NUMBER]:45 a.m. on 7/21/11 and interviewed at that time. She indicated the resident and her room were being observed one on one, since 7/19/11 at 11:00 p.m. She had come in at 3:00 a.m. and had been assigned to watch the room and resident. At that time, the resident was heard to yell "Help, Help." The CNA was observed to enter the room and asked the resident what she needed. CNA #10 indicated she had to get help and exited the room to find another CNA to help her. She indicated two staff were doing all care. CNA #11 arrived at 5:45 a.m. on 7/21/11 and was interviewed at that time. She indicated she was taking over the one on one. She indicated she had heard Resident E had claimed CNA #6 raped her. She indicated she had worked Saturday night, Sunday night, and Monday night, 2:00 a.m. to 2:00 p.m. She indicated no one had questioned her about anything, "no nurse, no Administrator, no DoN (Director of Nurses), no detective..." She indicated staff were to always go with two persons to Resident E's room, even before the allegation, because the resident didn't always tell the truth. RN #5 was administering medications on the 400 and 500 halls. She was interviewed at 5:50 a.m. on 7/21/11. She indicated she had worked the night shift 7/18/11 to 7/19/11. She indicated CNAs #6 and #9 had been the CNAs working with her. She indicated nothing unusual happened that night. The resident had not complained of anything to her. She indicated she had heard from co-workers that Resident E alleged CNA #6 had raped her during that night shift. She indicated she was always in the hallway, or at the nurses' station and heard staff in and out of rooms. She indicated again, nothing unusual occurred. "We all know who she is...when she knows he's working (CNA #6), she's always calling out his name." She indicated she had not had anyone from the facility staff, or anyone else ask her any questions about that night and had received no request for any statement, "You are the first to ask." On 7/21/11 at 8:30 a.m., the Interim Administrator, Corporate Nurse Consultant #1, Corporate Nurse Consultant #2, and the Corporate Director of Operations were interviewed. According to the Interim Administrator, the facility had not initiated staff interviews on 7/19/11. She indicated a police detective had arrived at 3:30 p.m. and indicated he did not want them to interview CNA #6 before he had a chance to do so. She indicated the detective called the CNA from her office and scheduled a time for him to come to the police department for an interview, 5:00 p.m. that date; the facility was not involved in the interview. She indicated the police detective did not ask them not to interview other staff. The Interim Administrator indicated, during the 8:30 a.m. interview, after the police detective's visit, she made a phone call to the corporate legal department. She indicated she was told the legal department would be involved and indicated she was asked not to interview staff, that "counsel needed to be on the ground." The Corporate Nurses indicated the attorney had arrived on 7/20/11 and was returning 7/21/11. They indicated she had done some staff interviews on 7/19/11, but they did not know who was interviewed. The Administrator indicated, during the 8:30 a.m. interview, it was around 11:30 a.m. Tuesday morning (7/19/11) that Resident E reported the allegation to the CNA. The CNA immediately reported it to the DoN. Resident E's facility clinical record review began on 7/21/11 at 6:30 a.m. The record indicated the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident's most recent quarterly Minimum Data Set (MDS) Assessment, dated 5/27/11, included, but was not limited to, the following: Unclear speech, rarely/never understood, rarely/never understands, long term and short term memory problems, severely impaired decision making, disordered thinking, [MEDICAL CONDITION], extensive assistance of two staff for bed mobility, total dependence of two staff for transfers, and unable to ambulate. She was assessed as always incontinent of bowel and bladder, had signs and symptoms of pain, and had experienced unplanned weight loss. The resident's most recent full MDS assessment, a significant change MDS dated [DATE], included, but was not limited to, the following: communication clear, Brief interview for Mental Status score of 05/15, with 15/15 being alert and oriented, no [MEDICAL CONDITION] or behaviors identified, extensive assistance of two staff for bed mobility, and transfers, and unable to walk. The assessment indicated she was always incontinent of bowel and bladder, experienced pain, but had experienced no weight loss. The resident was currently receiving hospice services. The nurse aide assignment sheets for the 400 and 500 halls were provided by CNA #10 on 7/22/11 at 10:26 a.m. and reviewed at that time. Under "Special Needs," was indicated the following: "two for care non-skid slipper socks when out of bed BEHAVIORS. HOSPICE roho air mattress KEEP SET ON #4." Nurses' notes/progress notes were reviewed from 6/8/11 through 7/22/11 and included, but were not limited to, the following: "7/18/11 07:57 (7:57 a.m. ) Resident slept well during the night on no pressure mattress, with floor mats on floor for safety." "Late Entry 7/19/2011 12:40 (12:40 p.m.) Note text: Resident reported allegations of abuse, MD (medical doctor) made aware of allegations et new order received for resident to go to ER (emergency room ) for evaluation et tx (treatment); poa (power of attorney) (name) notified of residents allegations of abuse et permission obtained for resident to go to (name of hospital) main campus for nessary (sic) tx related to allegations. Residents (sic) poa stated, "THIS WAS OBSERED ET RIDICULOUS ALSO A WASTE OF TIME BUT DO WHAT EVER WE WANTED TO DO." (sic) transportation arranged et resident transported to (name of hospital)." "7/19/2011 16:03 (4:03 p.m.) Resident refused ADL (activities of daily living) care this am (morning) despite 2 attempts by staff." "7/19/11 20:08 (8:08 p.m.) @ 1900 (7:00 p.m.) res (resident) return to (name of facility) on srecther (sic) per ambulance, escorted per 2 (name of ambulance company) personnel. No c/o (complaints) noted upon return. N.O. (new order) received for [MEDICATION NAME] (for nausea) 4 mg Q 6 hrs (every six hours) PRN (as needed) times 3 doses and update Dr. (name) in AM." "7/19/11 23:27 (11:27 p.m.) Res. resting quietly in bed at this time. Res. in good humor, taking meds without difficulty, no periods of anxity (sic), normal demeaner (sic), res. calling out to staff by name as normal in ADLs." "7/20/11 06:55 (6:55 a.m.) "1 on 1 observation started. Resident had uneventful night, mainly sleeping. Verbalized needs and wants. C/O (complaint of) hurting. Reassurance and redirect provided with little success. [MEDICATION NAME] 0.25 ml (milliliters) given @ 0035 (12:35 a.m.) for pain and general discomfort. Resting comfortably during noc's. 1 on 1 observation provided by female staff thru the night. No further C/O of pain or discomfort and was resting comfortable..." "7/20/2011 14:55 (2:55 p.m.) General Note. Providing 1:1 with (name) 2:00 - 2:45 p.m. resident hollered "help." This SSD (Social Service Director) entered room, resident stated she was wet when asked what she needed. Nursing notified of need to provide peri-care. When asked if she remembered going to hospital yesterday, she responded, 'Yes'. (sic) When asked if she knew what the reason for transfer to hospital was, she responded, 'I was raped'. (sic)..." At 1:00 p.m. on 7/21/11, the Interim Administrator, Corporate Nurses #1 and #2, the Corporate Director of Operations, and the Corporate Attorney were interviewed. The Administrator indicated their investigation began as soon as the allegation was reported. She indicated they immediately interviewed the resident and did a physical assessment. They notified the physician, the family, and the police and got orders to send the resident to the hospital for evaluation and treatment. The facility Social Services employees began interviews of alert and oriented residents, and they began full body assessments on all dependent residents. When queried about staff interviews, they indicated the police detective had arrived at around 3:30 p.m. on 7/19/11. He had requested they not interview CNA #6 until he had a chance to. The Interim Administrator indicated she called her corporate office after the visit with the detective and was told to wait for legal representation prior to proceeding with staff interviews. At that time, they indicated the Corporate Attorney had arrived on 7/20/11 in the afternoon. When queried, they indicated four (4) staff members had been interviewed on 7/20/11, one nurse, two CNAs and a Social Worker; they did not identify the individuals. When queried further, they indicated the CNA and nurse who worked with CNA #6 on the 400/500 halls the night in question had not been interviewed, but "would be by the end of the day (7/21/11)." They indicated the investigation was still in process. The Corporate staff indicated their policy was to suspend the staff member immediately and begin the investigation. On 7/22/11 at 8:50 a.m., the Administrator and Corporate Nurses and Director of Operations indicated their attorney had given them permission to proceed with staff interviews, and interviews had been conducted the during the previous evening and night shifts. They provided documentation of those interviews. The questions for staff were typed on pieces of paper and each one had handwritten answers from each staff person interviewed. The questions included the following: "What have you heard? Have you ever seen or heard a staff member be inappropriate either verbally or physically with a resident? If so, who did you report to? Have you noticed a staff member be unaccounted for extensive periods of time? If so, did you report this and to whom did you report it? Is there anything else?" CNA #13 was interviewed, on 7/22/11 at 9:07 a.m. She indicated she had worked on 7/19/11, on the day shift. She indicated, "I think I took care of her...I did change her, by myself." She indicated she remembered changing the resident's incontinence brief; the resident had not complained. The resident's brief had an off-white colored discharge in it, but she indicated the resident always had that. She indicated the resident had said nothing to her and the first thing she heard about the allegation was when they were sending her to the hospital. CNA #14 was interviewed on 7/22/11 at 10:20 a.m. She indicated she had arrived on the unit that morning around 8:00 a.m. She indicated the resident did not want a bath that morning, which was a little unusual. She indicated she approached the resident again later, sometime around 11 a.m. or so. At that time, Resident E, stated to her, "(CNA #6's first name) raped me, (name) raped me." She indicated she immediately left the room and found the first nurse she could find, the Staff Development Nurse. The Staff Development Nurse told her to tell the DoN immediately and she did. She indicated she had provided the resident peri-care around 10:30 a.m. and nothing unusual had occurred or was observed, and the resident had not reported the allegation at that time. CNA #14 indicated she "normally" used two people in Resident E's room, but not all the time, "I don't always take ." She indicated the reason they normally used two staff was "based on her history." The DoN was re-interviewed, on 7/22/11 at 10:30 a.m. She indicated the instructions, "two for care," was on the assignment sheet prior to the allegation and the instructions were due to false reports in the past (not of rape). She indicated, if she had been able to interview CNA #6, she would have asked him if he had two people with him all the time, and if not, why, but law enforcement had not allowed the facility to interview him. CNA #9 was re-interviewed on 7/22/11 at 11:30 a.m. She indicated she worked the night shift 7/18/11-7/19/11. She indicated she worked the 400 hall and CNA #6 worked the 500 hall, where Resident E resided. She indicated she did not assist CNA #6 with Resident E at any time during that shift. She indicated some CNAs liked to stay on their own halls and some liked to do bed checks together and CNA #6 would usually work by himself. When queried about residents who needed two staff for assistance, she indicated there were times when she did not get a second staff member to help. RN #5 was re-interviewed, on 7/22/11 at 11:45 a.m. When queried, she indicated she could not say either way whether or not she assisted CNA #6 with Resident E on the night of 7/18-7/19/11. She did not remember. She indicated nothing unusual happened that night. When queried about bed checks and whether or not CNA #6 did them by himself, she indicated sometimes CNAs, in general, would take two, if it was a resident who fought, or needed more help. She indicated she had not taken a lunch break that night, that she was the only nurse, and was always on one hall or the other. She indicated she did not know, for sure, whether or not CNA #6 cared for Resident E by himself or not. On 7/22/11 at 2:50 p.m., the Interim Administrator, Corporate Nurse #1, the Director of Nurses (DoN), and the Director of Operations were interviewed. When queried if they had asked CNA #9 and RN #5 whether or not they ever helped CNA #6 in Resident E's room, they indicated they had only asked the questions on the paper. The policy and procedure for "Reporting Alleged Violation," regarding abuse, no date, was provided by the HFA on 07/12/11 at 9:00 A.M., who indicated it was current. The policy and procedure included, but was not limited to, the following: "Policy It is the policy of this center to take appropriate steps to prevent the occurrence of: -abuse... Definitions: The following definitions are pursuant to the interpretive guidelines for F223. Abuse Abuse is the will infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, main or mental anguish... Sexual abuse Sexual abuse includes, but is not limited to: -sexual harassment -sexual coercion -sexual assault Where the circumstances of the alleged violation warrants, the DNS (Director of Nursing Services) or designee initiates a physical and mental assessment of the resident and documents the findings. Only factual information is documented, not assumptions. The DNS also notifies the attending physician regarding the alleged violation and findings and documents the contact... Investigation The ED (Executive Director, Administrator) or DNS conducts all investigations. In the event an alleged violation occurs when neither of these people are in the center, the charge nurse is responsible for initiating the investigation procedure. The investigation includes interviews of employees, visitors or residents who may have knowledge of the alleged incident. Only factual information is documented - not assumptions or speculation. Written statements from involved parties are not requested. The documentation of the investigation is kept in the ED's office in an administrative file. The medical record is reviewed to determine the resident's past history and condition and its relevance to the alleged violation..." 2. Resident F's clinical record was reviewed on 7/21/11 at 6:50 a.m. A Nurse's note, dated 06/30/11 at 04:18 (4:18 A.M.), indicated, "(local ambulance company) her (sic) to transport. Resident told EMT's (Emergency Medical Technician's) that she had been rapped (sic), that she was being held hostage, that her fron (sic) teeth were knocked out...." The Nursing note lacked any documentation that the HFA (Health Facility Administrator) had been notified. In an interview with the HFA, on 07/21/11 at 8:15 A.M., she indicated, "We saw that one (the nursing note) the next morning, reviewing things in the morning meeting...The nurse did not call at that time, her assumption was (Resident F) was talking out of her head...didn't take it as an allegation of abuse...we re-educated the nurse for reporting..." An inservice training record, dated 6/30/11, provided by the HFA on 07/21/11 at 2:00 P.M., indicated, "Staff will understand that they are to report anything odd or unusual, even if they feel it is a behavior to their DON (Director of Nursing), ED (Executive Director) or ADON (Assistant Director of Nursing) at anytime AM or PM." The policy and procedure for abuse, provided by the HFA on 07/12/11 at 9:00 A.M., indicated, "Reporting Alleged Violations Responsibility: It is the responsibility of all associates to immediately report any alleged violation of abuse...Policy It is the policy of this facility to take appropriate steps to prevent...abuse...It is also the policy of this facility to take appropriate steps to ensure that all alleged violations of ...abuse...are reported immediately to the Executive Director of the facility...The facility investigates each such alleged violation thoroughly..." This federal tag relates to complaint number IN 878. 3.1-28(a)

Based on record review and interview, the facility failed to ensure the investigation, for 1 of 3 residents reviewed for allegations of sexual assault, was thorough and to ensure key parts of the investigation were completed timely, in that staff members on duty at the time of the alleged incident were not interviewed timely. (Resident E) The facility also failed to ensure 1 of 3 resident allegations of sexual assault was reported immediately to the administrator of the facility, in that the administrator was unaware of the allegation until the record was reviewed after the resident was transferred to the hospital. (Resident F) Findings include: 1. On 7/19/11 at 1:00 p.m., the Interim Administrator and Director of Nurses (DoN) indicated Resident E had alleged she was raped by a CNA (CNA #6) on the previous night shift. The Administrator indicated the resident had told a CNA (CNA #14), at around 11:30 a.m., who immediately informed the Director of Nurses and the facility had begun investigating. She indicated the resident was being sent to the hospital for examination and the police had been called. The CNA had been notified that he was not to report to work until further notice due to an investigation. On 7/19/11 at 4:00 p.m., the DoN and Administrator indicated a detective from the local police department had been in and asked them not to talk to the alleged perpetrator until he had the opportunity to interview him. The resident was still at the hospital at that time. On 7/20/11 at 8:30 a.m., the DoN indicated the resident had returned from the hospital during the evening and no new orders had been given and no information from the hospital was received. The resident had been placed on one to one observation, where a staff person monitored the room, from the hallway. Two staff were doing all care on the resident. On 7/21/11 at 5:22 a.m., the building was entered. CNAs #8 and #9 were observed working on the 400 hall. CNA #8 indicated he was brand new and had only been working for a week. He indicated he and CNA #9 had been working as a team. They would get report, pass ice water, start bed checks, do paperwork, then restart bed checks. He indicated, because he was new, they were working together to do bed checks, so he could be introduced by the other CNA and learn what each resident needed. CNA #8 indicated he had not worked on 7/18-7/19 night shift. CNA #9 was then interviewed, at 5:30 a.m. She indicated she had worked Monday (7/18-7/19) night shift, Tuesday, and Wednesday. She indicated she worked 400 hall and CNA #6 had worked 500 hall. She indicated some CNAs chose to work their hall alone and some preferred to work together as a team. She indicated that she had worked by herself on Monday night, 7/18-7/19/11. She indicated she would still go over to the hall if help was needed, or to answer lights. The CNA indicated she had not been questioned by anyone else about that night, i.e. no facility personnel, or others. A Hospice RN was present on the unit. She was interviewed at 5:40 a.m. on 7/21/11, and she indicated Resident E was on her caseload. She indicated she was requested to come in on 7/19/11 to witness an interview and physical assessment of Resident E. She indicated she and the Minimum Data Set (MDS) assessment coordinator had been in the room together. The resident reported to them she had been raped on the night shift and indicated it was CNA #6 who raped her. She indicated the physical assessment was completed. The resident was wet, so her brief was changed. She indicated they had put the brief and linens used to cleanse the resident in a bag and saved it for the police investigation. She indicated there were no red marks, no significant bruises, except for several small bruises, none of them new, on her arms and knees. There were no red marks. The resident had a flat affect throughout the interview and exam. She indicated the interview and assessment happened "around noon." She indicated, according to the MDS coordinator, the story was consistent. She further stated, "Unfortunately, I know this resident and she's not always truthful." CNA #10 was observed seated outside Resident E's room [ROOM NUMBER]:45 a.m. on 7/21/11 and interviewed at that time. She indicated the resident and her room were being observed one on one, since 7/19/11 at 11:00 p.m. She had come in at 3:00 a.m. and had been assigned to watch the room and resident. At that time, the resident was heard to yell "Help, Help." The CNA was observed to enter the room and asked the resident what she needed. CNA #10 indicated she had to get help and exited the room to find another CNA to help her. She indicated two staff were doing all care. CNA #11 arrived at 5:45 a.m. on 7/21/11. She indicated she was taking over the one on one. She indicated she had heard Resident E had claimed CNA #6 raped her. She indicated she had worked Saturday night, Sunday night, and Monday night, 2:00 a.m. to 2:00 p.m. She indicated no one had questioned her about anything, "no nurse, no Administrator, no DoN (Director of Nurses), no detective..." She indicated staff were to always go with two persons to Resident E's room, even before the allegation, because the resident didn't always tell the truth. RN #5 was administering medications on the 400 and 500 halls. She was interviewed at 5:50 a.m. on 7/21/11. She indicated she had worked the night shift 7/18/11 to 7/19/11. She indicated CNAs #6 and #9 had been the CNAs working with her. She indicated nothing unusual happened that night. The resident had not complained of anything to her. She indicated she had heard from co-workers that Resident E alleged CNA #6 had raped her during that night shift. She indicated she was always in the hallway, or at the nurses' station and heard staff in and out of rooms. She indicated again, nothing unusual occurred. "We all know who she is...when she knows he's working (CNA #6), she's always calling out his name." She indicated she had not had anyone from the facility staff, or anyone else ask her any questions about that night and had received no request for any statement, "You are the first to ask." On 7/21/11 at 8:30 a.m., the Interim Administrator, Corporate Nurse Consultant #1, Corporate Nurse Consultant #2, and the Corporate Director of Operations were interviewed. According to the Interim Administrator, the facility had not initiated staff interviews on 7/19/11. She indicated a police detective had arrived at 3:30 p.m. and indicated he did not want them to interview CNA #6 before he had a chance to do so. She indicated the detective called the CNA from her office and scheduled a time for him to come to the police department for an interview, 5:00 p.m. that date; the facility was not involved in the interview. She indicated the police detective did not ask them not to interview other staff. The Interim Administrator indicated, during the 8:30 a.m. interview, after the police detective's visit, she made a phone call to the corporate legal department. She indicated she was told the legal department would be involved and indicated she was asked not to interview staff, that "counsel needed to be on the ground." The Corporate Nurses indicated the attorney had arrived on 7/20/11 and was returning 7/21/11. They indicated she had done some staff interviews on 7/19/11, but they did not know who was interviewed. The Administrator indicated, during the 8:30 a.m. interview, it was around 11:30 a.m. Tuesday morning (7/19/11) that Resident E reported the allegation to the CNA. The CNA immediately reported it to the DoN. Resident E's facility clinical record review began on 7/21/11 at 6:30 a.m. The record indicated the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident's most recent quarterly Minimum Data Set (MDS) Assessment, dated 5/27/11, included, but was not limited to, the following: Unclear speech, rarely/never understood, rarely/never understands, long term and short term memory problems, severely impaired decision making, disordered thinking, [MEDICAL CONDITION], extensive assistance of two staff for bed mobility, total dependence of two staff for transfers, and unable to ambulate. She was assessed as always incontinent of bowel and bladder, had signs and symptoms of pain, and had experienced unplanned weight loss. The resident's most recent full MDS assessment, a significant change MDS dated [DATE], included, but was not limited to, the following: communication clear, Brief interview for Mental Status score of 05/15, with 15/15 being alert and oriented, no [MEDICAL CONDITION] or behaviors identified, extensive assistance of two staff for bed mobility, and transfers, and unable to walk. The assessment indicated she was always incontinent of bowel and bladder, experienced pain, but had experienced no weight loss. The resident was currently receiving hospice services. The nurse aide assignment sheets for the 400 and 500 halls were provided by CNA #10 on 7/22/11 at 10:26 a.m. and reviewed at that time. Under "Special Needs," was indicated the following: "two for care non-skid slipper socks when out of bed BEHAVIORS. HOSPICE roho air mattress KEEP SET ON #4." Nurses' notes/progress notes were reviewed from 6/8/11 through 7/22/11 and included, but were not limited to, the following: "7/18/11 07:57 (7:57 a.m. ) Resident slept well during the night on no pressure mattress, with floor mats on floor for safety." "Late Entry 7/19/2011 12:40 (12:40 p.m.) Note text: Resident reported allegations of abuse, MD (medical doctor) made aware of allegations et new order received for resident to go to ER (emergency room ) for evaluation et tx (treatment); poa (power of attorney) (name) notified of residents allegations of abuse et permission obtained for resident to go to (name of hospital) main campus for nessary (sic) tx related to allegations. Residents (sic) poa stated, "THIS WAS OBSERED ET RIDICULOUS ALSO A WASTE OF TIME BUT DO WHAT EVER WE WANTED TO DO." (sic) transportation arranged et resident transported to (name of hospital)." "7/19/2011 16:03 (4:03 p.m.) Resident refused ADL (activities of daily living) care this am (morning) despite 2 attempts by staff." "7/19/11 20:08 (8:08 p.m.) @ 1900 (7:00 p.m.) res (resident) return to (name of facility) on srecther (sic) per ambulance, escorted per 2 (name of ambulance company) personnel. No c/o (complaints) noted upon return. N.O. (new order) received for [MEDICATION NAME] (for nausea) 4 mg Q 6 hrs (every six hours) PRN (as needed) times 3 doses and update Dr. (name) in AM." "7/19/11 23:27 (11:27 p.m.) Res. resting quietly in bed at this time. Res. in good humor, taking meds without difficulty, no periods of anxity (sic), normal demeaner (sic), res. calling out to staff by name as normal in ADLs." "7/20/11 06:55 (6:55 a.m.) "1 on 1 observation started. Resident had uneventful night, mainly sleeping. Verbalized needs and wants. C/O (complaint of) hurting. Reassurance and redirect provided with little success. [MEDICATION NAME] 0.25 ml (milliliters) given @ 0035 (12:35 a.m.) for pain and general discomfort. Resting comfortably during noc's. 1 on 1 observation provided by female staff thru the night. No further C/O of pain or discomfort and was resting comfortable..." "7/20/2011 14:55 (2:55 p.m.) General Note. Providing 1:1 with (name) 2:00 - 2:45 p.m. resident hollered "help." This SSD (Social Service Director) entered room, resident stated she was wet when asked what she needed. Nursing notified of need to provide peri-care. When asked if she remembered going to hospital yesterday, she responded, 'Yes'. (sic) When asked if she knew what the reason for transfer to hospital was, she responded, 'I was raped'. (sic)..." At 1:00 p.m. on 7/21/11, the Interim Administrator, Corporate Nurses #1 and #2, the Corporate Director of Operations, and the Corporate Attorney were interviewed. The Administrator indicated their investigation began as soon as the allegation was reported. She indicated they immediately interviewed the resident and did a physical assessment. They notified the physician, the family, and the police and got orders to send the resident to the hospital for evaluation and treatment. The facility Social Services employees began interviews of alert and oriented residents, and they began full body assessments on all dependent residents. When queried about staff interviews, they indicated the police detective had arrived at around 3:30 p.m. on 7/19/11. He had requested they not interview CNA #6 until he had a chance to. The Interim Administrator indicated she called her corporate office after the visit with the detective and was told to wait for legal representation prior to proceeding with staff interviews. At that time, they indicated the Corporate Attorney had arrived on 7/20/11 in the afternoon. When queried, they indicated four (4) staff members had been interviewed on 7/20/11, one nurse, two CNAs and a Social Worker; they did not identify the individuals. When queried further, they indicated the CNA and nurse who worked with CNA #6 on the 400/500 halls the night in question had not been interviewed, but "would be by the end of the day (7/21/11)." They indicated the investigation was still in process. The Corporate staff indicated their policy was to suspend the staff member immediately and begin the investigation. On 7/22/11 at 8:50 a.m., the Administrator and Corporate Nurses and Director of Operations indicated their attorney had given them permission to proceed with staff interviews, and interviews had been conducted the during the previous evening and night shifts. They provided documentation of those interviews. The questions for staff were typed on pieces of paper and each one had handwritten answers from each staff person interviewed. The questions included the following: "What have you heard? Have you ever seen or heard a staff member be inappropriate either verbally or physically with a resident? If so, who did you report to? Have you noticed a staff member be unaccounted for extensive periods of time? If so, did you report this and to whom did you report it? Is there anything else?" CNA #13 was interviewed, on 7/22/11 at 9:07 a.m. She indicated she had worked on 7/19/11, on the day shift. She indicated, "I think I took care of her...I did change her, by myself." She indicated she remembered changing the resident's incontinence brief; the resident had not complained. The resident's brief had an off-white colored discharge in it, but she indicated the resident always had that. She indicated the resident had said nothing to her and the first thing she heard about the allegation was when they were sending her to the hospital. CNA #14 was interviewed on 7/22/11 at 10:20 a.m. She indicated she had arrived on the unit that morning around 8:00 a.m. She indicated the resident did not want a bath that morning, which was a little unusual. She indicated she approached the resident again later, sometime around 11 a.m. or so. At that time, Resident E, stated to her, "(CNA #6's first name) raped me, (name) raped me." She indicated she immediately left the room and found the first nurse she could find, the Staff Development Nurse. The Staff Development Nurse told her to tell the DoN immediately and she did. She indicated she had provided the resident peri-care around 10:30 a.m. and nothing unusual had occurred or was observed, and the resident had not reported the allegation at that time. CNA #14 indicated she "normally" used two people in Resident E's room, but not all the time, "I don't always take ." She indicated the reason they normally used two staff was "based on her history." The DoN was re-interviewed, on 7/22/11 at 10:30 a.m. She indicated the instructions, "two for care," was on the assignment sheet prior to the allegation and the instructions were due to false reports in the past (not of rape). She indicated, if she had been able to interview CNA #6, she would have asked him if he had two people with him all the time, and if not, why, but law enforcement had not allowed the facility to interview him. CNA #9 was re-interviewed on 7/22/11 at 11:30 a.m. She indicated she worked the night shift 7/18/11-7/19/11. She indicated she worked the 400 hall and CNA #6 worked the 500 hall, where Resident E resided. She indicated she did not assist CNA #6 with Resident E at any time during that shift. She indicated some CNAs liked to stay on their own halls and some liked to do bed checks together and CNA #6 would usually work by himself. When queried about residents who needed two staff for assistance, she indicated there were times when she did not get a second staff member to help. RN #5 was re-interviewed, on 7/22/11 at 11:45 a.m. When queried, she indicated she could not say either way whether or not she assisted CNA #6 with Resident E on the night of 7/18-7/19/11. She did not remember. She indicated nothing unusual happened that night. When queried about bed checks and whether or not CNA #6 did them by himself, she indicated sometimes CNAs, in general, would take two, if it was a resident who fought, or needed more help. She indicated she had not taken a lunch break that night, that she was the only nurse, and was always on one hall or the other. She indicated she did not know, for sure, whether or not CNA #6 cared for Resident E by himself or not. On 7/22/11 at 2:50 p.m., the Interim Administrator, Corporate Nurse #1, the Director of Nurses (DoN), and the Director of Operations were interviewed. When queried if they had asked CNA #9 and RN #5 whether or not they ever helped CNA #6 in Resident E's room, they indicated they had only asked the questions on the paper. The policy and procedure for "Reporting Alleged Violation," regarding abuse, no date, was provided by the HFA on 07/12/11 at 9:00 A.M., who indicated it was current. The policy and procedure included, but was not limited to, the following: "Policy It is the policy of this center to take appropriate steps to prevent the occurrence of: -abuse... Definitions: The following definitions are pursuant to the interpretive guidelines for F223. Abuse Abuse is the will infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, main or mental anguish... Sexual abuse Sexual abuse includes, but is not limited to: -sexual harassment -sexual coercion -sexual assault Where the circumstances of the alleged violation warrants, the DNS (Director of Nursing Services) or designee initiates a physical and mental assessment of the resident and documents the findings. Only factual information is documented, not assumptions. The DNS also notifies the attending physician regarding the alleged violation and findings and documents the contact... Investigation The ED (Executive Director, Administrator) or DNS conducts all investigations. In the event an alleged violation occurs when neither of these people are in the center, the charge nurse is responsible for initiating the investigation procedure. The investigation includes interviews of employees, visitors or residents who may have knowledge of the alleged incident. Only factual information is documented - not assumptions or speculation. Written statements from involved parties are not requested. The documentation of the investigation is kept in the ED's office in an administrative file. The medical record is reviewed to determine the resident's past history and condition and its relevance to the alleged violation..." 2. Resident F's clinical record was reviewed on 7/21/11 at 6:50 a.m. A Nurse's note, dated 06/30/11 at 04:18 (4:18 A.M.), indicated, "(local ambulance company) her (sic) to transport. Resident told EMT's (Emergency Medical Technician's) that she had been rapped (sic), that she was being held hostage, that her fron (sic) teeth were knocked out...." The Nursing note lacked any documentation that the HFA (Health Facility Administrator) had been notified. In an interview with the HFA, on 07/21/11 at 8:15 A.M., she indicated, "We saw that one (the nursing note) the next morning, reviewing things in the morning meeting...The nurse did not call at that time, her assumption was (Resident F) was talking out of her head...didn't take it as an allegation of abuse...we re-educated the nurse for reporting..." An inservice training record, dated 6/30/11, provided by the HFA on 07/21/11 at 2:00 P.M., indicated, "Staff will understand that they are to report anything odd or unusual, even if they feel it is a behavior to their DON (Director of Nursing), ED (Executive Director) or ADON (Assistant Director of Nursing) at anytime AM or PM." The policy and procedure for abuse, provided by the HFA on 07/12/11 at 9:00 A.M., indicated, "Reporting Alleged Violations Responsibility: It is the responsibility of all associates to immediately report any alleged violation of abuse...Policy It is the policy of this facility to take appropriate steps to prevent...abuse...It is also the policy of this facility to take appropriate steps to ensure that all alleged violations of ...abuse...are reported immediately to the Executive Director of the facility...The facility investigates each such alleged violation thoroughly..." This federal tag relates to complaint number IN 878. 3.1-28(c) 3.1-28(d)

Based on record review, observation, and interview, the facility failed to ensure 1 of 3 residents reviewed for allegations of sexual assault, was free of evidence of sexual assault, in that the hospital record indicated there were signs and symptoms of an assault. The facility failed to ensure facility staff on duty at the time of the allegation were interviewed timely, and failed to ensure two persons cared for the resident prior to the allegation, as indicated in the written plan of care. (Resident E) Finding includes: During interview on 7/19/11 at 1:00 p.m., the Interim Administrator and Director of Nurses (DoN) indicated Resident E had alleged she was raped by a CNA (CNA #6) on the previous night shift. The Administrator indicated the resident had told a CNA (CNA #14), at around 11:30 a.m., who immediately informed the Director of Nurses and the facility had begun investigating. She indicated the resident was being sent to the hospital for examination and the police had been called. The CNA had been notified that he was not to report to work until further notice due to an investigation. During interview on 7/19/11 at 4:00 p.m., the DoN and Administrator indicated a detective from the local police department had been in and asked them not to talk to the alleged perpetrator until he had the opportunity to interview him. The resident was still at the hospital at that time. During interview on 7/20/11 at 8:30 a.m., the DoN indicated the resident had returned from the hospital during the evening and no new orders had been given and no information from the hospital was received. The resident had been placed on one to one observation, where a staff person monitored the room, from the hallway. Two staff were doing all care on the resident. On 7/21/11 at 5:22 a.m., the building was entered. CNAs #8 and #9 were observed working on the 400 hall. CNA #8 indicated he was brand new and had only been working for a week. He indicated he and CNA #9 had been working as a team. They would get report, pass ice water, start bed checks, do paperwork, then restart bed checks. He indicated, because he was new, they were working together to do bed checks, so he could be introduced by the other CNA and learn what each resident needed. CNA #8 indicated he had not worked on 7/18-7/19 night shift. CNA #9 was then interviewed, at 5:30 a.m. She indicated she had worked Monday (7/18-7/19) night shift, Tuesday, and Wednesday. She indicated she worked 400 hall and CNA #6 had worked 500 hall. She indicated some CNAs chose to work their hall alone and some preferred to work together as a team. She indicated that she had worked by herself on Monday night, 7/18-7/19/11. She indicated she would still go over to the hall if help was needed, or to answer lights. The CNA indicated she had not been questioned by anyone else about that night, any other night, or questioned about anything else. A Hospice RN was present on the unit, at 5:40 a.m. on 7/21/11. She indicated Resident E was on her caseload. She indicated she was requested to come in on 7/19/11 to witness an interview and physical assessment of Resident E. She indicated she and the Minimum Data Set (MDS) assessment coordinator had been in the room together. The resident reported to them she had been raped on the night shift and indicated it was CNA #6 who raped her. She indicated the physical assessment was completed. The resident was wet, so her brief was changed. She indicated they had put the brief and linens used to cleanse the resident in a bag and saved it for the police investigation. She indicated there were no red marks, no significant bruises, except for several small bruises, none of them new, on her arms and knees. There were no red marks. The resident had a flat affect throughout the interview and exam. She indicated the interview and assessment happened "around noon." She indicated, according to the MDS coordinator, the story was consistent. She further stated, "Unfortunately, I know this resident and she's not always truthful." CNA #10 was observed seated outside Resident E's room [ROOM NUMBER]:45 a.m. on 7/21/11 and was interviewed at that time. She indicated the resident and her room were being observed one on one, since 7/19/11 at 11:00 p.m. She had come in at 3:00 a.m. and had been assigned to watch the room and resident. At that time, the resident was heard to yell "Help, Help." The CNA entered the room and asked the resident what she needed. CNA #10 indicated she had to get help and exited the room to find another CNA to help her. She indicated two staff were doing all care. CNA #11 was observed in the facility at 5:45 a.m. on 7/21/11. During interview at that time, she indicated she was taking over the one on one. She indicated she had heard Resident E had claimed CNA #6 raped her. She indicated she had worked Saturday night, Sunday night, and Monday night, 2:00 a.m. to 2:00 p.m. She indicated no one had questioned her about anything, "no nurse, no Administrator, no DoN (Director of Nurses), no detective..." She indicated staff were to always go with two persons to Resident E's room, even before the allegation, because the resident didn't always tell the truth. Upon observation, RN #5 was administering medications on the 400 and 500 halls on 7/18/11 at 5:50 a.m. She was interviewed at 5:50 a.m. on 7/21/11. She indicated she had worked the night shift 7/18/11 to 7/19/11. She indicated CNAs #6 and #9 had been the CNAs working with her. She indicated nothing unusual happened that night. The resident had not complained of anything to her. She indicated she had heard from co-workers that Resident E alleged CNA #6 had raped her during that night shift. She indicated she was always in the hallway, or at the nurses' station and heard staff in and out of rooms. She indicated again, nothing unusual occurred. "We all know who she is...when she knows he's working (CNA #6), she's always calling out his name." She indicated she had not had anyone from the facility staff, or anyone else ask her any questions about that night and had received no request for any statement, "You are the first to ask." On 7/21/11 at 8:30 a.m., the Interim Administrator, Corporate Nurse Consultant #1, Corporate Nurse Consultant #2, and the Corporate Director of Operations were interviewed. According to the Interim Administrator, the facility had not initiated staff interviews on 7/19/11. She indicated a police detective had arrived at 3:30 p.m. and indicated he did not want them to interview CNA #6 before he had a chance to do so. She indicated the detective called the CNA from her office and scheduled a time for him to come to the police department for an interview, 5:00 p.m. that date; the facility was not involved in the interview. She indicated the police detective did not ask them not to interview other staff. The Interim Administrator indicated, during the 8:30 a.m. interview, after the police detective's visit, she made a phone call to the corporate legal department. She indicated she was told the legal department would be involved and indicated she was asked not to interview staff, that "counsel needed to be on the ground." The Corporate Nurses indicated the attorney had arrived on 7/20/11 and was returning 7/21/11. They indicated she had done some staff interviews on 7/19/11, but they did not know who was interviewed. The Administrator indicated, during the 8:30 a.m. interview, it was around 11:30 a.m. Tuesday morning (7/19/11) that Resident E reported the allegation to the CNA. The CNA immediately reported it to the DoN. The hospital Emergency Department Record, dated 7/19/11, was received from the local hospital Accreditation and Regulatory Nurse, on 7/21/11 at 11:05 a.m. and reviewed at that time. The hospital clinical record indicated the resident arrived at the Emergency Department at 2:23 p.m. on 7/19/11. The chief complaint was "Alleged Sexual Assault." The resident's history included the following Diagnoses: [REDACTED]. The history and physical information indicated the following: "...female who presents with complaint of sexual assault. She lives at the (Name of Facility). She stated that she was laying in bed about 4:00 this morning and a man who works there and put his penis in her vagina. She said he put his finger in her vagina as well. She denies any other complaints or injuries aside from the sexual assault." Documentation in the ED (Emergency Department) notes indicated a sexual assault kit was completed and the report indicated the following: debris found and collected from the resident's external genitalia, secretions found and collected externally and internally, abrasions noted in the vaginal canal, shearing force noted, the cervix was reddened and had bruising, abrasions noted internally, visible tears in the area and abrasions. The exam also indicated the resident had a bruise on her right buttock, 1 cm (centimeter) by 3 cm. The police were present for the exam and pictures were obtained. The resident was discharged from the hospital ED at 6:46 p.m. and was returned to the nursing home. The information sent with the resident to the facility on ly indicated for to return to the nursing home, resume prior orders, orders for an anti-nausea medication, and directions to report her progress to her physician the next day. Resident E's facility clinical record review began on 7/21/11 at 6:30 a.m. The record indicated the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident's most recent quarterly Minimum Data Set (MDS) Assessment, dated 5/27/11, included, but was not limited to, the following: Unclear speech, rarely/never understood, rarely/never understands, long term and short term memory problems, severely impaired decision making, disordered thinking, [MEDICAL CONDITION], extensive assistance of two staff for bed mobility, total dependence of two staff for transfers, and unable to ambulate. She was assessed as always incontinent of bowel and bladder, had signs and symptoms of pain, and had experienced unplanned weight loss. The resident's most recent full MDS assessment, a significant change MDS dated [DATE], included, but was not limited to, the following: communication clear, Brief interview for Mental Status score of 05/15, with 15/15 being alert and oriented, no [MEDICAL CONDITION] or behaviors identified, extensive assistance of two staff for bed mobility, and transfers, and unable to walk. The assessment indicated she was always incontinent of bowel and bladder, experienced pain, but had experienced no weight loss. The resident was currently receiving hospice services. The nurse aide assignment sheets for the 400 and 500 halls were provided by CNA #10 on 7/22/11 at 10:26 a.m. and reviewed at that time. Under "Special Needs," was indicated the following: "two for care non-skid slipper socks when out of bed BEHAVIORS. HOSPICE roho air mattress KEEP SET ON #4." Nurses' notes/progress notes were reviewed from 6/8/11 through 7/22/11 and included, but were not limited to, the following: "7/18/11 07:57 (7:57 a.m. ) Resident slept well during the night on no pressure mattress, with floor mats on floor for safety." "Late Entry 7/19/2011 12:40 (12:40 p.m.) Note text: Resident reported allegations of abuse, MD (medical doctor) made aware of allegations et new order received for resident to go to ER (emergency room ) for evaluation et tx (treatment); poa (power of attorney) (name) notified of residents allegations of abuse et permission obtained for resident to go to (name of hospital) main campus for nessary (sic) tx related to allegations. Residents (sic) poa stated, "THIS WAS OBSERED ET RIDICULOUS ALSO A WASTE OF TIME BUT DO WHAT EVER WE WANTED TO DO." (sic) transportation arranged et resident transported to (name of hospital)." "7/19/2011 16:03 (4:03 p.m.) Resident refused ADL (activities of daily living) care this am (morning) despite 2 attempts by staff." "7/19/11 20:08 (8:08 p.m.) @ 1900 (7:00 p.m.) res (resident) return to (name of facility) on srecther (sic) per ambulance, escorted per 2 (name of ambulance company) personnel. No c/o (complaints) noted upon return. N.O. (new order) received for [MEDICATION NAME] (for nausea) 4 mg Q 6 hrs (every six hours) PRN (as needed) times 3 doses and update Dr. (name) in AM." "7/19/11 23:27 (11:27 p.m.) Res. resting quietly in bed at this time. Res. in good humor, taking meds without difficulty, no periods of anxity (sic), normal demeaner (sic), res. calling out to staff by name as normal in ADLs." "7/20/11 06:55 (6:55 a.m.) "1 on 1 observation started. Resident had uneventful night, mainly sleeping. Verbalized needs and wants. C/O (complaint of) hurting. Reassurance and redirect provided with little success. [MEDICATION NAME] 0.25 ml (milliliters) given @ 0035 (12:35 a.m.) for pain and general discomfort. Resting comfortably during noc's. 1 on 1 observation provided by female staff thru the night. No further C/O of pain or discomfort and was resting comfortable..." "7/20/2011 14:55 (2:55 p.m.) General Note. Providing 1:1 with (name) 2:00 - 2:45 p.m. resident hollered "help." This SSD (Social Service Director) entered room, resident stated she was wet when asked what she needed. Nursing notified of need to provide peri-care. When asked if she remembered going to hospital yesterday, she responded, 'Yes'. (sic) When asked if she knew what the reason for transfer to hospital was, she responded, 'I was raped'. (sic)..." The resident's record indicated she was being followed by a Psychiatrist. The last visit was dated 6/27/11. The report indicated the behaviors and symptoms she was being seen for were agitation, afraid to die, anxiety, false beliefs, and jittery/nervous. During the visit, the Psychiatrist documented "denies mood or anxiety c/o." Hospice records were reviewed. A Nursing Clinical Note, dated 7/19/11 (no time), indicated the following: "No new orders per facility chart review. PRN (as needed) SNV (Skilled Nurse Visit) R/T (related to) allegation of abuse by facility staff. Requested to be present during questioning of pt. by facility RN MDS (name) RN. Witnessed. Pt. (with) (no) physical/mental/emotional s/s (signs/symptoms) abuse @ this time during this assessment. Pt. out (and) back to ER for evaluation. No results given to this RN." The Hospice Social Worker visited the resident on 7/20/11 at 11:10 a.m. She indicated the following: "Pt. made report to N. Home staff that she had been raped by a N. Home aide. N (nursing) Home is conducting investigation... Spoke to pt. about incident. Pt. is sticking to her story..." At 1:00 p.m. on 7/21/11, the Interim Administrator, Corporate Nurses #1 and #2, the Corporate Director of Operations, and the Corporate Attorney were interviewed. The Administrator indicated their investigation began as soon as the allegation was reported. She indicated they immediately interviewed the resident and did a physical assessment. They notified the physician, the family, and the police and got orders to send the resident to the hospital for evaluation and treatment. The facility Social Services employees began interviews of alert and oriented residents, and they began full body assessments on all dependent residents. When queried about staff interviews, they indicated the police detective had arrived at around 3:30 p.m. on 7/19/11. He had requested they not interview CNA #6 until he had a chance to. The Interim Administrator indicated she called her corporate office after the visit with the detective and was told to wait for legal representation prior to proceeding with staff interviews. At that time, they indicated the Corporate Attorney had arrived on 7/20/11 in the afternoon. When queried, they indicated four (4) staff members had been interviewed on 7/20/11, one nurse, two CNAs and a Social Worker; they did not identify the individuals. When queried further, they indicated the CNA and nurse who worked the 400/500 halls the night in question had not been interviewed, but "would be by the end of the day (7/21/11)." They indicated the investigation was still in process. The Corporate staff indicated their policy was to suspend the staff member immediately and begin the investigation. CNA #13 was interviewed, on 7/22/11 at 9:07 a.m. She indicated she had worked on 7/19/11, on the day shift. She indicated, "I think I took care of her...I did change her, by myself." She indicated she remembered changing the resident's incontinence brief; the resident had not complained. The resident's brief had an off-white colored discharge in it, but she indicated the resident always had that. She indicated the resident had said nothing to her and the first thing she heard about the allegation was when they were sending her to the hospital. CNA #14 was interviewed on 7/22/11 at 10:20 a.m. She indicated she had arrived on the unit that morning around 8:00 a.m. She indicated the resident did not want a bath that morning, which was a little unusual. She indicated she approached the resident again later, sometime around 11 a.m. or so. At that time, Resident E, stated to her, "(CNA #6's first name) raped me, (name) raped me." She indicated she immediately left the room and found the first nurse she could find, the Staff Development Nurse. The Staff Development Nurse told her to tell the DoN immediately and she did. She indicated she had provided the resident peri-care around 10:30 a.m. and nothing unusual had occurred or was observed, and the resident had not reported the allegation at that time. CNA #14 indicated she "normally" used two people in Resident E's room, but not all the time, "I don't always take ." She indicated the reason they normally used two staff was "based on her history." The DoN was re-interviewed, on 7/22/11 at 10:30 a.m. She indicated the instructions, "two for care," was on the assignment sheet prior to the allegation and the instructions were due to false reports in the past (not of rape). She indicated, if she had been able to interview CNA #6, she would have asked him if he had two people with him all the time, and if not, why, but law enforcement had not allowed the facility to interview him. CNA #9 was re-interviewed on 7/22/11 at 11:30 a.m. She indicated she worked the night shift 7/18/11-7/19/11. She indicated she worked the 400 hall and CNA #6 worked the 500 hall, where Resident E resided. She indicated she did not assist CNA #6 with Resident E at any time during that shift. She indicated some CNAs liked to stay on their own halls and some liked to do bed checks together and CNA #6 would usually work by himself. When queried about residents who needed two staff for assistance, she indicated there were times when she did not get a second staff member to help. RN #5 was re-interviewed, on 7/22/11 at 11:45 a.m. When queried, she indicated she could not say either way whether or not she assisted CNA #6 with Resident E on the night of 7/18-7/19/11. She did not remember. She indicated nothing unusual happened that night. When queried about bed checks and whether or not CNA #6 did them by himself, she indicated sometimes CNAs, in general, would take two, if it was a resident who fought, or needed more help. She indicated she had not taken a lunch break that night, that she was the only nurse, and was always on one hall or the other. She indicated she did not know, for sure, whether or not CNA #6 cared for Resident E by himself or not. The policy and procedure for "Reporting Alleged Violation," regarding abuse, no date, was provided by the HFA on 07/12/11 at 9:00 A.M., who indicated it was current. The policy and procedure included, but was not limited to, the following: "Policy It is the policy of this center to take appropriate steps to prevent the occurrence of: -abuse... Definitions: The following definitions are pursuant to the interpretive guidelines for F223. Abuse Abuse is the will infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, main or mental anguish... Sexual abuse Sexual abuse includes, but is not limited to: -sexual harassment -sexual coercion -sexual assault Where the circumstances of the alleged violation warrants, the DNS (Director of Nursing Services) or designee initiates a physical and mental assessment of the resident and documents the findings. Only factual information is documented, not assumptions. The DNS also notifies the attending physician regarding the alleged violation and findings and documents the contact... Investigation The ED (Executive Director, Administrator) or DNS conducts all investigations. In the event an alleged violation occurs when neither of these people are in the center, the charge nurse is responsible for initiating the investigation procedure. The investigation includes interviews of employees, visitors or residents who may have knowledge of the alleged incident. Only factual information is documented - not assumptions or speculation. Written statements from involved parties are not requested. The documentation of the investigation is kept in the ED's office in an administrative file. The medical record is reviewed to determine the resident's past history and condition and its relevance to the alleged violation..." This federal tag relates to complaint number IN 878. 3.1-27(a)(1)